Every finding on record at Oaks of Clearwater, The

Based on observations, record reviews, and interviews, the facility failed to ensure the kitchen met sanitation requirements for one kitchen of one during 3 days (09/30/2025, 10/01/2025 and 10/02/2025) of three days observed.Findings included: During kitchen tours conducted with the Certified Dietary Manager (CDM), on 9/30/2025 at 9:25 a.m., on 10/1/2025 at 11:15 a.m. and 1:16 p.m., the following observations were made.Upon entering the kitchen, there was no garbage can readily accessible to dispose used paper towels after washing hands. The CDM revealed they did have one but was not sure where it went. The hand washing sink area to include, the back wall, the floor, floor drain area, and the sink had approximately eight small flying insects flying around and landing on the sink, the floor, and the walls. The CDM stated not being aware of any issues causing the flying insects and did not notice them until it was just brought to their attention.The floor drain next to the hand washing sink was observed with several soiled plastic pipes. The floor drain metal plate was observed with a thick clear, grey and orange colored gelatinous substance. The substance appeared to be bio-growth. The CDM confirmed the drain growth and stated not being aware of the drain plate in that condition.The dish washing machine room revealed a large metal dish washing machine. The CDM revealed the kitchen operates a high temperature dish washing machine and revealed the outside sourced maintenance operator was at the facility about a week prior and performed routine maintenance. The CDM identified problems getting the water boosted to high level water temperatures and stated it takes some time to do so. The CDM revealed the machine was very old and the facility was trying to get another one.Observations of the dish machine revealed the top had a reddish-brown, flaky surface, leaving a non-cleanable surface, with pieces of brown colored metal debris on it. The front side of the dish washing machine was observed oxidized in a white and green color on the corners of the doors, leaving a non-cleanable surfaces. At the top left corner of the dishwashing machine, where one metal plate met another, a clear liquid substance was observed squirting from the dish washing machine onto the oxidized area.The floor under the dish washing machine and in front of the dish washing machine was observed with calcification and oxidation from the water from the machine. The floor under the dish washing machine was observed soiled with build -up debris.Observations of the walk-in refrigerator revealed the floor had debris and dirt-like substances, with oxidization revealing a reddish-brown, flaky surface, leaving a non-cleanable surfaces around the corners. The areas were with dirt and debris which appeared to be build -up on the surface, leaving a non-cleanable surfaces. The CDM did not have a cleaning schedule to show when the unit was cleaned and maintained.The walk- in refrigerator was observed with several round containers with unidentified food product. The products were liquid, and the outside of the containers were covered with the spilled over product. The CDM revealed the containers of stored food products should be clean and free from any spilled product. Observations in the walk-in freezer revealed icing on the ceiling of the unit, with icicles hanging approximately six inches long. There were large chunks of ice debris on the floor and in the mat holes. The CDM confirmed the ice build-up and revealed the icing does happen frequently. Observations in the walk-in freezer revealed a large brown box positioned on the bottom shelve of one of the racks. The box was opened and lined with a blue transparent plastic bag and the top of the bag was opened and draped over. The food contents within the bag were exposed to the elements. The box was not labeled, and the contents were frozen and frosted over. The CDM revealed the box contained frozen turkey legs/chicken legs. The CDM revealed they were for resident consumption and did not know the box and bag were opened. The CDM confirmed food items should not be exposed to the elements, and all foods should be properly stored and labeled in closed bags/containers and the dates the items were opened. The CDM confirmed all the food items in the box/bag were frosted and unlabeled. The area in the front of the kitchen was observed with a standing fan pointed at the inside of the kitchen where food was prepared and served. The fan housing was observed with dust and debris. The kitchen's steam table unit was observed during food service times with food items on it. The top housing was observed held up with metal chains. The chains on both sides were observed with dust and debris, hanging directly over exposed food. The juice and coffee stations revealed metal shelves with built up dust and debris and oxidization revealing a reddish-brown, flaky surface, leaving a non-cleanable surface. The CDM stated the food warmer had recently broken and fixed and had a dark brown or black substance on the inside that was leaking down the wall. The heating table was observed to have an overhead lighting with discoloration, calcium build up and grease-like substances on it. The freezer was observed to have papers and debris on the floor. The floors and walls were observed with dark colored substances. The freezer door was observed with jagged metal that stuck out, revealing a non-cleanable surface.An observation of an ice maker on the second floor, in a small room directly behind the nursing station, used for storage of resident's foods revealed a gelatinous bio-growth, green and purple in color and ice buildup on the ice making tray. The bio-growth was observed directly above ice and where new ice had fallen. An interview with the CDM could not determine who was responsible for the general maintenance of the machine.The outside grounds where the facility dumpsters and trash compactors were located was observed with a large green plastic container that had letters and words FCS and Cooking Oil on the front panel. An interview with the CDM revealed the container housed the kitchen's used cooking oil. Further observations revealed the container was full and was placed on an outlined oil catching container. The catch container was observed full with used cooking oil that had leaked out onto the parking lot. The parking lot was observed with oil and debris in the oil, and a foul odor which was emitted from the used cooking oil container. The CDM revealed the used oil in the container is emptied by an outside sourced company and believed the container was emptied every week or so. The CDM revealed being new to the facility by about two months. On 09/30/2025 at 9:43 a.m. an interview was conducted with the CDM during a tour of the kitchen. The CDM stated maintenance had been performed on the dish washing machine a week prior. The CDM stated the facility received three deliveries of food per day. The CDM stated the freezer was cleaned between every meal. The CDM stated the facility was working with a new vendor and was trying to replace the dish washing machine.During a kitchen tour on 10/01/2025 at 01:16 p.m., an interview was conducted with the CDM. The CDM stated the handwashing sink near the deep freezer, and the areas near it had been cleaned the prior week, during their weekly cleaning. The area was observed to have various multicolored substances on the walls, floors, drainage areas, floor around the drainage areas, and debris on the pipes, floors, drainage areas and walls, as observed on 09/30/2025. The CDM stated the double oven, food warmer, food condiments refrigerator, and the dish washer machine had been serviced a week or two prior. The CDM stated the equipment had failed to operate appropriately multiple times. The double oven was observed with various debris and grease-like substances. The CDM mentioned not being aware of whose responsibility it was to maintain and clean the ice maker.On 10/01/2025 at 03:08 P. M., an interview was conducted with the CDM. The CDM stated the ice machine on the second floor was used for resident's food and was being taken out. The CDM stated he did not know it was kitchen's responsibility to clean the ice machine on the second floor. The CDM stated, it was news to me!.On 10/02/2025 at 01:10 P. M., an interview was conducted with the Nursing Home Administrator (NHA), who was the quality assurance representative. The NHA revealed no performance improvement plans related to the kitchen or dietary services.Review of a facility policy titled Sanitation Inspection, dated 10/01/2025, showed: It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations. Policy Explanation and Compliance Guidelines: 1. All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects. 2. The department shall establish a sanitation program for food services based on applicable state and federal requirements. 3. The sanitation program will provide for inspections to be conducted of the food service areas. 4. Sanitation inspections will be conducted in the following manner: a. Daily: Food service staff shall inspect refrigerators/coolers, freezers, storage area temperatures, and dishwasher temperatures daily. b. Weekly: The dietary manager shall inspect all food service areas weekly to ensure the areas are clean and comply with sanitation and food service regulations. 5. Inspections will be conducted but not limited to the following areas: a. Dry storage, b. Freezer, c. Refrigerator, d. Dish room, e. Pot wash, f. Main production area, g. Food preparation area, and h. General dietary observations.6. The dietary manager shall develop and provide food service personnel with standard operating procedures for sanitation and daily inspections. Managers may familiarize staff with these procedures through various means such as monthly meetings, posted memorandums, training sessions and orientation of new personnel. 7. Inspection Score (from Sanitation Inspection Report): The dietary manager, as part of the department's QAPI program, will perform an in-depth analysis of the data obtained during the inspection utilizing the following: Numerator (The number of positives) divided by Denominator (the number of total opportunities) = Inspection Score 8. Inspection score will be formulated on each area being evaluated. Scores will then be compared to department goals. 9. Feedback will be reported to the food service staff and the QAPI Committee.

Based on record review and interviews, the facility did not ensure a water management plan was in place to assess, identify and monitor for Legionella and other opportunistic waterborne pathogens. Findings include: The facility was asked to provide their water management plan. On 10/2/25 at 11:30 a.m., the facility provided a water treatment contract invoice and a service report dated 7/7/25. Further review of the report revealed it was the quarterly service for the chilled loop which included testing of the pH (power of hydrogen measuring acidity of alkalinity), conductivity, iron, alkalinity, and sodium nitrate. The service report does not have documentation regarding water testing for Legionella and other waterborne pathogens.On 10/2/25 at 1:02 p.m., an interview was conducted with the Regional Director of Maintenance (RDOM) and the DOM. The DOM initially said he did not know if the facility had a water treatment plan as he had been in the position for two weeks. The Regional DOM said the facility recently changed water treatment companies. The facility has a signed agreement, but the company has not conducted their first water treatment yet. The Regional DOM reviewed the service report dated 7/7/25 and could not confirm if the water was tested for Legionella and other waterborne pathogens. The facility was unable to provide their Legionella facility assessment.A review of the facility's policy titled, Legionella Surveillance, revealed the following, It is the policy of this facility to establish primary and secondary strategies for the prevention and control of Legionella infections. Further review of the policy, under policy explanation and compliance guidelines, revealed the following, 1. Legionella surveillance is one component of the facility's water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water systems.A review of the facility's policy titled, Legionella Water Management Program, revised July 2017, revealed the following, Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. Further review of the policy, under policy interpretation and implementation, revealed the following, 1. As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team. 3. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. 5. The water management program includes the following elements: . b. A detailed description and diagram of the water system and the facility, including the following: . c. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including: .A review of a facility document titled, Water Management Program, revealed the following: Abstract: All facilities are required to demonstrate measures to minimize the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems and devices. It is recommended that facilities form a water management team which could include a variety of people with expertise to assist in the development of the most effective program possible. The following is a sample water management team charter which can be modified to address your facility's unique needs.

Based on observations, record review and interviews, the facility failed to ensure resident rooms, resident equipment and shower rooms equipment were maintained in a clean and sanitary manner during three days (9/30/2025, 10/1/2025, and 10/2/2025) of three days observed. Findings included: During facility wide tours on 9/30/2025 at 10:45 a.m., 10/1/2025 at 8:20 a.m., 1:00 p.m. and on 10/2/2025 at 8:27 a.m., observations were made of resident wheelchair armrests cracked and torn, resident rooms soiled, toilet devices and shower chairs were not maintained in a sanitary manner and were observed with biogrowth. 1. During multiple tours of the main community shower room, observations revealed two plastic shower chairs that were wet and appeared to have been just used. One white plastic shower chair with white plastic seating and backing was observed with heavy black and pink biogrowth on all four of the legs, at the wheel castors, as well as the connection pivot areas. The plastic backing and fabric were observed with a large amount of dark black biogrowth. Three privacy curtains were observed with spotty dark areas and lined black biogrowth near the bottom half. The resident room tours revealed the following: In room [ROOM NUMBER] a wheelchair was found with a cracked and torn right side of the armrest. In room [ROOM NUMBER] the bathroom was observed with a commode device with a brittle, reddish-brown, flaky coating on the metal surface. In room [ROOM NUMBER] a wheelchair was found with both the right side and lefts side armrests cracked and torn. In room [ROOM NUMBER] a wheelchair was found with both the right side and left side armrest cracked and torn. In room [ROOM NUMBER] the bathroom toilet lid was observed with a toilet seat with a painted surface scrapped off and leaving a non-cleanable surface. In room [ROOM NUMBER] a wheelchair was found with both the right and left side armrest cracked and torn. In room [ROOM NUMBER]a wheelchair was found with both the right and left side armrest cracked and torn. In room [ROOM NUMBER] a wheelchair was missing a right-side armrest pad. The resident stated not aware why the arm rest was missing, and it would be better and more comfortable to have one. In room [ROOM NUMBER] the ceiling was observed with heavy amounts of dust and debris on the ceiling and near the ceiling vent. In room [ROOM NUMBER] the ceiling vent was observed with a heavy amount of black biogrowth and with paint chipping and cracking. The wheelchair in bed b was observed with both the right and left side armrests cracked and torn. The resident revealed about his wheelchair, being terrible and stated having notified them to replace my armrests. The back room of the North dining/activity room where residents dine, an observation was made of two ceiling vents that were constantly dripping water onto the floor. The back room of the South dining room where residents dine, an observation was made of two ceiling vents that were constantly dripping water onto the floor. On 10/2/2025 at 11:00 a.m. an interview with the Housekeeping Director revealed housekeeping staff are responsible for the day-to-day cleaning of resident rooms, resident spaces and non-resident spaces. She confirmed housekeeping staff were responsible for cleaning community shower room. The housekeeping director revealed she was not aware of the dust and debris on the resident room ceilings, nor was she aware of the shower room having biogrowth on the shower chairs and the curtains. The housekeeping director revealed it was the nursing department's responsibility to clean the shower chairs after each use. She stated she was not aware how often or if the shower chairs were deep cleaned and or power washed. On 10/2/2025 at 1:00 p.m. an interview with the Maintenance Director revealed he was not sure who was responsible for the cleaning of shower chairs. The Maintenance Director confirmed the maintenance department was responsible for the general maintenance of resident wheelchairs. The Maintenance Director revealed himself and his staff do daily walk-throughs to look out for things such as broken wheelchairs. The Maintenance Director revealed if direct care staff or any staff see any problems with the wheelchairs, to include torn and cracked arm rests, they are to report it to his department either verbally or by electronic work order system. The Maintenance Director was unaware there were so many wheelchairs that needed maintenance and replacing of armrests. The Maintenance Director confirmed he did not have pending work orders for the stated concerns. On 10/2/2205 at 1:45 p.m., an interview with the Nursing Home Administrator (NHA) revealed the facility did not have a general housekeeping or wheelchair maintenance policy and procedure. The NHA revealed there was no documentation to show who was responsible for cleaning the shower room equipment and who was responsible for the general maintenance of resident rooms and resident equipment. 2. On 9/30/25 at 10:08 a.m., an observation of the bathroom in room [ROOM NUMBER] revealed a commode over the toilet with multiple areas of a brittle, reddish-brown, flaky coating on all four legs, as well as where the legs and arms of the chair meet. On 10/1/25 at 9:26 a.m., an observation of room [ROOM NUMBER] revealed the ceiling vent by the bed closest to the bathroom had cracked and chipped paint and was covered with an unknown, black-colored substance. Further observations of the bathroom in room [ROOM NUMBER] revealed the vent had the same concerns as the ceiling vent in the room. On 10/1/25 at 9:32 a.m., an observation of room [ROOM NUMBER] revealed multiple areas of an unknown, black-colored substance across the ceiling in the middle of the room. A resident in the room stated she was concerned it was, black mold, and said it was in other rooms as well. On 10/1/25 at 10:56 a.m., an observation of room [ROOM NUMBER] revealed an unknown-black colored substance across the bottom ledge under the air conditioning (a/c) vent. The resident in the room stated he was concerned about the substance being, black mold. He said he let the maintenance staff know about his concerns. Further observation of the bathroom in room [ROOM NUMBER] revealed the vent blades had multiple spots of a grey and white colored substance. A review of completed work orders from 7/1/25 to 10/1/25 revealed there were no work orders for rooms [ROOM NUMBER]. Further review of completed work orders revealed room [ROOM NUMBER] had a work order in July 2025, about a water leak in the ceiling. A review of current work orders revealed no work orders for rooms 200 to 203. On 10/2/25 at 1:02 p.m., an interview with the Maintenance Director revealed he had been in the position for two weeks. He said he was not aware of the concerns identified during the survey in rooms 200 to 203. A review of the completed work order for room [ROOM NUMBER] in July 2025 revealed he was not aware of the ceiling water leak in that room. An interview with the Regional Maintenance Director revealed the rooms seen with a black unknown substance could be removed by, Scraping the area with a broom. On 10/2/25 at approximately 7:45 a.m., an observation was made of the area under the East hallway handrails. The wall covering, simulating square tiles, was observed peeling away from the walls in numerous areas. On 10/2/25 during an 8:00 a.m. tour of the unit with the Nursing Home Administrator (NHA), the NHA observed the areas and stated she would put in a work order for the areas. The NHA stated the peeling wall coverings would not have been acceptable in her home. Photographic evidence was obtained.

