Every finding on record at Park Forest Care Center LLC

Based on observations, interviews and record review, the facility failed to ensure mechanical equipment was maintained in safe, operating condition for one (#2) of three residents reviewed for mechanical lifts out of three sample residents. Specifically, the facility failed to: -Ensure mechanical lift slings were routinely inspected, maintained and replaced according to the manufacturer's recommendations and professional standards, which resulted in a fall for Resident #2; and, -Ensure mechanical lifts were routinely maintained according to the manufacturer's recommendations.Findings include: I. Professional standardsThe Federal Drug Administration's (FDA) Patient Lift Safety Guide, undated, was retrieved on 7/8/26 from https://www.fda.gov/files/medical%20devices/published/Patient-Lifts-Safety-Guide.pdf. It read in pertinent part, Prepare equipment. Examine sling and attachment areas for tears, holes and frayed seams. Do not use sling with any signs of wear. Keep manufacturer's instructions close to your lift and always follow them. Sling Care. Do not share slings between patients unless slings are properly washed and disinfected. Do not use slings that are frayed, ripped or have holes. If the slings show signs of wear, replace it immediately. Contact information. If you have problems operating your lift, contact the manufacturer or supplier. If you experience an injury, quality problem or use error when using a patient lift, file a voluntary report or online through MedWatch, the FDA safety information and adverse event reporting program. II. Facility policy and procedureThe Preventative Maintenance Program policy and procedure, revised 2/10/26, was provided by the director of nursing (DON) on 7/7/26 at 4:29 p.m. It read in pertinent part, The maintenance director is responsible for developing and maintaining a schedule of maintenance services to ensure equipment is maintained in a safe and operable manner. If preventative maintenance is required, the maintenance director shall decide what tasks need to be completed and how often to complete them. Documentation shall be completed for all tasks and kept in the maintenance director's office for at least three years. III. Manufacturer's instructionsAccording to Invacare's Reliant 450 and Reliant 600 (mechanical lift) user manual (2018), page 33-34, retrieved on 7/8/26 from https://www.vitalitymedical.com/pdf/user-manual-invacare-reliant-600-lift.pdf?srsltid=AfmBOoqJXY8z9DONxsV1-kze_obZPbcqmCcc6ug54isqvzpVt-b8_-2E, The expected service life is eight years, presuming that the product is used daily and in accordance with safety instructions and maintenance instructions stated in this manual. Maintenance Safety Inspection Checklist: Regular cleaning will reveal loose or worn parts, enhance smooth operations and extend the lift expectancy. Follow the maintenance procedures described in this manual to keep your patient lift in continuous service. Sling and hardware. Check all sling attachments each time it is used to ensure proper connection and patient safety. Inspect sling material for wear. Inspect straps for wear. Keep lift and slings clean and in good working order. Any defect should be noted and reported to your dealer as soon as possible. Maintenance for the boom, the hangar bar, actuator assembly, cleaning and slings and hardware is recommended initially. Inspect and adjust monthly. IV. Mechanical lift sling and mechanical lift maintenance failuresA. ObservationDuring a facility walkthrough on 7/6/26, an Invacare Reliant 450 mechanical lift was observed on the women's unit at 2:18 p.m. with a handwritten note that read Out of service 6/2/26. Two Invacare Reliant 600 mechanical lifts were observed on the men's unit at 2:22 p.m. -However, there was no maintenance record for the Invacare Reliant 450 mechanical lift on why it was out of service (see interviews below).B. Record reviewThe 2/10/26 witnessed fall incident report revealed licensed practical nurse (LPN) #1 was called to Resident #2's room at approximately 8:00 a.m. by certified nurse aide (CNA) #1. LPN #1 arrived to the room and Resident #2 was on the floor. CNA #1 said Resident #2 fell while transferring from the bed to the chair. CNA #1 said the sling snapped off the mechanical lift. CNA #1 reported the resident fell from the bottom first and then the upper part of his body fell from the lift. The 2/11/26 interdisciplinary (IDT) event note revealed Resident #2's 2/10/26 incident was described as a witnessed fall during a Hoyer lift transfer. The root cause was a malfunction of equipment. The new intervention was that all Hoyer lift slings were replaced.A request of all work orders and routine maintenance records for all three mechanical lifts was made to the nursing home administrator (NHA) on 7/7/26 at 12:30 p.m. The records revealed the following: On 2/11/26, a staff member reported a Hoyer (mechanical) lift was very wobbly and unstable and rated the request a five. On 2/11/2026, a maintenance department employee documented that all bolts were tightened. -However, the record did not reveal which of the three mechanical lifts required service. On 5/28/26, a staff member reported a Hoyer lift's hand-held level that opened the legs often closed when transferring residents, especially the heavy residents and rated the request a four. On 5/28/26, a maintenance department employee documented it as completed. -However, the record did not reveal which of the three mechanical lifts required service and did not describe what was done to fix the mechanical lift. An email revealed an outside maintenance company performed diagnostics for three mechanical lifts on 6/24/26. The email revealed a technician completed the diagnostics and found although the mechanical lifts were older models, they were in proper working order with no issues identified. -However, the facility did not provide documentation to indicate that the three mechanical lifts were routinely inspected and maintained on a monthly basis, per the manufacturer's instructions (see manufacturer's instructions above).C. Facility's plan of correctionThe corrective action plan the facility implemented in response to the mechanical lift sling malfunction involving Resident #2 on 2/10/2026 was provided by the DON on 7/7/26 at 2:00 p.m.The corrective action plan identified the facility became aware of the issue on 2/10/26 and developed a performance improvement plan in response to Resident #2's fall due to the sling snapping. The facility completed education to all clinical staff and a return demonstration of mechanical lift use was completed by all clinical staff. On 2/10/26, the facility provided in-service training for all nursing staff on the facility policy for lifts and safety.The DON or the nursing home administrator (NHA) monitored mechanical lift transfers during rounds weekly for four weeks and then monthly for three months and then quarterly. All mechanical lift slings were monitored by the DON to ensure they are in good working condition for 12 weeks. -However, during the survey, additional concerns related to the failure to maintain mechanical lifts in safe operating condition were observed (see observations above).V. Staff interviewsCNA #2 was interviewed on 7/6/26 at 3:26 p.m. CNA #2 said she last received mechanical lift training in February 2026 or March 2026. She said she had worked at the facility for almost two years. She said each resident had their own sling in their room and in the laundry room. She said if a mechanical lift required repair or maintenance, she notified maintenance through an online system. She said she wrote a description of what was wrong and rated the importance of the request on a scale of one to five. She said if a mechanical lift required repair or maintenance, she rated the request as a five because it was important for the mechanical lift to be fixed as soon as possible. CNA #2 said there were two automatic mechanical lifts and one manual mechanical lift. She said one of the mechanical lifts was currently out of order because the legs of the lift were poor quality and unreliable. She said before she used a mechanical lift, she made sure the battery was in operating order, the legs looked okay and the remote worked. CNA #2 said she did not know where the mechanical lift manuals were stored and she said she did not know how to access the manuals.LPN #1 was interviewed via phone on 7/7/26 at 10:11 a.m. LPN #1 said she was the nurse who first found Resident #2 after the resident's fall on 2/10/26. She said the cause of the fall was due to the mechanical lift sling snapping. LPN #1 said she did not look at mechanical lift slings regularly, but more than one CNA had told her the slings were not in good condition. She said if there were any requests for sling replacements, the DON needed to be notified.CNA #1 was interviewed on 7/7/26 at 12:00 p.m. CNA #1 said the mechanical lift sling used to transfer Resident #2 (on 2/10/26) broke and the resident fell when he was close to sitting down on the chair. CNA #1 said she had worked at the facility for two years and the slings were never replaced (prior to the 2/10/26 incident) and they were not in good condition. CNA #1 said before the 2/10/26 incident with Resident #2, there was only one resident who had their own sling. She said for everyone else, staff used whatever sling they could find and there were never enough. CNA #1 said she reported the slings not being in good repair verbally, but she did not document the work order request. CNA #1 said the mechanical lifts frequently required maintenance and they were never fixed. Registered nurse (RN) #1 was interviewed via phone on 7/7/26 at 10:18 a.m. RN #1 said she was working the day of Resident #2's 2/10/26 fall from the mechanical lift. RN #1 said the cause of the fall was the sling stitching fell apart and snapped. RN #1 said she was unsure how long the slings had been in use prior to the 2/10/26 incident. RN #1 said after the incident, all residents who required a mechanical lift received their own slings and were labeled using a Sharpie or a machine label maker. The former director of supplies was interviewed via phone on 7/7/26 at 10:24 a.m. The director of supplies said she stopped working at the facility in December 2025. She said she saw the conditions of the mechanical lift slings and requested the slings to be replaced by asking the maintenance director (prior to the incident with Resident #2 on 2/10/26). The director of supplies said the slings were washed daily and there were holes in the slings and they were old. The maintenance director was interviewed on 7/7/26 at 12:30 p.m. The