Based on observations, staff interviews and record review, the facility failed to ensure an effective pest control program related to small flying insects in the kitchen, during two days (9/30/2025 and 10/1/2025) of three days observed. Findings included: On 9/30/2025 at 9:18 a.m. a kitchen tour was conducted with the Certified Dietary Manager (CDM). An observation was made of several small flying insects at the hand washing sink, approximately eight of these flying insects flying around and landing on the walls, the paper towel dispenser, the sink, and floor. The floor drain that had a metal plate was observed with gelatinous bio growth on it. The CDM revealed he had not seen them before until they were just pointed out. He confirmed there were more than a few insects flying around the hand washing sink but did not know exactly how long they had been in the area.A second tour of the facility on 10/1/2025 at 11:15 a.m. and at 1:30 p.m. revealed small flying insects in the area where the hand washing sink and floor drain was. Several more flying insects were observed in the food preparation and food service area of the kitchen. Dietary staff who were walking by were observed swatting at the insects from time to time. None knew where they were coming from. An interview with the CDM revealed the facility had a pest control program and that an outside sourced pest control company came out once a month for general treatment but has come out more frequently to treat any outbreaks of pests/insects. The CDM was not sure how the maintenance department was involved with treatment, but there was an electronic work order program that was used by staff and acts as a reporting system for any staff member if there were any concerns that need to be worked on, to include pest control. The CDM revealed the kitchen staff do know how to utilize the electronic work order reporting program and have done so in the past. The CDM confirmed flying insects in the kitchen space at and near the hand washing sink area, as well as in and around food preparation areas. The CDM did not know the exact date the pest control company was last out to treat for insects. On 10/1/2025 at 2:15 p.m. an interview with the maintenance director stated any staff member who observed any type of insect or pest, has been trained to utilize the electronic work order system and he checks that reporting system daily. He confirmed if there were any work orders/reports of pests or insects, he would call the pest control company to come out to treat in between their regular weekly visits. The maintenance director revealed he did not have any current work orders the past one week to include any reports of insects in the kitchen. The maintenance director was unaware of a backed up or clogged up drain near the hand washing sink in the kitchen and was not aware of insects in and around this area.The maintenance director provided the last pest control company treatment reports that included visits on 5/20/2025, 6/17/2025, 8/18/2025, and 9/16/2025, related to the treatment for flying insects. The reports did not specify which areas were treated. The Maintenance director provided the facility and outside sourced pest company contract for review. The contract reviewed revealed an effective date of 7/25/2021 and revealed the pest control company would come out the facility for maintenance treatment on a weekly basis. The contract revealed the following pests/insects would be treated for; All general pests: cockroaches, ants, spiders, silverfish, earwigs, millipedes, springtails, etc. The list did not specify treatment for small flying insects. Further, the contract revealed the outside of the building would be treated on a monthly basis.The maintenance director revealed he was not able to provide a pest control policy and procedure for review.

Based on observations, record reviews, and interviews the facility failed to address pharmacy recommendations for one resident (#9) of five residents sampled for the unnecessary administration of medications.Findings included: On 9/30/25 at 10:30 a.m. Resident #9 was observed sitting in wheelchair in room with television playing. The resident replied to introduction with nonsensical speech. Review of Resident #9's active orders as of 10/2/25 at 12:27 p.m. revealed the diagnosis for rifaximin was other symbolic dysfunctions. An interview was conducted with the Director of Nursing (DON) on 10/1/25 at approximately between 3:00 and 6:00 p.m. The DON provided one pharmacy recommendation for Resident #8 and reported the facility continued to look for the rest of the requested recommendations. An interview was conducted with the Nursing Home Administrator (NHA) on 10/2/25 at 1:42 p.m. The NHA stated they were waiting for pharmacy to send the pharmacy recommendation policy. The NHA provided on 10/2/25 at 2:12 p.m. the July, August, and September pharmacy recommendations. The received documents did not contain recommendations for all of the requested residents and did not reveal pharmacy recommendations had been made during the requested times and did not reveal pharmacy had reviewed the medications to determine if there were any recommendations or not. Review of a pharmacy recommendation obtained on 10/2/25 at approximately 2:00 p.m. from the Nursing Home Administrator (NHA) showed a recommendation had been printed on 8/29/25 asking for the physician to consider changing the diagnosis of Resident #9's Xifaxan (rifaximin) from other symbolic dysfunctions to other irritable bowel syndrome. The recommendation explained the Food and Drug Association (FDA) had not labeled other symbolic dysfunctions as an approved indication for the medication. The recommendation showed the physician/prescriber response was the diagnosis (dx) changed to anxiety 09/18/25 and signed illegibly. The recommendation was not dated. Review of policy – Documentation and Communication of Consultant Pharmacist Recommendations, effective March 2019, revealed The consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist observations and recommendations regarding residents medication therapies are communicated to those with authority and/ or responsibility to implement the recommendations, and are responded to in an appropriate and timely fashion. The policy included but not limited to the following procedures: A. A record of the consultant pharmacist observations and recommendations is made available to in an easily retrievable form to nurses, prescribers, and the care planning team. This should include: 1) documentation on the appropriate form of the date each medication regimen review is completed and notation of the findings in the medical record or other designated site. 2) A standard format utilized by clinical care providers, such as SOAP (Subjective, Objective, Assessment, and Plan) or FARM notes (See Appendix 11: SOAP and FARM formats for clinical notes) 3) The consultant pharmacist documents potential or actual medication related problems, irregularities, and other medication regimen review findings appropriate for prescriber and/ or nursing review. C. Recommendations are acted upon and documented by the facility staff and/or the prescriber. If the prescriber does not respond to recommendation directed to him/her within a reasonable time frame/ within 30 days, the Director of Nursing and/ or the consultant pharmacist may contact the medical director. F. Recommendations regarding implementation of facility policies, procedures, and/ or methods of medication administration are made by the consultant pharmacist when appropriate. Review of a facility policy titled, Medication Regimen Review, effective March 2019, revealed The consultant pharmacist performs a comprehensive review of each resident's medication regimen at least monthly. The medication regimen review (MRR) includes evaluating the resident's response to medication therapy to determine that the resident maintains at the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy period findings and recommendations are reported to the Director of Nursing and the attending physician, and if appropriate, the medical director and/ or the administrator. The policy included but not limited to the following: C. While MRRs Are generally conducted in the facility, off site MRR's are acceptable when a review is requested in the following conditions are met: 1) the consultant pharmacist is not present in the facility, and 2) it is not possible for the consultant pharmacist to visit the facility within a reasonable time frame. If a consultation is needed when the pharmacist is off site: 3. The findings are found, faxed, or emailed within (24 hours) to the director of nursing or designee and or documented in stored with the other consultant pharmacist recommendations in the resident's active record. F. Resident specific irregularities and/ or clinically significant risk resulting from or associated with medications or documented in the residence active record and reported to the Director of Nursing and/ or prescriber as appropriate. G. Recommendations are acted upon and documented by the facility staff and/or the prescriber. 1) Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing. 3) the director of nursing or designated licensed nurse address and document recommendations that do not require a physician intervention, e. g., monitor blood pressure.

Based on record review and interviews, the facility failed to ensure documentation was accurate and complete in the Electronic Medical Record (EMR) for one resident (#35) out of 13 residents reviewed.Findings included: Resident #35 was admitted to the facility on [DATE]. Review of Resident #35's medical record revealed medical diagnosis to include muscle wasting and atrophy, difficulty in walking, generalized anxiety disorder, and dementia.Review of the Minimum Data Set (MDS) dated [DATE], section C revealed the resident had a Brief Interview Mental Status of 09, which meant the cognition of Resident #35, was moderately impaired. Section GG of the MDS revealed the resident required supervision or touching assistance. It showed Resident #35 required partial or moderate assistance for toilet transfers. Section H revealed Resident #35 was incontinent frequently.Review of a Certified Nursing Assistant (CNA) Kardex (A documentation platform used by staff with instructions to specific resident care needs) revealed missing incontinence documentation for Resident #35 on 09/03/2025, 09/05/2025 - 09/10/2025, 09/17/2025, 09/27/2025 and 09/28/2025.On 10/01/2025 at 05:32 P. M., an interview was conducted with Staff E CNA. Staff E stated documentation should be completed at least once each shift. Staff E stated there was no reason documentation could not be completed, unless there was a system failure, of which Staff E stated there had been no system failure in the past 30 days. On 10/01/2025 at 05:40 P. M., an interview was conducted with Staff A CNA. Staff A stated there is no paper charting and all charting was performed electronically. Staff A stated incontinence care should be documented at the time of service or by the end of the shift.On 10/01/2025 at 05:50 P. M., an interview was conducted with Staff B CNA. Staff B stated incontinence care should be documented every shift and after meals.On 10/02/2025 at 07:32 A. M., an interview was conducted with Staff D CNA and Staff F CNA, at the same time. Staff D and Staff F stated incontinence care should be provided every two hours or as needed. Staff D and Staff F stated documentation must be added to the chart and there was no reason it would be missing unless it didn't happen.On 10/02/2025 at 07:48 A. M., an interview was conducted with Staff C Licensed Practical Nurse (LPN). Staff C stated appropriate supervision of CNAs included looking at their charting. Staff C stated no charting means the action didn't happen. Staff C stated, how would CNAs know otherwise? On 10/02/2025 at 07:48 A. M., an interview was conducted with Staff G LPN. Staff G stated CNAs are given rounds and they are made aware of residents who are incontinent and who is not incontinent. Staff G stated CNAs are observed throughout their shifts to ensure services were provided. Staff G stated if it wasn't documented it didn't happen. On 10/02/2025 at 07:48 A. M., an interview was conducted with the Director of Nurses (DON). The DON stated charting should be completed at the time of service or at the end of the shift. The DON stated if it isn't documented, it didn't happen.Review of a policy dated 04/21/2025, revised 10/02/2025, and titled Documentation in Medical Record, showed the following: Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Policy Explanation and Compliance Guidelines: 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. 3. Documentation may be performed manually or as per the facility's specific electronic medical record software.

Based on observations, record reviews, and interviews the facility failed to ensure ambulatory residents did not have access through an unlockable door to a functioning four-burner glass top stove located in one of two activity/dining rooms on the west hall for three residents (#23, #39, #45) of 27 sampled residents and failed to ensure safety of handrails for one handrail of one located next to the nursing station. Findings included:On 10/1/25 at approximately 8:45 a.m. an observation was conducted of an unlockable room at the southwest end of the unit. The room contained a functioning four- burner glass top stove. The clock was observed working and one of four burners turned red with heat emitting from it when the knob was turned to the on position.An interview was conducted with Staff I, Licensed Practical Nurse (LPN) on 10/1/25 at 8:54 a.m. The staff member stated the room was for resident's activities, luncheons, and sometimes for quiet time with families.On 10/1/25 at 9:50 p.m. Resident #23 ambulated with a 4-wheel walker into the northwest common/dining room. The resident stated the northwest room was for independent diners and the southwest room was for dependent residents. During the interview with the resident, Resident #39 was observed sitting in wheelchair propelling self in and out of the southwest common/dining room.Review of Resident #23's clinical record showed the resident was admitted on [DATE]. The resident's quarterly Minimum Data Set revealed the resident scored 15 of 15 on the Brief Interview of Mental Status (BIMS) indicating an intact cognition.Review of Resident #39's clinical record showed the resident was admitted on [DATE]. The resident's Minimum Data Set (MDS) dated [DATE] revealed the resident scored 9 of 15 on the BIMS score interview indicating moderate cognitive impairment.On 10/1/25 at 1:26 p.m. Resident #45 was observed propelling self into the southwest common/dining room. The resident was observed alone in the room with stove and reported coming into the room sometimes. Review of Resident #45's clinical record showed the resident was admitted on [DATE]. The resident's MDS dated [DATE] revealed the resident's BIMS score of 8 of 15, indicating a moderate cognitive impairment. On 10/2/25 at approximately 7:33 a.m. an observation was made of an approximately 3-4 foot section of handrail attached to the wall next to the nursing station. The handrail did not have curved ends and revealed silver metal brackets attached to the wall. The brown linear rail did not cover the silver areas.On 10/2/25 at 8:00 a.m. an observation was made with the Nursing Home Administrator (NHA). The NHA stated the southwest room was used for dining and did not think the door had ever been shut. The NHA reported thinking the stove did not work and the box above the stove contained a switch which turned the stove off. A demonstration revealed the stove becoming red with heat. The NHA stated she saw the issue and removed the knobs from the back of the stove. The NHA confirmed the residents could have burned themselves. A continued tour of the unit with the NHA revealed the missing ends to the handrail and the NHA agreed a resident could injure themselves on the exposed areas.Photographic evidence was obtained.