maintenance director said he had worked at the facility for over 35 years. He said the facility had three mechanical lifts. The maintenance director said he was responsible for the maintenance of the mechanical lifts and the nursing staff was responsible for the maintenance of the mechanical lift slings. The maintenance director said he did not know what the manufacturer's instructions were for how often routine maintenance should be completed on the mechanical lifts. The maintenance director said staff should submit a work order request when maintenance was needed on the mechanical lifts; however, most CNAs told him verbally about a mechanical lift concern while he was in the hallway. The maintenance director said he did not document every time a CNA told him something needed to be fixed on the mechanical lifts. The maintenance director said he should be better at documenting the work orders for the mechanical lifts. The maintenance director said the facility had had the three mechanical lifts for about ten years. He said he did not know the expected service life of the mechanical lifts. The maintenance director said the most frequent mechanical lift maintenance requests CNAs made were that there was hair in the wheels of the mechanical lift or that the mechanical lift's batteries needed to be replaced. The maintenance director said he was not aware one of the mechanical lifts had an out of order sign on it. He said to his knowledge, all mechanical lifts were in working order. The NHA was interviewed on 7/7/26 at 1:46 p.m. The NHA said the maintenance department was responsible for the maintenance of mechanical lifts. He said staff should use the electronic work order process to make mechanical lift maintenance requests. He said the maintenance department should follow the manufacturer's instructions for routine maintenance of the mechanical lifts. The NHA said the 6/24/26 outside diagnostic maintenance of the mechanical lifts was completed because the facility was setting up new systems and they wanted to make sure all equipment was functional. The NHA said nursing staff was responsible for the maintenance of the slings. The DON and the NHA were interviewed together on 7/7/26 at 3:33 pm. The DON and the NHA said the DON was not at the facility on 2/10/26. The DON said the cause of Resident #2 falling to the floor was that the mechanical lift sling was not in good condition. The DON and the NHA said they were unable to verify how long the mechanical lift slings had been in use prior to 2/10/26. The DON said she was responsible for keeping track of all residents who required a mechanical lift sling and what size sling the resident required. The DON said each resident had at least two slings. The DON said there had been no further incidents related to mechanical lift sling failure since 2/10/26. The NHA said the maintenance record documentation should have been more clear in order to determine which mechanical lift was serviced and what maintenance was completed to resolve the work order.

Based on record review and interviews, the facility failed to ensure one (#11) of three residents reviewed for feeding tube out of 22 sample residents received necessary care and services to remain free from neglect. Resident #11 was nonverbal and dependent on staff for nutrition and hydration through a gastrostomy tube (G-tube). The resident was unable to communicate needs, discomfort, or hunger and relied entirely on staff to provide ordered tube feeding. The physician's orders revealed the resident required continuous enteral feeding with scheduled water flushes to meet the resident's nutritional and hydration needs.On 1/28/26, the resident's tube feeding was not administered beginning at 4:00 p.m. until 6:00 a.m. on 1/29/26. Record review revealed no documentation that the ordered tube feeding was provided during this time period. Nursing documentation reflected that the failure to administer the tube feeding was identified after the fact, and the physician was notified on 1/29/26. The facility failed to ensure follow-up and continuity of care to meet the resident's nutritional needs during this extended period.The resident's representative said the incident caused increased fear and anxiety regarding the resident's care and said she was stressed by learning the resident's tube feeding was not provided as ordered and said that had the resident been aware, he would have been mad and would have requested transfer to another facility.Specifically, registered nurse (RN) #3 and RN #4 failed to take necessary steps to ensure Resident #11 received his enteral nutrition, which was his sole means of nutrition Finding include:Record review, observations and interviews confirmed the facility corrected the deficient practice related to Resident #11's tube feeding prior to the onsite investigation conducted on 2/3/26 to 2/9/26. The deficiency was cited as past non-compliance with a correction date of 1/29/26.I. Facility investigationThe nursing home administrator (NHA) provided an investigation on 2/4/26 at 12:49 p.m. regarding the failure to administer ordered tube feeding to Resident #11. The investigation identified RN #3 and RN #4 as the staff responsible for not administering the resident's tube feeding as ordered.An investigative report documented the initial reported incident on 1/28/26 