Based on observations, record reviews, and interviews the facility failed to obtain Level II Pre-admission screening and resident reviews (PASARR) for two residents (#8 and #9) of twenty-five initially sampled residents. Findings included: 1.) Review of Resident #8's clinical record showed the resident was admitted on [DATE] and 9/12/25. The record revealed diagnoses and onset dates of bipolar type schizoaffective disorder (onset 4/11/25), severe unspecified dementia with psychotic disturbance (onset 4/11/25), unspecified anxiety disorder (onset 4/11/25), unspecified epilepsy not intractable with status epilepticus (onset 4/11/25), unspecified depression (onset 4/11/25), and unspecified mood (affective) disorder (onset 6/23/25). Review of Resident #8's Agency for Healthcare Administration (AHCA) Nursing Home Transfer and Discharge Notice, dated 6/3/25, which the facility provided upon request for the resident's PASARR, showed the resident was being transferred to an acute care facility as needs could not be met at the facility and was Going for Mental Health eval (evaluation). Review of Resident #8's Level I PASARR, dated 4/22/25 showed screening was completed at the facility and included the diagnoses of anxiety disorder, bipolar disorder, depressive disorder, schizophrenia, and mood affective disorder. The screening showed the resident had previously received services for mental illness (MI), had no indicators for decision-makings, no dementia or related neurocognitive disorders, no diagnosis or suspicion of serious mental illness (SMI) or intellectual disability, and a Level II PASARR evaluation was not required. Review of Resident #8's progress notes showed an admission note, dated 6/5/25 revealing the resident had been sent to an acute care facility for auditory hallucinations. The note showed the resident had a history of dementia, schizophrenia, depression, and seizures. Review of Resident #8's psychiatric note dated 6/5/25 showed the resident had a chronic psychiatric history including schizoaffective disorder, generalized anxiety disorder (GAD), depression, and mood order. The note revealed the resident had been receiving long-term psychiatric treatment and was residing in a skilled nursing facility due to progressive psychiatric and functional decline. The note showed the resident had recently been hospitalized under a [NAME] Act after expressing the need to be hospitalized for paranoia, delusional thinking, and presented with acute mental status changes which was stabilized with medication and supportive care. Review of Resident #8's psychiatric note dated 9/22/25 revealed the resident had a longstanding psychiatric history with multiple psychiatric hospitalizations most recently under the [NAME] Act in May 2025 for psychiatric decompensation. The note revealed the resident continued to demonstrate obsessive preoccupation with vitamins. The diagnoses included with the note was hoarding disorder, generalized anxiety disorder, recurrent moderate major depressive disorder, and depressive type schizoaffective disorder.Review of Resident #8's clinical record and the requested documents did not reveal the facility had obtained a Level II PASARR for the resident. 2.) Review of Resident #9's admission Record showed the resident was admitted on [DATE] and readmitted on [DATE]. The record revealed the resident's principal diagnosis on 10/21/24 was neurocognitive disorder with Lewy bodies and included diagnoses of cognitive communication deficit (onset 6/19/23), unspecified schizoaffective disorder (onset 6/9/23), not otherwise specified mental disorder (onset 10/25/23), generalized anxiety disorder (1/4/20), unspecified single episode major depressive disorder (onset 1/4/20), alcohol dependence in remission (onset 10/21/24), and unspecified mood (affective) disorder (onset 9/27/23).Review of Resident #9's Preadmission Screening and Resident Review (PASARR) dated 1/2/20, revealed the resident had alcoholism and a history of Lewy Body dementia. The Level I screening was completed by a rehabilitation hospital and revealed the resident did not have a diagnosis or suspicion of Serious Mental Illness (SMI) or Intellectual Disability (ID), and a Level II PASARR evaluation was not required.An interview was conducted with the Social Service Director (SSD) on 10/2/25 at 9:33 a.m. The SSD revealed they did not do PASARRs. The SSD stated knowing how to do them but did not do them at this facility. The SSD admitted to working at the facility since July 2025 and nursing did the PASARRs, specifically the Unit Manager.An interview was conducted with Staff H, Licensed Practical Nurse/Unit Manager on 10/2/25 at 9:49 a.m. The staff member revealed they did not do PASARRs, and Social Services did them. An interview was conducted with the Nursing Home Administrator (NHA) on 10/2/25 at 9:58 a.m. The NHA reported the Director of Nursing (DON) was responsible for PASARRs but did not know if the current DON had access. The NHA stated the other past DONs had access to the PASARR system. On 10/2/25 after 10:00 a.m. an interview was attempted with the Director of Nursing (DON). The DON was unavailable for interview. Review of the policy - Resident Assessment Coordination with PASARR Program, revised/reviewed 10/2/25, showed This Facility coordinates assessments with the pre admission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs.1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities in related conditions in accordance with the State's Medicaid rules for screening.a. PASARR Level I - Initial pre-screening that is completed prior to admission: i. Negative Level I screen - permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later.ii. Positive Level I screen - Necessitates a PASARR Level II evaluation prior to admission.b. PASARR Level II - a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/ or rehabilitative services the individual needs.2. The facility will only admit individuals with a mental disorder or intellectual disability who the State mental health or intellectual disability authority has determined as appropriate for admission.6. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority.7. Recommendations, such as any specialized services, from a PASARR level II determination and/or PASARR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care.8. Any level II resident who experiences a significant change in status will be referred promptly to the state mental health or intellectual disability authority for additional resident review. Examples include:a. A resident who demonstrates increased behavioral, psychiatric, or mood-related symptoms.b. A resident with behavioral, psychiatric, or mood-related symptoms that have not responded to ongoing treatment.c. A resident who experiences an improved medical condition - such that the residents' plan of care or placement recommendations may require modifications.d. A resident whose significant change is physical, but has behavioral, psychiatric, or mood-related symptoms, or cognitive abilities, that may influence adjustment to an altered pattern of daily living.e. A resident whose condition or treatment is or will be significantly different than described in the resident's most recent PASARR Level II evaluation and determination.9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include:a. A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis).b. A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR.c. A resident transferred, admitted , or readmitted to the facility following an inpatient psychiatric stay or equally intensive treatment.

Based on observations, record reviews, and interviews the facility failed to ensure a medication error rate of less than 5.00%. Thirty-one medication administration opportunities were observed, and four errors were identified for three residents (#50, #25 and #46 ) of eight residents observed. These errors constituted a 12.9% medication error rate. 1). On 9/30/25 at 11:15 a.m. an observation of medication administration with Staff K, Licensed Practical Nurse (LPN)/Charge Nurse (CN) was conducted with Resident #50. The staff member obtained a blood glucose level from the resident. The staff member returned to the medication cart, cleaned the glucometer and reviewed the resident's insulin sliding scale order for insulin lispro. Staff K removed the resident's Kwik pen of insulin lispro [NAME] (opened 9/25), applied a needle to the cartridge and dialed the dosage selector to 8 (units). The resident was injected with 8 units into the left upper arm. An interview was conducted with Staff K immediately after returning to the medication cart. The staff member reported being educated on the use of an insulin pen, not sure of priming the pen, had been educated but could not remember. During an interview on 10/1/25 at an unknown time, the Director of Nursing (DON) reported being aware of the insulin pen not being primed and stated how do you not know about priming the insulin. 2). On 10/1/25 at 3:29 p.m. an observation of medication administration with Staff C, Licensed Practical Nurse (LPN) was conducted with Resident #25. The staff member dispensed one 6.25 milligram (mg) tablet of Carvedilol. The electronic medication profile was observed to contain parameters for the resident's Carvedilol. The staff member reported not having to take the resident's blood pressure (prior to administration) and entered the resident's room with the medication. The staff member was asked what the resident's blood pressure was and again Staff C stated not having to take the resident's blood pressure, saying, (the medication) did not have parameters. Staff C was asked to check the physician order. The staff member reviewed the resident's Carvedilol order and reported the order was to hold under (systolic) 110 or (heart rate) 60. Staff C returned to the resident and obtained a blood pressure of 130/72 and a heart rate of 55. The staff member reported having to check the order, returned to the med cart and stated the medication was to be held due to pulse under 60. The staff member documented the blood pressure and pulse. Review of Resident #25's September Medication Administration Record (MAR) showed the resident was to receive 6.25 mg of Carvedilol by mouth two times a day for congestive heart failure (CHF), hold for systolic blood pressure (SBP) less than (<) 110 or diastolic (DBP) <60 or heart rate <60. The MAR did not have a location for staff to document the resident's blood pressure prior to each dose. Review of Resident #25's progress note, effective 10/1/25 at 3:33 p.m. revealed a blood pressure of 130/72 and pulse of 55, however the note did not document whether the medication had been held due to the parameters. 3). On 10/2/25 at 7:36 a.m. a medication observation with Staff G, Licensed Practical Nurse (LPN) was conducted with Resident #46. The staff member obtained from the resident a blood pressure of 158/75, returned to the medication cart, and dispensed the following medications:- amlodipine 10 milligram (mg) oral tablet- escitalopram 10 mg oral tablet- losartan potassium 100 mg oral tablet- metoprolol tartrate 50 mg oral tablet- tizanidine 2 mg oral tablet- buspirone hydrochloride 10 mg oral tablet- morphine sulfate 30 mg oral tablet- trelegy ellipta inhaler- ipratropium/albuterol 0.5/3 mg/3 milliliter (mL)The staff member stated during the dispensing, the Buspar (buspirone) and Morphine was not showing up (on electronic medication profile) because they were 9 a.m. medications. The staff member dispensed the Morphine then obtained the narcotic count binder from the nursing station, saying it had a shower list on it, so it's everywhere. The staff member confirmed dispensing 7 oral tablets. Staff G entered Resident #46's room at 7:46 a.m., administering the inhaler trelegy, at 7:48 a.m. the staff member handed the medication cup containing the oral medications to the resident who swallowed them, the staff member opened the top of the nebulizer pipe and squirted the vial of ipratropium/albuterol into it. The staff member left the resident's room at 7:49 a.m. informing Resident #46 of returning to shut off the nebulizing machine. An interview was conducted with Staff G on 10/2/25 at 7:49 a.m. The staff member confirmed the resident's buspar and morphine were not due till 9:00 a.m. Review of Resident #46's physician orders revealed the resident's buspar was to be given twice daily at 9:00 a.m. and 5:00 p.m. The orders revealed the resident was to receive Morphine every 12 hours for pain and per Staff G's interview was scheduled at 9:00 a.m. and at 9 p.m. Review of Resident #46's progress notes, on 10/2/25 at 11:33 a.m. did not reveal the physician was notified of the early administration of buspar and/or morphine. During an interview on 10/2/25 at 11:31 a.m. the observation of medication administration was discussed with Staff H, Licensed Practical Nurse/Unit Manager (LPN/UM). The staff member stated medications are to be given one hour before and after the scheduled time. Staff H stated the observation of Resident #46's buspar and morphine were errors (due to being administered early). Review of policy - Medication Administration, reviewed/revised by the Nursing Home Administrator on 10/2/25, revealed Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The compliance guidelines included but not limited to the following:8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physicians prescribed parameters.10. Ensure the six rights of medication administration are followed: a. Right resident b. Right drug c. Right dosage d. Right route e. Right time f. Write documentation12. Compare medication source (bubble pack, vial, etcetera) with MAR to verify resident name, medication name, form, dose, route, and time.a. Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects.b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician.20. Sign MAR after administered. For those medications requiring vital signs, record vital signs on to the MAR.The policy included examples of medication timing (excluding insulin) which showed twice daily (BID) medications to be administered at 9:00 a.m. and 9:00 p.m., daily (QD) at 9:00 a.m. The policy revealed medications, including Carvedilol, which required administration after meals or with food.Review of policy - Insulin Pen, reviewed/revised by the NHA on 10/2/25 revealed It is the policy of this facility to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge. The compliance guideline included but was not limited to:6. Insulin pens will be primed prior to each use to avoid collection on air in the insulin reservoir.

Based on record review and interview, the facility failed to ensure a Notice of Medicare Non-Coverage (NOMNC) was provided to notify when Medicare covered services would terminate and inform the beneficiary of the right to appeal the decision, for three residents (#31, #40, and #55) of three residents sampled for the provision of the NOMNC.Findings included: Review of Resident #31's clinical chart, the admission record, documented an admission in 11/2024 with a readmission of 02/18/2025 with a family member designated as a responsible party. The diagnoses list included: Cerebral Infarction, Chronic Obstructive Pulmonary Disease (COPD) and Adult Failure to Thrive. Review of Resident #31's most recent quarterly Minimum Data Set (MDS) cognitive section dated 08/23/2025, revealed a Brief Interview for Mental Status (BIMS) score of six, indicated severe memory and orientation problems. Review Resident #31's medical record revealed the resident had received a Medicare Part A Skilled Services episode which started on 02/18/2025 and terminated on 04/16/2025. Review of Resident #31's electronic health record on 10/02/2025 revealed there was no presence of a Notice of Medicare Non-Coverage (NOMNC) being issued to Resident #31, or the responsible party for the notification of the termination of Medicare Part A Skilled Services which terminated on 04/16/2025. Review of Resident #40's clinical chart, documented an admission on [DATE]. The face sheet reflected a family member was designated as Resident #40's Power of Attorney (POA). The diagnoses list included Spinal Stenosis and cognitive communication deficit.Review of Resident #40's most recent quarterly BIMS cognitive section showed a BIMS score of 12, which showed moderate problems with thinking and memory. Further review of the chart reflected Resident #40 had received a Medicare Part A Skilled Services episode which started on 03/01/2025 and terminated on 04/17/2026.Review of Resident #40's electronic health record on 10/02/2025 revealed no presence of a NOMNC being issued to Resident #40 or the POA for the notification of the termination of Medicare Part A Skilled Services which terminated on 04/17/2025. Review of Resident #55's clinical chart, the admission record, documented an admission on [DATE] with a family member designated as an emergency contact. The diagnoses list included metabolic encephalopathy and acute respiratory failure with hypoxia. Further review of the chart reflected Resident #55 had received a Medicare Part A Skilled Services episode which started on 03/29/2025 and terminated on 04/16/2025. Review of Resident #55's electronic health record on 10/02/2025 revealed no presence of a NOMNC being issued to Resident #55 or the family member for the notification of the termination of Medicare Part A Skilled Services which terminated on 04/16/2025. During an interview conducted on 10/02/2025 at 10:57 a.m. the Social Service Director stated, the NOMNC for the three residents requested, does not exist. I will ask for medical records, but I did not find a copy of the NOMNC in the electronic health record.There was no further documentation presented by the facility during the survey that would support Resident #31, #40, and #55, had received a NOMNC to detail when the Medicare-covered services would terminate and inform the beneficiary the right to appeal the decision.The facility did not provide a policy or procedure for NOMNC notifications.

Based on observations, record reviews and interviews the facility failed to obtain an accurate Preadmission Screening and Resident Review (PASARR) for one resident (#9) of twenty-five sampled residents. Findings included: Review of Resident #9's Preadmission Screening and Resident Review (PASARR) dated 1/2/20, revealed the resident had alcoholism and history of Lewy Body dementia. The screening showed the resident did not have a diagnosis or suspicion of Serious Mental Illness (SMI) or Intellectual Disability (ID) and a Level II PASARR evaluation was not required. The Level I screening was completed by a rehabilitation hospital. Review of Resident #9's admission Record showed the resident was admitted on [DATE] and readmitted on [DATE]. The record revealed the resident's principal diagnosis on 10/21/24 was neurocognitive disorder with Lewy bodies and included diagnoses of cognitive communication deficit (onset 6/19/23), unspecified schizoaffective disorder (onset 6/9/23), not otherwise specified mental disorder (onset 10/25/23), generalized anxiety disorder (1/4/20), unspecified single episode major depressive disorder (onset 1/4/20), alcohol dependence in remission (onset 10/21/24), and unspecified mood (affective) disorder (onset 9/27/23). Review of Resident #9's psychiatric note, dated 7/10/25, showed a Gradual Dose Reduction (GDR) was not to be attempted and was clinically contraindicated. The note included diagnoses of generalized anxiety disorder, major depressive disorder recurrent severe without psych features, unspecified schizoaffective disorder, and alcohol dependence in remission. An interview was conducted with the Social Service Director (SSD) on 10/2/25 at 9:33 a.m. The SSD revealed they did not do PASARRs. The SSD stated knowing how to do them but did not do them at this facility. The SSD admitted to working at the facility since July 2025 and nursing did the PASARRs, specifically the Unit Manager.An interview was conducted with Staff H, Licensed Practical Nurse/Unit Manager on 10/2/25 at 9:49 a.m. The staff member revealed they did not do PASARRs, and Social Services did them. An interview was conducted with the Nursing Home Administrator (NHA) on 10/2/25 at 9:58 a.m. The NHA reported the Director of Nursing (DON) was responsible for PASARRs but did not know if the current DON had access. The NHA stated the other past DONs had access to the PASARR system. On 10/2/25 after 10:00 a.m. an interview was attempted with the Director of Nursing (DON). The DON was unavailable for interview. Review of the policy - Resident Assessment Coordination with PASARR Program, revised/reviewed 10/2/25, showed This Facility coordinates assessments with the pre admission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs.1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities in related conditions in accordance with the State's Medicaid rules for screening.a. PASARR Level I - Initial pre-screening that is completed prior to admission: i. Negative Level I screen - permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later.ii. Positive Level I screen - Necessitates a PASARR Level II evaluation prior to admission.6. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority.9. Any resident who exhibits A newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include: a. A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis).b. A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR.c. A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR.