and follow-up actions that included review of physician orders, record review, staff interviews, resident assessment, continuous education, in-servicing on tube feeding, neglect and reporting. The investigation, corrective actions, and facility wide education were completed on 1/29/26.On 1/28/26 at approximately 4:00 p.m., the resident's tube feeding orders were not administered by the assigned RN. The oncoming shift was provided inaccurate information regarding the tube feeding being on hold, and the resident did not receive tube feeding per physician orders from 4:00 p.m. on 1/28/26 until 6:00 a.m. on 1/29/26.On 1/29/26 at 9:30 a.m., the facility identified the missed tube feeding. The interdisciplinary team (IDT) reviewed Resident #11's physician's orders, the medication administration (MAR) and the treatment administration record (TAR) to verify tube feeding orders and administration. The RN #1 completed a resident assessment and noted no concerns. The facility documented the resident was not interviewable and did not observe any behavioral changes.Interviews documented the day shift (RN #3) said there was no tube feeding formula in the facility, while the assistant director of nursing (ADON) and central supply visually observed tube feeding formula in the facility. The night shift (RN #4) said the day shift nurse advised the tube feeding order was on hold and did not follow up regarding supply status.The investigation documented the resident was not interviewed due to severe cognitive impairment and inability to communicate.The investigation documented RN #3 and RN #4 were identified as the staff responsible for placing the resident's tube feeding orders on hold and not administering tube feeding as ordered on 1/28/26. Documentation and interviews reflected RN #3 placed the tube feeding orders on hold, provided inaccurate information to the oncoming shift regarding the tube feeding being on hold, and did not ensure follow-up regarding tube feeding availability. Interviews documented RN #4 was informed the tube feeding order was on hold and did not follow up to verify tube feeding supply availability or clarify physician orders.The investigation documented interviews documented the day shift RN #3 said there was no tube feeding formula available in the facility. Interviews further documented the ADON and central supply visually observed tube feeding formula available in the facility on 1/28/26.The investigation documented interviews documented the night shift RN #4 said the day shift RN #3 advised the tube feeding order was on hold and said the night shift RN #4 did not follow up regarding tube feeding supply status.The investigation documented the ADON provided a written statement and it read in pertinent part that on 1/28/26 at 6:30 a.m., the ADON informed RN #3 and licensed practical nurse (LPN) #1 that tube feeding formula was scheduled for delivery that day and that formula was available in the facility for immediate use.The DON provided a written statement on 1/29/26 that read in pertinent part, on 1/29/26 at 8:53 a.m., the DON was notified the resident did not receive ordered tube feeding overnight beginning on 1/28/26. The DON contacted RN #3 by phone and RN #3 said there was no tube feeding formula available in the building. The statement documented the ADON confirmed that at 6:30 a.m. on 1/28/26, the resident's tube feeding formula was scheduled for delivery that day and a 1000 milliliter bag of formula was available in the building for immediate use. RN #3 acknowledged the information and said she understood. -However, the resident's order for continuous feeding at 75 ml per hour for 18 hours required 1350 milliliters, therefore the 1,000 milliliter supply was not sufficient to meet the ordered amount.The investigation documented several staff members throughout the facility were interviewed on 1/29/26. All staff interviewed denied concerns related to tube feeding supply availability and identified appropriate steps to take when supplies were unavailable, including contacting the pharmacy or central supply and clarifying physician orders when tube feeding was held.II. Facility plan of correctionA. Immediate action to correct the deficient practice for Resident #11The facility verified the physician's orders for tube feeding and verified tube feeding formula was available. The facility assessed Resident #11 after identifying the missed tube feeding and documented no findings noted. The facility ensured tube feeding was restarted and provided per physician's orders.B. Identification of other residentsOn 1/29/26 the facility reviewed tube feeding orders and documentation for residents receiving tube feeding to identify other residents who could be affected by the deficient practice. C. Systemic changesThe facility provided education and in-servicing on tube feeding, hydration, nutrition, neglect, and reporting requirements. On 1/29/26 the facility completed one-on-one training and competency checklist and evaluated nursing staff on tube feeding skills.D. MonitoringThe facility implemented weekly monitoring of tube feeding orders and tube feeding administration to ensure tube feeding was provided per physician orders.III. Facility policy and procedureThe Care and Treatment of Feeding Tubes Policy, implemented 12/1/25, was provided by the DON on 2/5/26 at 