Based on interviews and record review, the facility failed to thoroughly investigate a voiced grievance for one resident (#3) out of four sampled residents. Findings included:On 07/24/2025 at 02:35 P. M., a phone interview was conducted with Resident #3's family member. She stated she was unable to speak with the Nursing Home Administrator (NHA), via phone call because she could not be reached. She stated she was able to communicate with the NHA through text messaging. She stated she had concerns about the care her family member was getting and she notified the NHA of her concerns. She stated the NHA was dismissive of her. She stated she never heard from the facility with what happened. Review of Resident #3's medical records revealed she was admitted to the facility on [DATE], with a discharge date of 07/16/2025 to another facility. Diagnoses for Resident #3 included: wedge compression fracture of vertebra, and depression. A review of the progress notes revealed the following: 6/19/2025 12:01 Communication with FamilyNote Text: : On this day writer spoke with [family member]. [Family member] stated that resident's former roommate was screaming and yelling in the background while resident was on the phone with her and provider . [Family member] stated she did not appreciate the other resident's behavior and requested facility to move the other resident from near [Resident #3's] room .An interview was conducted on 07/24/2025 at 01:11 P. M., with the Social Services Director. She stated any needs or wants of residents go through her department and she makes sure grievances are resolved in a timely manner. She stated there were no grievances documented, related to Resident #3 for the month of June. She stated if a concern is raised by a resident, family member, or staff member in relation to a resident, then a grievance needs to be filed. She stated this applies to the Administrator and the Director of Nursing, (DON) as well.A review of grievance logs for the month of June 2025, revealed no grievances were filed related to Resident #3.On 07/24/2025 at 02:00 P. M., an interview was conducted with the Nursing Home Administrator (NHA). She stated in the month of June, around the sixteenth, she spoke with Resident #3's family member. She stated she told the family member she would look into the concerns. She stated she did not file a grievance and had no documentation to support an investigation into the family's concerns. She stated in lots of cases a concern is not considered a grievance unless it happens more than once.On 07/24/2025 the NHA provided the Resident and Family Grievances, policy for review, with a last revision date of 4/21/25, The policy revealed the following: Policy: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. Definitions: Prompt efforts to resolve include facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance. Policy Explanation and Compliance Guidelines:1. (Name and Title) has been designated as the Grievance Official and can be reached at (list contact information).2. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations.4. A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their LTC facility stay.8. Grievances may be voiced in the following forums: Verbal complaint to a staff member or Grievance Official. b. Written complaint to a staff member or Grievance Official. C. Written complaint to an outside party. d. Verbal complaint during resident or family council meetings. e. Via the company toll free Customer Service Line (if applicable).10. Procedure: e. The Grievance Official, or designee, will keep the resident appropriately apprised of progress towards resolution of the grievances. f. The facility will take appropriate action in accordance with State law if an alleged violation of resident's rights is confirmed by the facility or an outside entity, such as State Survey Agency, Quality Improvement Organization, or local law enforcement agency. g. In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. The written decision will include at a i. The date the grievance was received. ii. The steps taken to investigate the grievance. iii. A summary of the pertinent findings or conclusions regarding the resident's concern (S). iv. A statement as to whether the grievance was confirmed or not confirmed. v. Any corrective action taken or to be taken by the facility as a result of the grievance. vi. The date the written decision was issued.

Based on resident record review, resident and staff interviews, observations, and policy and procedure review, the facility did not ensure an injury of unknown origin was thoroughly investigated in a timely manner for one resident (#1) of three residents reviewed for alleged violations of abuse and mistreatment. Findings included: Review of the record for Resident #1 revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disorder and anxiety; anxiety disorder; major depressive disorder; other specified persistent mood disorders; pain, unspecified; polyneuropathy; and unspecified mood affective disorder. Review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 5 out of 15, indicating severe cognitive impairment. The assessment revealed Resident #1 required substantial/maximum assistance for toileting hygiene. A review of Resident #1's care plan revealed a Focus, Resident #1 is at risk for recurring skin tears and bruising due to fragile skin, initiated 9/13/23 and revised 4/29/24. Interventions included use caution during transfer to reduce risk for recurring injuries. During an observation and interview on 4/17/25 at 11:00 am., Resident #1 was observed lying down in bed covered in her blanket. She was observed with a bandage on her top right forehand above her right eye. She had a black and blue colored bruise about two to three inches underneath her right eye. Resident #1 had purple and black colored bruising on her right shoulder and purple colored bruising on the top of her right hand. Resident #1 stated the bruise on her face came from a fall she had when she tried to get out of bed. She stated she was not able to remember how she got the bruise on her right hand. Review of Resident #1's nursing notes dated 4/11/25 at 6:42 p.m. and authored by Staff C, Licensed Practical Nurse (LPN), revealed: Note Text: Writer was coming out of another resident's room and overheard the patient screaming and fighting with the patient (sic). Writer went in resident's room to assess what was going on and the nursing aids were trying to change the patient and the patient was resisting and telling them in Greek not to touch her and to call her son. She also reported her right hand was hurting. Patient was offered pain medication but the patient declined. NP (Nurse Practitioner) and Unit manager were notified of the incident and pending orders from NP. The nursing notes also revealed a late entry nursing note authored by Staff C, LPN, created on 4/18/25 at 11:31 a.m., with an effective date of 4/11/25 at 6:42 p.m. The note revealed: Late entry, April ,2024 (sic) at 1842 pm. Writer intervened as the nurse in charge upon assessing patient noticed slight discoloration of right hand, patient was also holding hand and saying she was in pain. Writer offered the patient Tylenol for pain management, however patient declined, writer then offered an ice pack, however patient refused and was upset and requested that this writer and nursing assistant leave the room. Writer and nursing assistant left the room as requested by patient. An interview was conducted with the Interim Director of Nursing (DON) and Interim Nursing Home Administrator (NHA), on 4/17/25 at 12:15 p.m. The DON stated she investigated the incident involving Resident #1, checked on the resident, and saw the physician ordered an x ray. The DON stated Resident #1 is alert and confused but does not like to be changed and when they put her in bed she complained of pain to her right hand. The DON stated she interviewed the nurse involved, but not the CNAs involved in the incident. She stated she should have interviewed the CNAs and she was waiting for them to get back to her, but they did not called her back. The NHA stated to the DON, I asked you to get a statement from the CNAs. The DON replied, I didn't get statements, they didn't get back to me. During the interview, the DON could not recall the CNAs names involved in the incident with Resident #1. The DON stated the nurse told her they were changing Resident #1, she had a push back, and she complained of pain in her right hand. The DON stated she didn't get the whole story and she could not determine if Resident #1 was injured or abused by the CNA and it is still an open investigation. An interview was conducted with Staff D, LPN Unit Manager (UM) on 4/17/25 at 1:09 p.m. Staff D, LPN UM, stated the event with Resident # 1 happened on a Friday night and she had a bruise from the incident, so he obtained an order for an x-ray. He stated he received a phone call around 6:30 p.m. or 6:45 p.m., on 4/11/25 from the 3-11 p.m. nurse, who told him, during care, Resident #1 was swatting at the CNAs and complained of pain on her hand. Staff D, LPN UM stated the CNA involved was Staff A, CNA and this occurred while she was trying to change the resident. He stated he texted the Director of Nursing (DON) following the incident to inform her. An interview was conducted with Staff C, LPN on 4/17/25 at 1:33 p.m. She stated she was assisting a patient in another room and then she was coming out of the other room she heard Resident #1 yelling get out leave me alone. She stated Staff A, Certified Nursing Assistant (CNA) and Staff B, CNA were trying to change Resident #1 and she was swatting at them. Staff C, LPN stated, I don't know what she hit or what happened to her hand. She kept screaming her hand her hand. Staff C, LPN stated her nursing note on 4/11/25 should have documented the patient was screaming and fighting with a CNA, not a patient. Staff C, LPN stated she talked to Staff A, CNA, but did not talk to Staff B, CNA about what occurred. The staff member stated she tried to talk to Resident #1, however, she was irate and yelling in Greek. She stated she reached out to the provider to obtain an order for an X ray. A phone interview was conducted with Staff B, CNA, on 1/17/25 at 2:20 p.m. Staff B, CNA stated she was in the shower area with another resident and the resident's family member, when the family member told her she was hearing screams and someone yelling stop, get away. She stated she went into Resident 1#'s room and observed Resident #1 lying in her bed and Staff A, CNA, was trying to change her. She stated Resident #1 was yelling, telling Staff A, CNA to get away, and was flapping her arms at her. She stated Staff A, CNA grabbed Resident #1's hand in a gentle way and Resident #1 was crying. Staff B, CNA stated she told Staff A, CNA, to leave the room. She stated Resident #1 kept saying Staff A, CNA hurt her hand as she continued to cry. Staff B, CNA stated nobody from the facility asked her to write a statement relating to the incident. A follow up interview was conducted with Staff C, LPN, on 4/17/25 at 4:24 p.m. She stated Resident #1 was telling them get out and when she entered the room, Resident #1 was crying and stated her hand was hurting. Staff C, LPN asked the resident what happened and the resident answered in Greek. Staff C, LPN asked Staff A, CNA, what happed and she stated she was trying to change Resident #1. Staff C, LPN asked Staff B, CNA about the incident and Staff B, CNA stated she was not sure if Resident #1 hurt her hand by swinging it or when they rolled the resident onto her side. Staff C, LPN informed Staff D, LPN Unit Manager of the incident. An interview was conducted with Staff E, MDS Coordinator, on 4/18/25 at 10:09 a.m. Staff E, MDS stated she saw the nursing note written by Staff C, LPN and contacted the Interim Administrator and the Interim DON on 4/12/25 in the morning. She stated she told then there was an issue and they need to look at the note in the chart for Resident #1. Review of an undated facility policy and procedure entitled Abuse, Neglect and Exploitation revealed the following: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. V. Investigation of Alleged Abuse, Neglect, and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, is warranted when suspicion of abuse neglect or exploitation, or reports of abuse, neglect of exploitation occur. B. Written procedures for investigation include: 1. Identifying staff responsible for the investigation; . 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and /or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation.

Based on observation, record review and interview the facility failed to ensure food was labeled and dated when stored in the walk-in refrigerator, the walk-in refrigerator log was completed daily and the dishwasher was functioning properly in accordance with professional standards for food service safety in one of one kitchen with the potential to affect 51 of census of 52 residents. Findings included: An observation on 09/18/23 7:00 a.m. revealed food items located in the kitchen's walk-in refrigerator were not labeled and dated. The food items not labeled or dated included: (Photographic Evidence Obtained) - metal container of white thick gravy - metal container of brown thick gravy - A bag of 10 eggs - A bag of six rolls - A bag of cut broccoli - A bag of approximately 12 hot dogs - A wrapped up cucumber - Two heads of lettuce. During an interview on 09/18/23 at 7:05 a.m. Staff D, Dining Room Manager (DRM) confirmed the food items were not labeled or dated. Staff D, DRM stated that all food should be labeled and dated before being stored in the walk-in refrigerator. An observation on 09/18/23 at 7:07 a.m. showed the walk-in refrigerator temperature monitoring log was not completed for 09/17/23. (Photographic Evidence Obtained) During an interview on 09/18/23 at 7:08 a.m. Staff D, DRM stated, The refrigerator temp (temperature) log should have been completed for yesterday, and confirmed the log was incomplete. An observation on 09/18/23 at 7:15 a.m. revealed steam rising up from the floor around the dishwasher. The hot water from the dishwasher was observed not draining down the designated hole below the dishwasher and was flooding the floor. The hot water was observed flooding the floor from the clogged designated drain and flowing down another drain located in front of the dishwasher. During an interview on 09/18/23 at 7:20 a.m. Staff E, Dietary Staff (DS) stated, It doesn't normally overflow, but maintenance continues to try to fix it. Staff E, DS was observed turning down the water flow to the dishwater with a water valve above the dishwasher on the wall. Staff E, DS stated he turned down the water flow to the dishwasher to help keep it from flooding the floor. A review of the facility's policy titled, Food Receiving and Storage, revised date July 2014, showed, 7. All foods stored in the refrigerator or freezer will be covered, labeled, and dated. 13c. Refrigerators must have a working thermometers and be monitored for temperatures according to state specific guidelines.

Based on observation, record review and interview the facility failed to ensure a safe, clean and homelike environment for six resident rooms (#200, #202, #207, #212, #213, and #224) of 22 rooms in the facility. Findings included: 1. An observation on 09/18/23 at 3:34 p.m. of Resident room [ROOM NUMBER] revealed: (Photographic Evidence Obtained) - Multiple ceiling tiles throughout the room were separate or disconnected from the rest of the ceiling. - The air vent located near the door had dust build up in the vent. - Wallpaper was torn and missing around the air vent. - Ceiling tiles had bio growth that discolored areas of the tiles. - A white garbage bag with multiple gnats flying in and around the bag was located on the top of a clothing armoire. During an interview on 09/20/23 at 2:00 p.m. the Director of Nursing (DON) and Assistant Director of Nursing/Unit Manager (ADON/UM) observed the bag of gnats in Resident room [ROOM NUMBER]. ADON/UM looked at the bag of gnats and stated, .I hate bugs. The DON stated this bag of gnats would need to be disposed of and she would go get a garbage bag for proper disposal. ADON/UM stated someone must have left food or something in that bag and it must have been up there for a while. The DON was unaware of how long the bag had been stored on top of the armoire. During an interview on 09/20/23 at 5:08 p.m. the Central Service Director (CSD) stated housekeeping should be checking and cleaning high and low areas of resident rooms daily. The CSD stated housekeeping would also be responsible for dusting the air vents in resident rooms. The CSD toured Resident room [ROOM NUMBER] and stated, room [ROOM NUMBER] was not very pretty. The CSD stated the area around the air vent needed to be replaced, the tiles needed to be replaced and the area around the air vent would also need to be disinfected. The CSD stated room [ROOM NUMBER] would also need maintenance to look at why the ceiling was slipping and replace the defective tiles and fix the slipping issue. The CSD stated housekeeping would need to be dusting the vents and the wallpaper around the air vent would need to be replaced. 46234 2. An observation was made on 9/18/23 at 7:09 a.m. in Resident room [ROOM NUMBER] of a sheet spread on the floor just inside the doorway. The sheet was completely soaked with water. An unnamed staff member passed and said the air conditioning vent had been leaking there for a couple of days. On 9/18/23 at 7:17 a.m. the sheet on the floor had been replaced with a dry blanket and trash can to catch the water. On 9/20/23 at 11:51 a.m. maintenance was observed to be in Resident room [ROOM NUMBER] working on the air conditioning vent leak. The two residents in room [ROOM NUMBER] had just been served their lunch trays and were eating while maintenance was continuing to work. At this time the DON was in the room and she observed maintenance working while residents were eating lunch. She confirmed the work should have stopped when it was time for the residents to eat. (Photographic Evidence Obtained) 3. An observation was made on 9/18/23 at 7:11 a.m. of items including a bed, two chairs, two shelves, boxes, wheelchair, and a prosthetic leg piled in the hallway. On 9/18/23 at 8:22 a.m. those items were observed to be in Resident room [ROOM NUMBER]. On 9/19/23 while eating lunch, the resident in room [ROOM NUMBER] said he wished they would move the stuff out of his room, pointing to the shelves, boxes, and prosthetic leg piled on the bed across from him. (Photographic Evidence Obtained) 4. An observation was made on 9/18/23 at 1:16 p.m. in Resident room [ROOM NUMBER] of a hole in the wall with a water stain. The water stain has bio-growth on it. This hole and stain are just to the right as you walk in the resident's room. (Photographic Evidence Obtained) An interview was conducted on 9/20/23 at 4:58 p.m. with the CSD. She confirmed the vent in Resident room [ROOM NUMBER] had been leaking for four days and they were trying to figure out the problem. She said it should have never been set up with a sheet/blanket and can to catch the water. The CSD said it was brought to her attention that maintenance was working in the room while residents were eating. She said that should not have happened and she would be educating staff. 46498 5. During a facility tour on 09/18/23 at 10:00 a.m. Resident room [ROOM NUMBER] was observed with loose toilet rails attached to the resident's toilet inside the bathroom. 6. During a facility tour on 09/18/23 at 10:15 a.m. Resident room [ROOM NUMBER] was observed with an extension cord with other electronics plugged into the cord on a resident's bed while the resident was resting in bed. During an interview on 09/20/23 at 4:47 p.m. the CSD confirmed managing both the facility's housekeeping and maintenance departments and that she was unaware the toilet grab bars in the bathroom of Resident room [ROOM NUMBER] were loose. She said it was a safety issue for the facility and the residents. The CSD said the maintenance worker was expected to make rounds in the facility and check to make sure things, like resident grab bars, ceiling tiles, etc., are in good functioning order. The CSD said residents should not have power cords in their bed because it was a safety issue. A review of the facility policy titled, Physical Environment, undated, revealed: It is the policy of the facility to provide care and services related to Physical Environment. A review of the facility policy titled, Resident Rooms, undated, revealed: It is the policy of the facility to provide areas large enough to comfortably accommodate the needs of the residents who usually occupy this space, in accordance to State and Federal regulations. 3. The facility will provide each resident with: d. Functional furniture appropriate to the resident's needs. A review of the facility policy, titled, Safe Environment, undated, revealed: It is the policy of the facility to provide a safe environment in accordance to State and Federal regulation. 1. The facility will be designed, constructed, equipped and maintained to protect the health and safety or residents, personnel, and the public.

Based on observation, interview, and record review, the facility failed to maintain confidentiality of Protected Health Information (PHI) related to a bulletin board located in one of one nurses' station for a census of 52 residents related to having Do Not Resuscitate (DNR), mobility, tube feeding, and dialysis status being visible and accessible to visitors, residents, and staff members. The information was displayed at the nurse's station and the East Wing hallway bulletin board. Findings included: An observation on 09/19/23 at 9:00 a.m., behind the nurses' station located between the east and west wing, revealed a cart that contained all of the resident charts that showed the resident's name, room number and status of Do Not Resuscitate (DNR) for twenty-eight residents. (Photographic Evidence Obtained) An additional observation on 09/19/23 at 9:00 a.m. revealed a bulletin board located on the East Wing hallway with a sign titled, 11-7 Get Up List and displayed two columns labeled as Dependent and Independent. This list showed resident room numbers, their first names and last names. In addition, a document titled, Master Diet Type 9/18/2023 was observed on the bulletin board and contained pages of information listing resident names with their room numbers, diet type, diet texture, fluid consistency, and additional directions (identifying tube feeds and dialysis status). (Photographic evidence obtained) During an interview on 09/20/23 at 3:52 p.m. Assistant Director of Nursing/Unit Manager (ADON/UM) stated the facility protects resident PHI by locking computer screens and turning papers with PHI upside down when not in use. ADON/UM confirmed information regarding a resident's DNR, mobility, dialysis and enteral feeding statuses is considered confidential. During an interview on 09/20/23 at 4:22 p.m. the Director of Nursing (DON) stated all staff receive Health Insurance Portability and Accountability Act (HIPAA) training at the beginning of their employment and confidentiality of PHI is emphasized. The DON confirmed a resident's DNR, mobility, dialysis and tube feeding status are PHI. Immediately following the interview, an observation was conducted with the DON of the cart with resident charts and of the bulletin board on the East Wing hallway with the 11-7 Get Up List and Master Diet Type 9/18/2023 document. The DON immediately removed the 11-7 Get Up List from the bulletin board. A review of a policy titled, Resident Respect, Dignity, and Confidentiality approved January 26, 2016, revealed: Confidentiality: Treat Resident information as confidential by all staff members and do not disclose without first obtaining permission from the resident/ responsible party. Procedures: 3. Staff will receive training on HIPAA and resident information confidentiality requirements. A review of facility policy titled, Staff Education, approved January 26, 2016, revealed: Orientation Process All employees of [facility Name] are trained in the initial orientation process with human resources covering a minimum but not limited to the following: M. HIPAA.

Based on record review and interview the facility failed to accurately assess a discharge on the Minimum Data Set (MDS) for one resident (#56) of three residents reviewed for transfer and discharge. Findings included: A review of Resident #56's Admission Record showed Resident #56 was admitted to the facility with diagnoses of Parkinson's Disease, dysphasia, pneumonitis and dysphonia. A review of the Discharge Return Not Anticipated MDS, dated [DATE], showed in Section A 2100 Discharge Status that Resident #56 was discharged to an Acute hospital. Review of a physician order, dated 07/19/23, showed, discharge to apartment in Assisted Living Facility. Review of a Plan of Care Note, dated 6/28/2023, showed, Care plan meeting held with IDT (interdisciplinary team), [spouses] they are both residents at facility, plan for residents to transition back to ALF (assisted living facility). Review of a Discharge Summary, dated 07/19/23, showed, Resident discharged to upstairs apartment. Resident assisted by CNAs (certified nursing assistants). All personal effects given. Medications sent upstairs. During an interview on 09/20/23 at 10:40 a.m. Staff F, MDS Coordinator (MDSC) stated Resident #56 was discharged upstairs to an assisted living apartment on 07/20/23. Staff F, MDSC reviewed Resident #56's MDS Discharge Return Not Anticipated, dated 07/20/23. Staff F MDSC stated Section A 2100 showed Resident #56 was discharged to an acute hospital which was wrong. Staff F MDSC stated, Oh that is an error, it must be a computer glitch, as Resident #56 was discharged upstairs to the assisted living community. Staff F, MDSC was observed immediately modifying Resident #56's MDS Discharge Return Not Anticipated, dated 07/20/23, during the interview.

Based on observation, record review and interview the facility failed to revise the person centered care plan to reflect the use of the word mama to communicate and identify the needs by one resident (#37) with communication limitations of thirty-two residents sampled. Findings included: On 9/18/2023 at 7:00 a.m. Resident #37 was observed laying down in bed dressed in her nightgown, with her bedside table next to her bed. Resident #37 was not able to communicate when she was asked questions. On 9/20/2023 at 3:45 p.m. Resident #37 was observed laying down in bed dressed in her nightgown, trying to express herself, but was unable to communicate her needs. A review of the Admission Record revealed Resident #37 was admitted to the facility on [DATE], with diagnoses to include hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia following cerebral infarction, altered mental status, unspecified and adult failure to thrive. A review of the Minimum Data Set (MDS), dated [DATE], Section C - Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of no score recorded in Section C0500. Further review of the MDS Section C100 - Cognitive Skills for Daily Decision Making revealed a score of 3 indicating Resident # 37 was severely impaired. A review of a care planned Focus, dated 4/13/2023, revealed Resident #37 had a communication problem r/t (related to) Expression Aphasia post Cerebral Vascular Accident, CVA. A review of the care plan goal was documented as staff would anticipate and meet needs of Resident #37. Interventions included to encourage resident to make needs known through nonverbal communication as able. Pointing at objects, nodding head, Observe for verbal and nonverbal s/s (signs/symptoms) of pain or discomfort i.e. facial expression, crying out, moaning, grimacing, restlessness, protective body. During an interview on 9/20/2023 at 9:00 am., Staff B, Certified Nursing Assistant (CNA) said when she was distributing breakfast trays to resident rooms, she overheard Resident #37 shouting out for her mama from her room. When she went to check on the resident, she said Resident #37 was lying in bed soaking wet from the night shift. Staff B said Resident # 37 was unable to communicate her needs, but she calls out for her mama and that's how she knows something is wrong. She stated if she was not a regular staff member, she wouldn't know the resident needed help when she calls out for her mama. During an interview on 9/20/2023 at 11:25 p.m. with Staff G, CNA said she's takes care of Resident #37 and she's able to understand what the resident wants most of the time, and especially when she uses the word mama. She said if she never worked with the resident before she would not know the resident needed something when she calls out for her mama. Staff G said she doesn't get the resident out of bed because she knows the resident doesn't like to get up. During an interview on 9/20/2023 at 2:45 p.m. the Assistant Director of Nursing/Unit Manager (ADON/UM) said Resident #37 calls out for her mama whenever she needs something. The ADON/UM said the word mama should be care planned because they use agency staff a lot and it would help them to identify Resident #37 has a need. A review of the facility policy, titled, Care Plan, Comprehensive Person- Centered, revised December 2016, showed: Policy Statement - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident . 8. The comprehensive, person - centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being.

Based on record review and interview and facility failed to refer three residents (#18, #30 and #45) of four residents for a Level II Pre-Admission Screening and Resident Review (PASARR) upon a significant change in status assessment. Findings included: 1. A review of Resident #30's Admission Record showed Resident #30 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy, neurocognitive disorder with Lewy Body Dementia, generalized anxiety disorder and major depressive disorder, single episode. Resident #30 was later diagnosed with schizoaffective disorder on 06/09/23. Review of Resident #30's Level I Pre-Admission Screening and Resident Review (PASARR), dated 01/02/20 showed, Resident #30 had Lewy Body Dementia and was marked No diagnosis or suspicion of Serious Mental illness or intellectual disability indicated. There was no PASARR referral for a Level II PASARR upon new diagnosis of schizoaffective disorder on 06/09/23. 2. A review of Resident #45's Admission Record showed Resident #45 was admitted to the facility on [DATE] with diagnoses of dysphagia, paralysis of vocal cords and larynx, and chronic atrial fibrillation. Resident #45 was later diagnosed with major depressive disorder, recurrent, mild on 08/16/21 and dementia, unspecified severity with agitation on 02/20/23. Review of Resident #45's Level I PASARR, dated 08/10/21, showed, Resident #45 had a psychotic disorder with multiple questions marked yes in Section II for decision making. There was no PASARR referral for a Level II PASRR upon new diagnosis of dementia, unspecified severity with agitation on 02/20/23. 46498 3. A review of Resident #18's Admission Record revealed she was admitted to the facility on [DATE], with diagnoses to include major depressive disorder, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. A review of the PASARR Level I Screen, dated 6/30/21, Section I - Decision Making A. and B, revealed it was not completed to reflect Resident #18's mental illness. During an interview on 09/19/23 at 3:00 p.m. Director of Nursing (DON) stated that Residents #18, #30 and #45's PASARRs should have been updated to show the new diagnosis of serious mental illness after admission and submitted for a Level II. The DON stated the facility had never really had a process for PASARRs before besides just reviewing them upon admission, but the facility will now develop a PASARR process. A review of the policy title, Coordination-Pre-admission Screening and Resident Review, undated showed, 2. b. Referring all Level II residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for Level II resident review upon a significant change in status assessments.

Based on observation, record review and interview the facility failed to ensure one resident (#209) of six residents observed for in-room dining and two residents (#4 and #26) of nine residents observed for communal dining received a dignified dining experience. Findings included: 1. An observation, on 09/18/23 at 4:43 p.m. showed Resident #209 sat in her wheelchair at a bedside table and stated, I am hungry. Resident #209's roommate was observed with a dinner tray eating as Resident #209 watched her roommate eat dinner. Resident #209 stated her tray always came late and on a different cart. Resident #209 stated she had been receiving her tray later, after her roommate was served, since being admitted to the facility three days ago. (Photographic Evidence Obtained) During an interview on 09/18/23 at 4:45 p.m. Staff A, Licensed Practical Nurse (LPN) stated the tray pass was a problem around here. Staff A, LPN stated food should be delivered to roommates together but that did not always happen because the trays came on different carts at different times. An observation on 09/18/23 at 5:01 p.m. showed Resident #209 received her dinner tray at 5:01 p.m. A review of Resident #209's Admission Record showed Resident #209 was admitted to the facility on [DATE] with diagnoses of cellulitus of lower left leg, urinary tract infection, left hip pain and an unspecified open wound. A review of the Minimum Data Set (MDS), dated [DATE], showed in Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). Review of an active physician order, dated 09/15/23, showed, Regular diet, regular texture, thin consistency. 2. An observation on 09/19/23 at 11:58 a.m. showed Residents #22, #40, #26 and #4 were all seated together at a table in the dining room. Resident #22 and Resident #40 were observed with their lunch trays eating while Resident #26 and Resident #4 had no lunch tray. Resident #26 and Resident #4 were observed watching Resident #22 and #40 eat while they waited on lunch trays. An empty tray cart was sat in the dining room where all the lunch trays had been distributed from. At approximately 12:06 p.m. a second tray cart arrived in the dining room and Resident #26 and Resident #4 were then served their lunch trays. (Photographic Evidence Obtained) During an interview on 09/20/23 at 12:56 p.m. Staff B, Certified Nursing Assistant (CNA) stated staff served food trays off the tray carts based on availability. Staff B, CNA stated the kitchen puts the resident trays on the cart and we serve them as they come. Staff B, CNA stated there are times when residents are not served at the same time because that is how the kitchen sent the trays up. Staff B, CNA stated sometimes residents have to wait on their trays when others, at the same table or their roommates, would be served and already eating. During an interview on 09/20/23 at 1:05 p.m. Staff C, CNA stated the facility's policy was for all residents to be served per table or room together (at the same time). A review of the facility's policy, Dining Room Audits, revised date 01/2009, showed, Policy Statement Our facility audits food service department regularly to ensure that residents needs are met and that dining is a safe and pleasant experience for residents. The auditor will assess: d. If residents at each table are served together.