12:10 p.m. The policy read in pertinent part that, Feeding tubes would be utilized according to physician orders, including the kind of feeding and its caloric value, volume, duration, and frequency of flushes. The policy further read that enteral nutrition must be administered consistent with practitioner orders and that licensed nursing staff were responsible for administering tube feeding as ordered and monitoring the resident during tube feeding administration.IV. Resident #11A. Resident statusResident #11, age less than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), the diagnoses included crushing injury of head, dysphagia (difficulty swallowing), hypotension (low blood pressure) and bradycardia (slower than normal heart rate). The 1/21/26 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of zero out of 15. He was dependent on staff with completing all activities of daily living (ADL).B. Resident representative interviewThe resident representative was interviewed on 2/5/26 at 10:44 a.m. She said the DON informed her on 1/29/26 that Resident #11's tube feeding was not administered because the facility ran out of his specific formula, however, they had a similar formula available and initiated that formula. She said she did not notice any changes in Resident #11's condition or behavior around that time. She said she was concerned about his laboratory draws, especially if he went without fluids, as he was dependent on fluids through tube feeding. She said the event caused her significant stress and said Resident #11 would have been upset and would have asked her to move him to another facility. She said this incident increased her fear and anxiety regarding his care planning. She said she was concerned about how staff did not administer his tube feeding, which frightened her, and because of this incident she checked on him more frequently.C. Record review The tube feeding care plan, initiated 5/29/25, documented the resident required tube feeding related to dysphagia. Pertinent interventions included holding the feedings if the residual was between 250 ml and 500 ml, cleansing the percutaneous endoscopic gastrostomy tube (PEG tube) site with normal saline or wound cleanser, patting dry gently with clean gauze, administering extra 200 ml water flushes via G-tube four times a day and flushing 200 ml water via G-tube before and after continuous feeding two times a day, administering continuous Isosource 1.5 via G-tube at 75 ml per hour, obtaining and monitoring lab and diagnostic work as ordered and reporting results to the physician and follow up as indicated, consulting the registered dietitian (RD) quarterly and as needed to monitor caloric intake, estimating needs and making recommendations for changes to tube feeding as needed, and noting the resident was dependent with tube feeding and water flushes and staff were to refer to the physician's orders for current feeding orders.The nutrition care plan, initiated 3/12/25 and revised 1/21/26, documented the resident had a nutritional problem or potential nutritional problem related to swallowing concerns. Pertinent interventions included obtaining and monitoring laboratory and diagnostic work as ordered and reporting results to the physician with follow up as indicated, monitoring, documenting and reporting to the physician as needed signs and symptoms of malnutrition, monitoring, documenting and reporting as needed signs and symptoms of dysphagia, and consulting the RD dietitian to evaluate and make diet change recommendations as needed.A review of progress notes dated 1/28/26 through 1/29/26 revealed the following:A nursing progress note, dated 1/28/26 at 8:28 p.m., revealed the enteral feed order was placed on hold.A nursing progress note, dated 1/29/26 at 4:39 p.m., revealed that the tube feeding remained on hold.-The 1/28/26 and 1/29/26 nursing progress notes did not indicate why the tube feeding was on hold. A review of a nursing progress note, dated 1/29/26 at 1:07 p.m., revealed the physician was notified that the resident's tube feed order was not administered per the order on 1/28/26. The physician gave orders to continue to monitor the resident and report any changes in condition.Review of the February 2026 CPO revealed the following physician's order:Continuous Isosource 1.5 (or equivalent- Jevity 1.2) via G-tube at 75 milliliters per hour (ml/hr) for 18 hours. Start at 6:00 a.m. and run until midnight or until total volume of 1350 ml is reached ordered 2/3/26.V. Staff interviewsLPN #1 was interviewed on 2/4/26 at 3:47 p.m. LPN #1 said he had not experienced issues with insufficient medical supplies to complete resident care tasks and said certified nurse aides (CNA) had not reported running out of supplies. LPN #1 said when supplies were unavailable, staff were expected to contact the pharmacy or obtain supplies from central supply and said in an emergency, staff could obtain needed supplies from a local store. LPN #1 said tube feedings could be held for showers or medical procedures but said a physician order was required to hold or restart tube feeding.The DON was interviewed on 2/5/26 at 11:00 a.m. She said RN #3 did not hang the tube feeding that was due at 4:00 p.m. on 1/28/26 and passed that information to RN #4. She said RN #4 followed RN #3's direction to hold the tube feeding. She said on the morning of 1/29/26 at about 8:50 a.m., while she was at the nurses' station, RN #1 informed her that Resident #11 did not receive his nutrition because RN #3 had told RN #1 the tube feeding was on hold due to no supply of formula available in the building.The DON said she had spoken with the ADON on the morning of 1/28/26 regarding running low on formula, however, there was still 1,000 ml of formula in the building and staff were directed how to obtain it. She said after the event they took measures to ensure the resident maintained adequate nutritional intake, including obtaining a new order for an alternate formula that was available at the facility. She said if staff believed tube feeding cannot be administered due to lack of supplies, they are expected to notify the supply coordinator and the DON. She said the supply coordinator typically placed orders on Monday with expected delivery the next day on Tuesday, however, that week the supplies were not received until Wednesday for an unknown reason.The DON said the required process for handoff communication between shifts was for the nurse giving report to verbally communicated to the next shift and ensured orders were in place. She said she would never tell staff to hold orders and would ensure alternate orders were obtained to maintain continuity of care. She said when tube feeding was not administered as ordered, the physician and power of attorney would be notified.The DON said after the event they ordered laboratory tests for monitoring and results were within normal limits. She said they notified the physician and the physician was not concerned and did not give new orders. She said the laboratory results drawn on 1/29/26 were similar to those obtained on 1/6/26. She said the resident remained at baseline after the event and did not observe distress or behaviors.The DON said it was important for the resident to receive his tube feeding without lapse because he was nothing by mouth and received his nutrition and fluids through tube feeding and if he did not receive it, it could lead to dehydration or weight loss. She said a performance improvement plan was implemented in which a nurse manager audited and ensured supplies were available daily and on Fridays verified there were adequate supplies for the weekend and notified the DON if supplies were low. She said only the physician could hold a tube feeding and she expected the nurses to know this.The supply coordinator was interviewed on 2/5/26 at 12:05 p.m. She said she had worked at the facility for a little over one month. She said her first day of training was on 12/27/25 and she began working as a full time employee the first week of January 2026. She said she prepared the supply orders on 1/26/26 at 12:30 p.m. and the NHA submitted the order on 1/26/26.The supply coordinator said to avoid running out of tube feeding supplies, contingency plans were in place when scheduled deliveries were delayed, such as ordering extra supplies or borrowing from sister facilities. She said staff notified her either verbally or by leaving notes when they were running low on supplies, and she reviewed those daily and would place an order immediately. She said as long as the order was placed before 12:30 p.m., they expect delivery the next business day.The NHA was interviewed on 2/5/26 at 12:50 p.m. She said that Resident #11 was traditionally on Isosource 1.5 and on 1/28/26 the facility did not have Isosource 1.5 available but had Isosource 1.2 available, and the nurse did not hang the tube feeding. She said the nurse was provided information on the morning of 1/28/26 that the next shipment would be delivered between 10:00 a.m. and 2:00 p.m.The NHA said the facility had a system in place to ensure tube feeding supplies were available at all times by completing a sweep of the facility to locate supplies, maintained an additional supply room with extra stock, and if those resources were exhausted, reaching out to sister facilities that carried the same formulas.LPN #2 was interviewed on 2/9/26 at 10:41 a.m. She said she obtained tube feeding formula from the storage room located at each nurse's station and, if none was available, she checked the central supply. She said if no formula was available, she would check other halls and notified her manager, and if after hours, contacted the on-call nurse for assistance.LPN #2 said she received education approximately two weeks ago regarding tube feeding, which included ensuring residents received the correct formula at the correct rate and notified the physician or pharmacy if she noticed inconsistencies in orders. She said when caring for a resident receiving tube feeding, she was expected to communicate with the previous nurse, reviewed progress notes, ensured the feeding was running as scheduled, checked residuals and notify the provider if residuals are greater than 250 ml.LPN #2 said if a nurse told her the order was on hold, she would ask the reason, document it, and contact the DON, pharmacy or the NHA for clarification. She said she would place tube feeding on hold and not hang it only if there was an order to hold or if the resident showed signs of abdominal discomfort, and she would notify the provider immediately.LPN #2 said two weeks ago there were prior supply issues in which limited formula was available and staff