Based on interviews with the facility's nursing and administrative staff, a family member, the facility Medical Director, and a review of clinical and hospital records and facility policies and procedures, it was determined that facility administration failed to utilize resources effectively and efficiently to protect the rights for one (#1) of 7 sampled residents related to the resident's right to receive cardiopulmonary resuscitation (CPR) in the case of a cardiopulmonary arrest. Facility administration failed to ensure that Resident #1's expressed wishes for end of life decisions were honored, and CPR was provided at the time of Resident #1's death. Facility administration failed to ensure that the policies and procedures were put in place, and Resident #1's advance directive regarding code status was identifiable in case of cardiopulmonary arrest. Resident #1 was readmitted to the facility after an 8- day hospitalization and approximately sixteen hours later was noted to be absent of pulse or respirations. The facility failed to initiate CPR because the admission paperwork was not completed, and the licensed nurse that was assigned to Resident #1 could not locate any documentation that indicated CPR should be performed per Resident #1's wishes. The failure of administration to utilize available resources effectively and efficiently for the appropriate identification of advance directives at the time of Resident #1's death represented a system wide failure that could also lead to failure to honor a Do Not Resuscitate order when wanted by a resident. This resulted in findings of Immediate Jeopardy, past non-compliance, on [DATE]. The Immediate Jeopardy was determined to be corrected on [DATE] prior to the survey. Findings included: In a review of the job description for Rehab Administrator, dated August, (YEAR), included under, Essential Functions of the Job: .Implement personnel policies and procedures and assure compliance by staff. Hire, train, motivate, supervise and evaluate Rehab Department personnel. Assure quality patient care is provided consistent with company policies and budget objectives. Ensure that facility meets the company's established standards as well as standards of accreditation established by licensing and certification agencies . Further review also included, As an essential function of the job, the Rehab Administrators are regularly called on to effectively report emergencies such as resident's condition changes, as well as accidents and incidents, complaints and grievances by residents and their families, etc. It is determined that Rehab Administrator has the ability to communicate with others and do not pose a direct threat to the safety or health of self or others. On [DATE] at 1:23 p.m., a telephone interview was conducted with Resident #1's daughter. She stated that it was her mother's wishes to receive CPR if her heart stopped. Since her mother's dementia had worsened, it was also her wish, as the responsible party, that her mother receive CPR if her heart stopped beating. She confirmed that there were NO Do Not Resuscitate orders. She stated that she was aware that her mother did not receive CPR when she passed away, and she heard it was because the nurse that was caring for her said that it was too late to administer CPR when it was finally noted that she was no longer breathing. A review of Resident #1's clinical record revealed a face sheet that indicated an original admission to the facility on [DATE], and was most recently re-admitted on [DATE]. Resident #1's daughter was listed as the responsible party and emergency contact. Further review included a nursing entry that was dated the day after re-admission, [DATE] at 7:30 a.m., which indicated Resident #1 had died . Medical [DIAGNOSES REDACTED]. The Medical Certification and Medicaid Transfer Form (AHCA form-3008) dated [DATE] included under H. Advance Care Planning: Do Not Resuscitate (DNR), and this was checked NO. Additional review of the nursing assessment dated [DATE] indicated under Neurological that Resident #1 was alert and appropriate, but was oriented to person only. A review of Resident #1's hospital record revealed a Discharge Summary that included an admitted for Resident #1 of [DATE] and a discharge date of [DATE]. Under History of Present Illness the physician stated, .multiple frequent admissions to the hospital from the (skilled) nursing facility, consulted Palliative Care multiple times to address code status since family requested FULL CODE with frequent admissions. Further review included a History and Physical for the admission date of [DATE] and under History of Present Illness included: Recently I consulted palliative care to get help with the code status. Do not resuscitate could not be obtained. Further review of Resident #1's clinical record and nursing notes included an entry dated [DATE] at 7:40 a.m. that stated, During resident care, (Resident #1) found at 5:30 a.m. unresponsive, without vitals. Confirmed absence of vitals with second nurse. On-call doctor called back and confirmed record of death. Power of Attorney (POA) and funeral home contacted. Resident's body removed at 7:30 a.m. There was no documentation that CPR or any lifesaving interventions were provided to resuscitate Resident #1 as per her wishes. On [DATE] at 3:10 p.m., an interview was conducted with the Director of Nursing (DON). She stated that if a resident had indicated that they did not want to be resuscitated, then a Do Not Resuscitate (DNR) order form was placed on the clinical record. If a resident or their responsible party had chosen not to complete a DNR order, then CPR should be performed. She confirmed that this information should be readily available to the nurse at all times. She stated if a resident was found without pulse or respirations, a licensed nurse should check the electronic record and then the paper record for code status, and proceed accordingly. The DON stated that this should only take a few seconds, and may be done by a secondary nurse at the assigned nurse's direction. The DON was asked about the incident with Resident #1 on [DATE]. The DON said that she was notified by Nurse B, on the morning of [DATE], that Resident #1 did not receive CPR as per her wishes. She stated that Nurse B, who worked the 7:00 a.m. to 3:00 p.m. shift on [DATE], was given report by Nurse A, who had been assigned to Resident #1 for the preceding 11:00 p.m. to 7:00 a.m. shift. She stated that Nurse A told Nurse B that Resident #1 had passed away and no resuscitative attempts had been provided, but Nurse B was familiar with the resident, and knew that she had wanted CPR, so Nurse B brought this to the DON's attention immediately. She confirmed that Nurse A noted that Resident #1 was not breathing at 5:30 a.m. on [DATE]. The DON stated that Nurse A said that he did not do CPR because the resident was already cold to touch, and Nurse A had felt that it was too late to perform CPR. She confirmed that there was no policy or procedure that indicated it was acceptable for a nurse not to attempt CPR, if the nurse thought that it was too late. She confirmed that not performing CPR was a violation of Resident #1's rights. The DON stated that she immediately began an investigation, which included the required reporting. She stated the investigation revealed that Resident #1's admission paperwork, which included Form 3008 indicated she was to receive CPR in case of cardiopulmonary arrest, was not uploaded into the electronic record, and no clinical record had been created for Nurse A to reference Resident #1's end of life wishes. She had no explanation why Nurse A did not look for the 3008 form to determine whether to perform CPR or not. The DON stated that Nurse C, who was assigned when Resident #1 was re-admitted to the facility on [DATE] at 1:10 p.m., stayed until 8:00 p.m. that evening to complete paperwork and ensure that clinical records were completed, but she had no explanation why this was not done for Resident #1. She stated that both Nurse A and Nurse C's employment was terminated shortly after this incident. A review of the facility's policy and procedure titled, Advance Directives last reviewed (MONTH) 26, (YEAR), stated under Purpose: It is the policy of our community to recognize and support the rights of every resident to make his/her own choice regarding the medical care he/she receives or does not wish to receive. Further review of the facility's policies included, Cardiopulmonary Resuscitation last revised (MONTH) 26, (YEAR), that stated, Purpose: To ventilate and establish circulation for a resident with absence of respirations and pulse. Care Plan Documentation Guidelines included, Resident's wishes when regarding CPR. On [DATE] at 9:30 a.m., an interview was conducted with the Administrator. She stated that her position as the facility's Administrator began on [DATE], over a week after the incident of [DATE] occurred, and the prior Administrator's termination date was [DATE]. She stated that she was aware that honoring advance directives was an extremely important resident right, and she would ensure that corrective measures were implemented to prevent this from occurring again. The Administrator confirmed that code status should be readily available in a skilled nursing facility, and if the code status is full code, then CPR should be performed. The Administrator stated that all licensed and direct care staff were certified in CPR, and the facility's pharmacist was an American Heart Association Basic Life Support Instructor, who provides CPR training to the staff. The Administrator confirmed that the identification and implementation of advance directives was a topic that was brought to the facility's Quality Assurance Performance Improvement (QAPI) program, was corrected, and currently remains a topic for monthly discussion, as audits were on-going. On [DATE] at 4:30 p.m. an interview and review of the facility's documentation of their QAPI program was conducted with the Director of Nursing. A review of the sign-in sheets and agenda for QAPI meetings held on (MONTH) 21 and (MONTH) 19, (YEAR) revealed the Medical Director attended and Advance Directives was listed as a topic for improvement. The DON stated that the daily audits of all new admissions were on-going as well as quarterly audits that included Advance Directive information, and encompassed the timely identification of code status. The facility's investigation as to the root cause of Resident #1's expressed directive for CPR from the resident and her family member not being honored by the facility was reviewed with the DON, on [DATE] at 4:45 p.m. The DON provided statements from Nurse A, who was assigned to Resident #1, and Nurse D, who was also working as the secondary nurse during the night shift when Resident #1 passed away. Both statements corroborated the clinical record that indicated no resuscitative attempts were provided. The DON stated that after learning of this event on [DATE], she immediately provided 1:1 re-education to all licensed staff that CPR must always be provided if a resident or their responsible party had not chosen a DNR order, and this information must be immediately accessible upon admission or re-admission on the electronic and paper clinical records. The DON said that the admission process was also reviewed with staff to ensure that critical information was entered immediately when the resident was admitted or readmitted to the unit. The DON stated this immediate re-educational in-service was followed and reviewed twice more on [DATE] and [DATE]. She provided the sign-in sheets that verified 100% of licensed staff attended. The DON stated the facility does utilize temporary licensed staffing from a nursing agency. She stated that she tries to get the same nurses and utilize the same agency, and makes it a priority that each and every new agency nurse also receives the same education regarding the identification of code status that nurses employed by the facility receive. She stated that there was at least one nurse employed by the facility present on all shifts to serve as a resource for a temporary nurse sent from an agency. Additionally, the DON stated that new admission checklist sheets were added at the beginning of (MONTH) (YEAR) to ensure all information was reviewed and entered into the clinical records. She stated that she personally signs off on each new admission checklist. The DON provided the checklists for (MONTH) (YEAR) for the 6 newly admitted residents in (MONTH) (YEAR). Under Nursing to Check, included a column titled, Code Status. All six checklists indicated each resident's code status was reviewed, verified, and entered. Each checklist was signed off at the bottom by the DON as a completed admission process. The DON stated that completing admission paperwork and entering all required data could take ,[DATE] hours. Because it can be difficult for the assigned nurse to complete this task while meeting the responsibilities of providing patient care, the Unit Manager was assigned new hours that extend into the evening shift so that she may assist with chart assembly and data entry. The DON stated that she also assisted with this task, and if a transfer comes after hours, the DON stated that she was available and able to access the electronic records remotely to ensure that required relevant information such as advance directives and full code orders were entered immediately. A review of deaths that occurred in the facility since [DATE] included seven residents: *Resident #2 was admitted to the facility on [DATE] and expired on [DATE] at 4:00 a.m. The resident and physician signed a DNR order on [DATE]. Further review of the nursing notes, dated [DATE], showed that the resident's wishes were honored and she was not resuscitated. *Resident #3 was admitted on [DATE] and expired on [DATE]. A DNR order was signed by the resident and physician on [DATE]. A review of the nursing note, dated [DATE], showed the family was at the bedside at the time of death, and the resident's wishes were honored without attempted resuscitation. *Resident #4 was admitted on [DATE], and expired on [DATE]. A DNR order, dated [DATE], was signed by the resident and physician. A review of a nursing entry, dated [DATE], indicated the resident's wishes were honored to not be resuscitated. *Resident #5 was admitted on [DATE] and expired on [DATE]. A DNR order was signed by the resident and her physician on [DATE]. A nursing note, dated [DATE], indicated that Hospice was notified when she was found to be deceased at 4:00 p.m., and her wishes to not be resuscitated were honored. *Resident #6 was admitted on [DATE] and expired on [DATE]. The resident and physician signed a DNR order on [DATE] and [DATE] respectively. Further review of the clinical record included an entry in the nursing notes, dated [DATE], that he expired without attempts to be resuscitated as per his wishes. *Resident #7 was admitted on [DATE] and expired on [DATE]. The resident and her physician signed a DNR order [DATE]. Further review of the nursing notes included an entry, dated [DATE], that indicated her wishes were honored not to receive attempts at resuscitation. Additional review included twenty-one current residents that had indicated they wished to be a full code. On [DATE] at 5:15 p.m., all twenty-one residents' electronic and paper charts were reviewed with the DON. She demonstrated that each of the twenty- one resident's code status was accessible within ,[DATE] seconds on the first page of the electronic record, and this information was corroborated on their paper chart within the physician's orders [REDACTED]. Further review of the facility's audits included Admission Checklists for the month of (MONTH) (YEAR) that indicated Code Status was reviewed and signed off as being promptly entered for all new admissions and re-admissions. A review of the facility's licensed staff included a total of 6 licensed nurses: three that work regularly on the 7:00 a.m. to 3:00 p.m. shift, one that works regularly on the 3:00 p.m. to 11:00 p.m. shift, and two that work on the 11:00 p.m. to 7:00 a.m. shift. Additional licensed nurses also include the Unit Manager and the DON. On [DATE] at 2:15 p.m., a telephone interview was conducted with Nurse B. She confirmed that she was the nurse that first learned from Nurse A that CPR had not been performed as per Resident #1's wishes on [DATE]. She stated that Nurse A was no longer employed, and she confirmed that multiple in-services were provided to ensure that all electronic and paper charts were completed promptly and code status was reviewed regularly and verified again if a resident became pulse-less or without respirations. She confirmed that now the Unit Manager also works to ensure that the clinical record was completed and readily accessible with code status information. Nurse B was asked, How important is it to honor advance directives? Nurse B stated that it was extremely important. She stated that when she heard that Resident #1 did not receive CPR as per the resident's wishes, she immediately informed the DON. On [DATE] at 2:30 p.m., a telephone interview was conducted with Nurse D. He stated that he was the secondary nurse that was working with Nurse A when Resident #1 expired on [DATE]. He continued to be employed on the 11:00 p.m. to 7:00 a.m. shift. He stated that Nurse A told him that Resident #1 was expected to die, and so he thought that she had a DNR order. He stated that he checks the electronic record and the paper chart to ensure code status so that he knows what to do if they have a cardiopulmonary arrest. He confirmed that checking the code status was of utmost importance to honor the resident's right of having an advance directive. He stated that he had recently attended a staff meeting in which this topic was reviewed. On [DATE] at 1:30 p.m., an interview was conducted with the Unit Manager. She stated that admissions usually come in during the day, and now she stays until around 8:00 p.m. to assist with completion of data entry to ensure all orders including code status get entered and are readily available for staff. She stated that she also assists with the audit process of all new admissions. She stated that she recalled, and participated in, the recent educational in-services provided for staff on how to identify code status promptly through checking the electronic clinical record as well as the paper record. On [DATE] at 10:15 a.m., an interview was conducted with Nurse E. She stated if a resident went pulse-less or was without respirations, she would verify their code status first in their electronic and paper records. She stated normally there is a team of people that assist when a death occurs, and she or another licensed nurse would verify code status immediately to determine if CPR was required for a full code. In addition to performing CPR for a full code, Nurse E stated that 911 was also called and CPR continued until the paramedics arrive. On [DATE] at 10:01 a.m., an interview was conducted with Nurse F. She stated that she looks in the record, or has another licensed nurse look in the electronic and paper records to verify code status in the case of cardiopulmonary arrest. She stated that she looks for verification of code status when there is no DNR order, and then proceeds as per the resident's, or their responsible party's expressed directive. On [DATE] at 5:00 p.m., an interview was conducted with Nurse G. She stated that she normally works the 3:00 to 11:00 p.m. shift. She stated that verification of advance directives and immediately determining if the resident requires CPR (is a full code) or has a DNR order is extremely important to know what to do if they become pulse-less or without respirations. She stated that this was done by checking the chart that includes the electronic record and paper record. On [DATE] at 12:50 p.m., Nurse H was interviewed. She stated that she works for a temporary staffing nursing agency. She was asked what the facility's expectations were for determining code status in the event of a cardiopulmonary arrest. She replied that she would check the chart first, and this included checking the computer record and paper chart, and look for a DNR order. If there is no DNR order, and the code status is full code then she would begin CPR immediately. She stated that this was reviewed with her by the facility staff. A review of the facility's employee records and CPR certification of licensed staff involved in the incident of [DATE] when Resident #1 did not receive CPR as per her and her family's wishes, as well as current licensed staff included the following: 1. Nurse A, who was assigned to Resident #1 when she expired, had a current Basic Life Support CPR card that expires 2020. 2. Nurse B, currently employed by the facility, had a current Basic Life Support CPR card that expires ,[DATE]. 3. Nurse C, who was assigned to Resident #1 when she was admitted , and failed to enter to her advance directives into a chart that could be located by other staff, had a Basic Life Support (BLS) CPR card that expires ,[DATE]. 4. Nurse D, who was the secondary nurse when Resident #1 expired and remains employed by the facility, has a current BLS card that expires ,[DATE]. 5. Nurse E, currently employed by the facility has a current BLS card that expires ,[DATE]. 6. Nurse F, currently employed by the facility, has a current BLS card that expires ,[DATE]. 7. Nurse G, currently employed by the facility, has a current BLS card that expires ,[DATE].

Based on interviews with the facility's nursing and administrative staff, the facility Medical Director, review of clinical and hospital records and facility policies and procedures, it was determined that the facility failed to protect the rights of 1 (#1) of 7 sampled residents related to the resident's right to receive cardiopulmonary resuscitation (CPR) in the case of a cardiopulmonary arrest. The facility failed to honor Resident #1's, and her family's expressed wishes for end of life decisions. Resident #1 was readmitted to the facility after an 8- day hospitalization , and approximately sixteen hours later was noted to be absent of pulse or respirations. The facility failed to initiate CPR because the admission paperwork was not completed, and the licensed nurse that was assigned to Resident #1 could not locate any documentation that indicated CPR should be performed as per Resident #1's wishes. The facility's failure to follow their own policy and procedure for the identification of advance directives represented a system wide failure that could lead to other residents' end of life wishes not being honored. Failure of the facility staff to implement advance directives correctly resulted in findings of Immediate Jeopardy, past non-compliance, on [DATE]. The Immediate Jeopardy was determined to be corrected on [DATE] prior to the survey. Findings included: A clinical record review included a face sheet that indicated Resident #1 was originally admitted to the facility on [DATE], and was most recently re-admitted on [DATE]. Resident #1's daughter was listed as the responsible party and emergency contact. Further review included a nursing entry that was dated the following day after re-admission on [DATE] at 7:30 a.m. that indicated Resident #1 had died . Medical [DIAGNOSES REDACTED]. The Medical Certification and Medicaid Transfer Form (AHCA form-3008) dated [DATE] included under H. Advance Care Planning: Do Not Resuscitate (DNR), and this was checked NO. Additional review of the nursing assessment dated [DATE] indicated under Neurological that Resident #1 was alert and appropriate, but was oriented to person only. A review of Resident #1's hospital record revealed a Discharge Summary that included an admitted for Resident #1 of [DATE] and a discharge date of [DATE]. Under History of Present Illness the physician stated, .multiple frequent admissions to the hospital from the (skilled) nursing facility, consulted Palliative Care multiple times to address code status since family requested FULL CODE with frequent admissions. Further review included a History and Physical for the admission date of [DATE] and under History of Present Illness included: Recently I consulted palliative care to get help with the code status. Do not resuscitate could not be obtained. On [DATE] at 1:23 p.m., a telephone interview was conducted with Resident #1's daughter. She stated that it was her mother's wishes to receive CPR if her heart stopped, and since her mother's dementia had worsened, it was also her wish, as the responsible party, that her mother receive CPR if her heart stopped beating. She confirmed that there were NO Do Not Resuscitate orders. She stated that she was aware that her mother did not receive CPR when she passed away, and she heard it was because the nurse that was caring for her said that it was too late to administer CPR when it was finally noted that she was no longer breathing. On [DATE] at 1:16 p.m., an interview was conducted with the Medical Director. He stated that he was very familiar with Resident #1 and had been providing care for her for some time. He confirmed that the resident and family had wanted the resident to be a full code and receive CPR if her heart stopped beating and/or she stopped breathing. Further review of Resident #1's clinical record and nursing notes included an entry dated [DATE] at 7:40 a.m. that stated, During resident care, (Resident #1) found at 5:30 a.m. unresponsive, without vitals. Confirmed absence of vitals with second nurse. On-call doctor called back and confirmed record of death. POA and funeral home contacted. Resident's body removed at 7:30 a.m. There was no documentation that CPR or any interventions were provided to resuscitate Resident #1 as per her wishes. On [DATE] at 3:10 p.m., an interview was conducted with the Director of Nursing (DON). She stated that if a resident has indicated that they do not want to be resuscitated, then a Do Not Resuscitate (DNR) order form is placed on the clinical record. If a resident or their responsible party has chosen not to complete a DNR order, then CPR should be performed. She confirmed that this information should be readily available to the nurse at all times. She stated if a resident was found without pulse or respirations, a licensed nurse should check the electronic record and then the paper record for code status, and proceed accordingly. The DON stated that this should only take a few seconds, and may be done by a secondary nurse at the assigned nurse's direction. The DON was asked about the incident with Resident #1 on [DATE]. The DON said that she was notified by Nurse B, on the morning of [DATE], that Resident #1 did not receive CPR as per her wishes. She stated that Nurse B, who worked the 7:00 a.m. to 3:00 p.m. shift on [DATE] was given report by Nurse A, who had been assigned to Resident #1 for the preceding 11:00 p.m. to 7:00 a.m. shift. She stated that Nurse A told Nurse B that Resident #1 had passed away and no resuscitative attempts had been provided, but Nurse B was familiar with the resident, and knew that she had wanted CPR, so Nurse B brought this to the DON's attention immediately. She confirmed that Nurse A noted that Resident #1 was not breathing at 5:30 a.m. on [DATE]. The DON stated that Nurse A said that he did not do CPR because the resident was already cold to touch, and Nurse A had felt that it was too late to perform CPR. She confirmed that there was no policy or procedure that indicated it was acceptable for a nurse not to attempt CPR, if the nurse thought that it was too late. She confirmed that not performing CPR was a violation of Resident #1's rights. The DON stated that she immediately began an investigation, which included the required reporting. She stated the investigation revealed that Resident #1's admission paperwork, which included Form 3008 that indicated she was to receive CPR in case of cardiopulmonary arrest, was not uploaded into the electronic record, and no clinical record had been created for Nurse A to reference Resident #1's end of life wishes. She had no explanation why Nurse A did not look for the 3008 form to determine whether to perform CPR or not. She stated that Nurse C, who was assigned when Resident #1 was re-admitted to the facility on [DATE] at 1:10 p.m., stayed until 8:00 p.m. that evening to complete paperwork and ensure that clinical records were completed, but she had no explanation why this was not done for Resident #1. She stated that both Nurse A and Nurse C's employment was terminated shortly after this incident. A review of the facility's policy and procedure titled, Advance Directives last reviewed (MONTH) 26, (YEAR), stated under Purpose: It is the policy of our community to recognize and support the rights of every resident to make his/her own choice regarding the medical care he/she receives or does not wish to receive. Further review of the facility's policies included, Cardiopulmonary Resuscitation last revised (MONTH) 26, (YEAR), that stated, Purpose: To ventilate and establish circulation for a resident with absence of respirations and pulse. Care Plan Documentation Guidelines included, Resident's wishes when regarding CPR. The facility's investigation was reviewed with the DON, on [DATE] at 4:45 p.m. The DON provided statements from Nurse A, who was assigned to Resident #1, and Nurse D, who was also working as the secondary nurse during the night shift when Resident #1 passed away. Both statements corroborated the clinical record that indicated no resuscitative attempts were provided. The DON stated that after learning this on [DATE], she immediately provided 1:1 re-education to all licensed staff that CPR must always be provided if a resident or their responsible party has not chosen a DNR order, and this information must be immediately accessible upon admission or re-admission on the electronic and paper clinical records. The DON said that the admission process was also reviewed with staff to ensure that critical information is entered immediately when the resident is admitted or readmitted to the unit. The DON stated this immediate re-educational in-service was followed and reviewed twice more on [DATE] and [DATE]. She provided the sign-in sheets that verified 100% of licensed staff attended. The DON stated the facility does utilize temporary licensed staffing from a nursing agency. She stated that she tries to get the same nurses and utilize the same agency, and makes it a priority that each and every new agency nurse also receives the same education regarding the identification of code status that nurses employed by the facility receive. She stated that there is at least one nurse employed by the facility present on all shifts to serve as a resource for a temporary nurse sent from an agency. Additionally, the DON stated that new admission check- list sheets were added at the beginning of (MONTH) (YEAR) to ensure all information was reviewed and entered into the clinical records. She stated that she personally signs off on each new admission check- list. The DON provided the checklists for (MONTH) (YEAR) for the 6 newly admitted residents in (MONTH) (YEAR). Under Nursing to Check, included a column titled, Code Status. All six check- lists indicated each resident's code status was reviewed, verified, and entered. Each checklist was signed off at the bottom, by the DON, as a completed admission process. The DON stated that the event, of [DATE], where Resident #1's and her family's expressed wishes for resuscitation were not honored, was reviewed in the facility's Quality Assurance Performance Improvement (QAPI) program. A review of the sign-in sheets and agenda for QAPI meetings, held on (MONTH) 21 and (MONTH) 19, (YEAR), revealed the Medical Director attended and Advance Directives was listed as a topic for improvement. The DON stated that completing admission paperwork and entering all required data could take ,[DATE] hours. Because it can be difficult for the assigned nurse to complete this task while meeting the responsibilities of providing patient care, the Unit Manager has new hours now that extend into the evening shift so that she may assist with chart assembly and data entry. The DON stated that she also assists with this task. If a transfer comes after hours, the DON stated that she was available and able to access the electronic records remotely to ensure that required relevant information such as advance directives and full code orders were entered immediately. A review of deaths that occurred in the facility since [DATE] included seven residents: *Resident #2 was admitted to the facility on [DATE] and expired on [DATE] at 4:00 a.m. A DNR order was signed by resident and physician on [DATE]. Further review of the nursing notes, dated [DATE], showed that the resident's wishes were honored and she was not resuscitated. *Resident #3 was admitted on [DATE] and expired on [DATE]. A DNR order was signed by resident and physician on [DATE]. A review of the nursing note, dated [DATE], showed the family was at the bedside at the time of death, and the resident's wishes were honored without attempted resuscitation. *Resident #4 was admitted on [DATE], and expired on [DATE]. A DNR order, dated [DATE], was signed by the resident and physician. A review of a nursing entry, dated [DATE], indicated the resident's wishes were honored to not be resuscitated. *Resident #5 was admitted on [DATE] and expired on [DATE]. A DNR order was signed by the resident and her physician on [DATE]. A nursing note, dated [DATE], indicated that Hospice was notified when she was found to be deceased at 4:00 p.m.; and her wishes to not be resuscitated were honored. *Resident #6 was admitted on [DATE] and expired on [DATE]. A DNR order was signed by the resident and physician on [DATE] and [DATE] respectively. Further review of the clinical record included an entry in the nursing notes, dated [DATE], that he expired without attempts to be resuscitated as per his wishes. *Resident #7 was admitted on [DATE] and expired on [DATE]. A DNR order was signed [DATE] by the resident and her physician. Further review of the nursing notes included an entry, dated [DATE], that indicated her wishes were honored not to receive attempts at resuscitation. Additional review included twenty-one current residents that had indicated they wished to be a full code. On [DATE] at 5:15 p.m., all twenty-one residents' electronic and paper charts were reviewed with the DON. She demonstrated that each of the twenty- one residents' code status was accessible within ,[DATE] seconds on the first page of the electronic record, and this information was corroborated on their paper chart within the physician's orders [REDACTED]. Further review of the facility's audits included Admission Checklists for the month of (MONTH) (YEAR) that indicated Code Status was reviewed and signed off as being promptly entered for all new admissions and re-admissions. A review of the facility's licensed staff included a total of 6 licensed nurses: three that work regularly on the 7:00 a.m. to 3:00 p.m. shift, one that works regularly on the 3:00 p.m. to 11:00 p.m. shift, and two that work on the 11:00 p.m. to 7:00 a.m. shift. Additional licensed nurses also include the unit manager and the DON. On [DATE], at 2:15 p.m., a telephone interview was conducted with Nurse B. She confirmed that she was the nurse that first learned from Nurse A that CPR had not been performed as per Resident #1's wishes on [DATE]. She stated that Nurse A was no longer employed, and she confirmed that multiple in-services were provided to ensure that all electronic and paper charts were completed promptly and code status was reviewed regularly and verified again if a resident became pulse-less or without respirations. She confirmed that now the Unit Manager also works to ensure that the clinical record was completed and readily accessible with code status information. Nurse B was asked, How important is it to honor advance directives? Nurse B stated that it was extremely important. She stated that when she heard that Resident #1 did not receive CPR as per the resident's wishes, she immediately informed the DON. On [DATE], at 2:30 p.m., a telephone interview was conducted with Nurse D. He stated that he was the secondary nurse that was working with Nurse A when Resident #1 expired on [DATE]. He continues to be employed on the 11:00 p.m. to 7:00 a.m. shift. He stated that Nurse A told him that Resident #1 was expected to die, and so he thought that she had a DNR order. He stated that he checks the electronic record and the paper chart to ensure code status so that he knows what to do if they have a cardiopulmonary arrest. He confirmed that checking the code status was of utmost importance to honor the resident's right of having an advance directive. He stated that he had recently attended a staff meeting in which this topic was reviewed. On [DATE], at 1:30 p.m., an interview was conducted with the Unit Manager. She stated that admissions usually come in during the day, and now she stays until around 8:00 p.m. to assist with completion of data entry to ensure all orders including code status get entered and are readily available for staff. She stated that she also assists with the audit process of all new admissions. She stated that she recalled, and participated in, the recent educational in-services provided for staff on how to identify code status promptly through checking the electronic clinical record as well as the paper record. On [DATE], at 10:15 a.m., an interview was conducted with Nurse E. She stated if a resident went pulse-less or was without respirations, she would verify their code status first in their electronic and paper records. She stated normally there is a team of people that assist when a death occurs, and she or another licensed nurse would verify code status immediately to determine if CPR was required for a full code. In addition to performing CPR for a full code, Nurse E stated that 911 was also called and CPR continued until the paramedics arrive. On [DATE], at 10:01 a.m., an interview was conducted with Nurse F. She stated that she looks in the record, or has another licensed nurse look in the electronic and paper records to verify code status in the case of cardiopulmonary arrest. She stated that she looks for verification of code status when there is no DNR order, and then proceeds as per the resident's, or their responsible party's expressed directive. On [DATE], at 5:00 p.m., an interview was conducted with Nurse G. She stated that she normally works the 3:00 to 11:00 p.m. shift. She stated that verification of advance directives and immediately determining if the resident requires CPR (is a full code) or has a DNR order is extremely important to know what to do if they become pulse-less or without respirations. She stated that this was done by checking the chart that includes the electronic record and paper record. On [DATE], at 12:50 p.m., Nurse H was interviewed. She stated that she works for a temporary staffing nursing agency. She was asked what the facility's expectations were for determining code status in the event of a cardiopulmonary arrest. She replied that she would check the chart first, and this included checking the computer record and paper chart, and look for a DNR order. If there is no DNR order, and the code status is full code then she would begin CPR immediately. She stated that the facility staff reviewed this with her. On [DATE] at 9:30 a.m., an interview was conducted with the Administrator. She stated that she was aware that honoring advance directives was an extremely important resident right, and she will ensure that corrective measures are implemented to prevent this from occurring again. The Administrator stated that all licensed and direct care staff were certified in CPR, and the facility's pharmacist was an American Heart Association Basic Life Support Instructor, who provides CPR training to the staff. A review of employee records and current certification in CPR was reviewed and included the following: 1. Nurse A, who was assigned to Resident #1 when she expired, had a current Basic Life Support CPR card that expires 2020. 2. Nurse B, currently employed by the facility, had a current Basic Life Support CPR card that expires ,[DATE]. 3. Nurse C, who was assigned to Resident #1 when she was admitted , and failed to enter to her advance directives into a chart that could be located by other staff, had a Basic Life Support (BLS) CPR card that expires ,[DATE]. 4. Nurse D, who was the secondary nurse when Resident #1 expired and remains employed by the facility, has a current BLS card that expires ,[DATE]. 5. Nurse E, currently employed by the facility has a current BLS card that expires ,[DATE]. 6. Nurse F, currently employed by the facility, has a current BLS card that expires ,[DATE]. 7. Nurse G, currently employed by the facility, has a current BLS card that expires ,[DATE].

Based on observation, interviews and record review, the facility failed to report an incident involving a resident who fell and suffered a severe injury. One (Resident #4), of four sampled residents, was identified by the facility as at risk for falls prior to the fall with injuries, yet the facility did not report, or thoroughly investigate the incident. Findings include: Resident #4, a [AGE] year old, was admitted to the facility on [DATE] after hospitalization from ,[DATE] to 10/28/11. Per the facility face sheet she had [MEDICAL CONDITION], an abnormal heart rhythm, [MEDICAL CONDITIONS], and a backache on admission. The nurse ' s admission assessment dated [DATE] at 1:10 p.m. stated she was identified to be at risk for falling and she required the assistance of two staff members for care and mobility. She was alert, verbal, with no obvious cognition factors. The physician ordered physical therapy for gait training and strengthening, to begin on 10/28/11. A care plan for fall prevention was initiated on 11/10/11 due to the resident ' s increased risk for falls, related to muscle weakness and deconditioning, impaired cardiac function, and oxygen dependence. There were six initial interventions to prevent falls. They were as follows: 1. Maintain bed in low , locked position 2. Maintain a safe uncluttered environment. 3. Question needs with all interventions. 4. Keep call light within resident ' s reach and reinforce need to use to summon staff for assistance. 5. Manage pain. 6. PT and OT to evaluate and treat. Review of the Physical Therapy (PT) notes revealed the resident was discharged from therapy to Restorative nursing care on 12/14/11. The summary dated 12/14/11 stated that the goals for ambulation and self care were partially met. The resident needed assistance with bed to chair transfers and had a three to five minute functional activity tolerance. Review of the Restorative Care Flow Record revealed that resident #4 refused ambulation assistance from 12/15 to 12/23/11. She received restorative care of range of motion exercises, with active assistance. Per the nurse ' s notes of 12/23/11 at 10:00 p.m. the resident had an unwitnessed fall and was found on the floor by a nursing assistant. She was bleeding from the forehead and complained of neck pain. She was transferred to the hospital for evaluation. Per the hospital physician ' s history and physical, dated 12/24/11, she was found to have a cervical spine fracture of C1 vertebrae, an injured left wrist (later diagnosed as a fracture), and a frontal scalp contusion from the fall. She was admitted to ICU for [REDACTED]. An operative report, dated 01/01/12 stated she received a procedure to insert a percutaneous gastrostomy (PEG)tube for liquid nutrition. The physician wrote that she had a cervical neck fracture following a fall and required alternate nutrition as she was likely to need a neck collar for an extended period of time. On 01/03/12 at 7:00 p.m. resident #4 returned to the facility. The nurse ' s notes stated she returned by stretcher with a neck collar, left wrist splint, Foley catheter, and a PEG tube feeding solution infusing. The next note, on 01/04/12 at 9:30 a.m. stated she was unable to communicate. She required total care and positioning every two hours. On 01/06/12 at 8:35 a.m. the Nursing Home Administrator(NHA) was interviewed. He recalled that he contacted someone within the corporation and discussed the fall. He was informed by the facility staff that resident #4 was not on fall precautions, therefore the facility could not have prevented the fall. He did not report the event. The NHA stated he and the DON investigated and took statements from staff members. They believed the resident was tangled in the oxygen tubing and fell . Review of the care plan in the presence of the NHA and DON confirmed that fall precautions and interventions were initiated on 11/10/11 and implemented six weeks prior to the fall. On 01/06/11 at 9:15 a.m. an attorney appointed case manager for the resident was interviewed by telephone. She stated that she worked for an attorney that shared the POA with a disabled relative of the resident. She stated that she visited the resident several times during the recent hospitalization and subsequent readmission to the facility. She stated she had observed a significant decline in the health of the resident after the injuries related to the fall. She had recommended Hospice care to the attorney. On 01/06/12 at 2:30 p.m. a third observation of resident #4 was conducted with the corporate RN. The resident was lying in bed with a hard plastic neck collar in place. Her neck is slightly hyperextended upward. She was on an inflated air mattress. The left side of her face was discolored with yellow/purple bruising covering most of the left side. She spoke softly to the corporate nurse. The left wrist and forearm had a splint in place. A [MEDICAL CONDITION] tube feeding was infusing. A Foley catheter was draining amber urine. She was weak and attempted to demonstrate use of the call bell. She was able to pull it after several attempts with verbal cues. This surveyor requested a demonstration of the lowest level of the bed at this time. The bed was in the same position as it was in during the two prior observations. The corporate nurse used the bed hand controls and lowered the bed several inches. The aide caring for the resident then locked the wheels. The corporate nurse confirmed that the bed was not in the lowest available position for this bed, at the time of this observation. Per the surveyor and facility staff measurements, the distance from the floor to the top of the standard facility mattress was 18-20 inches from the floor. The bed was observed at about the surveyor ' s hip level, approximately 32 inches. The care plan approaches for this resident stated the bed was to be in the lowest position, with the wheels locked. The corporate nurse confirmed that the additional bed elevation, as observed on this day, placed the resident at an unnecessary, increased distance to the floor, with the increased potential for another severe injury if she fell again. The corporate nurse agreed that the resident was significantly compromised as a result of the prior unwitnessed fall from an unknown height. The corporate nurse further stated that the corporation and the facility did use designated " low beds " when the need arose. She stated that the designated low beds, with the mattress on or very near the floor, were available and used throughout the corporation when necessary, with a physician's order [REDACTED]. No floor pads were observed for this resident on any of the three observations. She agreed that the resident continued as a high risk for falls. The corporate nurse confirmed that hospice care was ordered on [DATE] at 5:20 p.m. and the hospice nurse visited earlier in the day on 01/06/12 to assess her current needs. The facility was unable to provide documentation of a thorough investigation of the circumstances leading to the severe fall with injuries for resident #4. The height position of the bed and cognition status of the resident at the time of the fall were unknown. A fall investigation internal report stated that she was walking on a regular basis prior to the fall. However, the restorative aide documented that she had refused ambulation from 12/14 to 12/23/11, the day of the fall. The DON and NHA, at 8:35 a.m. on 1/6/12, confirmed that the resident was weak and under treatment for [REDACTED]. The NHA confirmed he did not file a Federal Immediate report about the event.

Based on observation, interviews, and record review the facility failed to utilize identified approaches to prevent an accident with serious injuries for one of four (#4) weak, medically fragile, and physically impaired residents sampled. The failure to implement these approaches contributed to an unwitnessed fall, leading to hospitalization for a cervical neck fracture, wrist fracture, and facial bruising for resident #4. Findings include: Resident #4 was a [AGE] year old with a history of kidney disease, heart disease, and osteoarthritis. She was admitted to the facility on [DATE]. Per the nurse ' s notes and assessment on admission, she was identified as at risk for a fall. On 12/23/11 at 10:00 p.m. the resident fell . She was found on the floor by an aide with a bleeding laceration of the forehead and complaining of head pain. She was sent to the hospital for evaluation and found to have a fracture of the cervical spine at C1, a fractured left wrist, and a frontal scalp contusion. She returned to the facility on [DATE] with a significant decline of condition. She required a cervical neck collar, a left wrist splint, a Foley catheter, and a gastric feeding tube with a nutritional solution infusing. Per the nursing admission assessment of 10/28/11, she was evaluated for a fall risk and had mobility " problems and with devices " . She scored 14 on the fall risk assessment and was determined to be at risk for a fall. The facility tool stated that a score of greater than 10 determined a resident to be at risk for falls. She was alert with no obvious cognition problems. The 10/28/11 nurses notes at 1:10 p.m. stated she had her own mobility assist devices, a walker and wheelchair for use at home, and a family member was to bring them in. On 11/10/11 a care plan was initiated for fall precautions with six approaches identified. The first approach was to maintain the bed in low position with the wheels locked. Other care plans included the monitoring of anticoagulation therapy, pain control for chronic low back pain, and activity intolerance related to generalized weakness. Review of the therapy notes revealed she began PT on 10/21/11. The therapist wrote that the reason for the referral was S/P (status [REDACTED]. The balance assessment stated greater than one attempt was needed to rise. She was discharged from therapy to restorative nursing on 12/14/11, after the goals were partially met. The discharge summary stated she was steady but used a walker, had stopping or discontinuity between steps, and the walking stance was with the heels almost touching. She had a marked sway of the trunk. On 12/14/11 she was to receive Restorative Nursing therapy. On 12/21/11 the nurse practitioner (NP) visited the resident. She stated that the resident was alert and oriented and in a pleasant mood. The resident stated to the NP that she was unable to eat, however the nurse stated she ate 50-75% of her diet and there was no change of her weight. The NP noted the muscle weakness and stated the treatment was for therapy to continue per the plan. Review of the nurse ' s notes, dated 12/19/11, no time specified, revealed that the nurse wrote that the resident complained of chest congestion. The doctor was notified and nebulizer treatments were ordered. The next note, dated 12/22/11 at 7:00 p.m. stated she complained of a cough and nausea. The physician was contacted and orders for a cough syrup and Phenergan for the nausea were obtained. On 12/22/11 review of the grievance complaint facility report revealed that the resident ' s son complained that the resident needed something for the nausea. The report was not timed. Review of the Restorative Care Flow record revealed that she, the resident, refused ambulation from 12/15 to 12/23/11. The documentation stated that she received active assisted (AA) range of motion daily during this time. Documentation for 12/24/11 and 12/25/11 was present on the flow record; however she was hospitalized at the time. The back of the Restorative Care Progress Note document contained a progress note dated 12/23/11 stating she refused two or three approaches daily due to nausea and an upset stomach. Review of the Medication Administration Record (MAR) revealed that the resident did not receive any doses of Phenergan for nausea while at the facility. A nurse ' s note on 12/23/11 at 10:00 p.m. stated the resident was found on the floor by an aide. She was bleeding from the forehead and complained of pain in her head. She was transferred to the hospital. On 12/24/11, per the hospital physician ' s History and Physical, the resident was assessed in the emergency room and found to have a cervical spine fracture, C1, related to a fall in the facility. A cervical spine collar was applied and she was admitted to the ICU for care and monitoring. A CT of the head showed a frontal scalp contusion. The physician assessment stated: 1. Cervical C1 spine fracture secondary to fall. Left wrist bruising was also noted. She was admitted to ICU. An operative report, dated 01/01/12 at 5:54 p.m., stated that the resident had a procedure for insertion of a percutaneous endoscopic gastrostomy (PEG) tube. The physician wrote that the indication for the procedure was " The patient has a history of neck fracture of cervical vertebrae 1 following a fall and requires alternative means of nutrition as she is likely to stay in a neck collar for a protracted period of time " . The findings of the endoscopic exam stated there was erosion with black eschar, consistent with stress ulcers, in the duodenum. A nurse ' s note, dated 01/03/12 at 7:00 p.m. revealed that she returned to the facility with a neck collar, a left wrist splint, a Foley catheter, and a gastric feeding tube in place. She was receiving gastric feedings of Jevity 1.5 at 55 cc per hour continuously. On 01/04/12 the N.P. visited the resident. She wrote that the visit was follow up for a recent hospitalization after the resident fell at the facility. She wrote that the resident was " now NPO " (nothing by mouth) due to the inability to swallow. The resident had respiratory failure during the hospitalization . The resident assessment revealed that she was lying in bed, unable to speak, with slight movements of her arms and no movement of either leg. On 01/06/12 the fall precaution care plan was updated with only one additional intervention. The new intervention was to use a personal safety alarm. The first intervention of maintaining the bed in low, locked position remained in place. On 01/05/12 at 7:00 p.m. an observation of the resident was conducted. The resident was drowsy and was unable to be interviewed. A family member at the bedside stated he was unhappy with the care and the failure to prevent the fall. The resident was observed to have a fixed, hard plastic neck brace in place, a Foley catheter was draining urine, and a gastric feeding tube was infusing liquid nutrition via a pump. The bed was not in the lowest position available for this style of bed. The resident was on a special mattress, further elevating the height of the entire bed from the floor. On 01/06/12 at 8:35 a.m. the NHA and DON were interviewed regarding the fall of 12/23/11. The NHA stated he conducted an internal investigation and was informed by staff that she , the resident, became tangled in the oxygen tubing and fell . He was told that she was attempting to go to the bathroom. There was no documentation regarding the height of the bed at the time of the fall. On 01/06/11 at 11:10 a.m. a second observation was made with facility staff attending. The MDS manager, DON, and NHA administrator were present. The bed and mattress were elevated to about hip level of the surveyor, approximately 32inches. The bed was not in the lowest available position. A special blue plastic mattress was on the bed, with a round inflated bolster noted along the edge facing the door. The resident was in the middle of the bed, covered with a sheet. The specialty mattress was significantly higher than the facility standard mattress, which measured 19-20 inches from the floor to the top of the standard mattress when in the lowest position. The facility MDS nurse stated that this type of bed frame as observed needed to be elevated off the floor in order to lock the wheels. She stated the facility used only this type of bed, to allow access to cleaning under it. The MDS nurse stated that they did not use designated " low beds " (beds where the mattress rested on or very near the floor) in the facility. The bed alarm was in place. The resident was alert and oriented. She attempted to demonstrate use of the call bell and eventually was able to do so. The resident had a firm plastic cervical collar in place with very limited neck and head mobility, and fixed visual fields straight ahead. The left side of her face had a very large area of yellow/ purple bruising (ecchymosis). She had a left hand splint on. A Foley catheter was draining urine and the gastric feeding solution was infusing. The MDS nurse confirmed she updated the care plan after the fall. She stated she had primary responsibility for assuring implementation of the approaches. The DON had no additional comments. On 01/06/12 at 2:30 p.m. a third observation was conducted with the corporate RN. This surveyor requested a demonstration of the lowest level of the bed. The bed was in the same position as it was in during the two prior observations. The corporate nurse used the bed hand controls and lowered the bed several inches. The aide caring for the resident then locked the wheels. The corporate nurse confirmed that the bed was not in the lowest available position for this bed, at the time of this observation. Per the surveyor and facility staff measurements, the distance from the floor to the top of the standard facility mattress was 18-20 inches from the floor. The bed was observed at about the surveyor ' s hip level, approximately 32 inches. The care plan approaches for this resident stated the bed was to be in the lowest position, with the wheels locked. The corporate nurse confirmed that the additional bed elevation, as observed on this day, placed the resident at an unnecessary, increased distance to the floor, with the increased potential for another severe injury if she fell again. The corporate nurse agreed that the resident was significantly compromised as a result of the prior unwitnessed fall from an unknown height. The corporate nurse further stated that the corporation and the facility did use designated " low beds " when the need arose. She stated that the designated low beds, with the mattress on or very near the floor, were available and used throughout the corporation when necessary, with a physician's order [REDACTED]. No floor pads were observed for this resident on any of the three observations. She agreed that the resident continued as a high risk for falls. The corporate nurse confirmed that hospice care was ordered on [DATE] at 5:20 p.m. and the hospice nurse visited earlier in the day on 01/06/12 to assess her current needs.

Based on observation, interview, and record review, the facility failed to provide equipment that was safe in that they had torn, jagged, and exposed foam for 3 (#22, #29, #78) out of 37 wheel chairs observed. Findings include: 1. On 11/29/2011 at 2:41 p.m., Resident #22's wheel chair was observed to have rips in the padding on both arm rests. The rips in the plastic on the arms were approximately 4 inches in length and created a sharp edge. The padding was exposed leaving an uncleanable surface. Staff was notified and, at approximately 4:00 p.m. on the same day, the chair was observed to be replaced. An interview was conducted on 11/29/2011 at approximately 2:46 p.m. with nurse #1 who stated that the resident, who uses the wheelchair, wears Geri sleeves to protect her forearms due to frequent skin tears. 2. On 12/01/2011, Resident #29's wheel chair was observed to have tears in the arm pads with the padding exposed. 3. An observation was made of Resident #78's electric wheel chair on 11/30/2011 at approximately 9:59 a.m. The Resident's electric wheelchair was in disrepair. Both arm rests had missing foam on the back side of the arm with the plastic cover jagged and rough. The back of the chair had missing foam pieces. A second observation was made on 12/01/2011 of the electric power chair. The foam was missing from approximately 1/3 of one arm rest and the other arm had torn, exposed foam. Both sides of the backrest had large rips located on the back side. The areas were approximately 5 " x 3 " and 5 " x 2 " in diameter. The seat of the chair and the foot rest were extremely dirty. At approximately 10:00 a.m. on 12/02/2011 the Administrator accompanied the surveyor to resident #78's room. She was unaware of the poor condition of the power chair. She stated that she does not remember when the last time the chair was recovered, but that the resident's daughter had it done. She said that she would telephone the resident's daughter regarding the condition of the chair. She stated that the chair is the resident's personal power chair and that he is responsible for the repair. The dirty seat and foot rest was shown to the Administrator who acknowledged that it need to be cleaned. She said that she would have staff clean the chair.