coordinated splitting available formula to ensure residents received their feedings. She said she checked the MAR and physician's orders to determine the correct formula and rate. She said she would feel hungry and neglected if she missed getting her meals.LPN #2 said when caring for a resident who did not receive tube feeding, she would contact the physician to determine the reason and notify the DON, and if after hours, she would notify the on-call nurse. She said a tube feeding order could be placed on hold if there was a physician's order, and if residual was above 250 ml then she would have called the physician for verification.LPN #2 said they had not had supply issues with residents who received tube feeding. She said the physician determined the type of formula and if an alternative formula had fewer calories, the physician would have determined the appropriate run rate.RN #2 was interviewed on 2/9/26 at 11:12 a.m. She said approximately two weeks ago she completed education related to tube feeding which included verifying flush rates, confirming tube placement, ensuring the correct resident and administering at the correct time.RN #2 said the dietary department or the physician determined the type of formula. She said if a resident required Isosource 1.5 and the facility only had Jevity 1.2 available, which would create a caloric deficit, she would speak with the RD to ensure the resident's nutritional needs were met. She said she would also consult theRD if a resident receiving Isosource 1.5 was diabetic or experiencing weight gain.RN #2 said if staff were unable to locate formula in the facility after checking available supplies, she would involve leadership including the DON, NHA and charge nurses to obtain formula from nearby sister facilities, and they did not allow a resident to go without tube feeding.The NHA, DON and ADON were interviewed together on 2/9/26 at 1:30 p.m. The NHA said the facility was not notified that Resident #11's tube feeding formula was out. The NHA said on 1/28/26 the facility received the Jevity 1.5 from their shipment. She said the facility identified that it did not have enough Jevity 1.5 available. She said the facility obtained Jevity 1.2 from a sister facility and had the physician's orders updated to run Jevity 1.2 as a substitute.-However, the facility did not provide the resident with any enteral nutrition the night of 1/28/26.The NHA said the vendor dropped off the facility's order at the front of the building and with the housekeeping department. She said she thought the facility's central supply staff was notified of the delivery.The ADON said she told the nurses in the morning on 1/28/26 that the tube feeding formula would be delivered that day.The DON said Resident #11 had a 4:00 p.m. start on the day the order was placed on hold. The DON said she spoke to the nurses who worked on the women's side of the facility. She said the nurses confirmed the tube feeding formula was available but was stored in the basement. She said the nurses went to the basement and retrieved the formula.The DON said once the LPN #2, who started at 6:00 a.m., received notification, LPN #2 called the physician to restart the tube feeding so the resident could receive nutrition. She said the physician provided orders for laboratory tests and to obtain the resident's weight. The DON said that even a late start for a tube feeding was better than not starting the tube feeding at all. The DON said she spoke with the resident's wife and updated her on the resident's tube feeding status.

Based on observations, record review and interviews, the facility failed to ensure two (#5 and #2) of seven residents reviewed for accidents out of 22 sample residents received adequate supervision to prevent accidents. Resident #5 was admitted on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, vascular dementia, unspecified severity, with other behavioral disturbance and unspecified symptoms and signs involving cognitive functions and awareness.Resident #5 was identified as a high fall risk. On 12/25/25, Resident #5 sustained an unwitnessed fall. On 12/29/25, the resident sustained an additional unwitnessed fall. The facility recommended implementing a communication board due to the resident's difficult communication. However, observations during the survey revealed the staff did not utilize the communication board. Resident #5 sustained an additional fall on 1/1/26, where she hit the back of her head. The resident was transferred to the hospital and received five stitches to the back of her head. Upon return from the hospital, the physician documented the staff were ordering a low bed to help prevent falls. However, observations revealed the resident's bed was not in the low position. The resident sustained an additional fall on 1/19/26.Specifically, the facility failed to:-Ensure person centered fall interventions were consistently implemented for Resident #5, who sustained multiple falls;-Ensure person centered fall interventions were implemented for Resident #2. Findings include: I. Facility policy and procedure The Fall prevention program policy, dated 12/1/25, was provided by the nursing home administrator (NHA) on 2/5/26 at 2:38 p.m. It revealed in pertinent part, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The facility utilizes a standardized risk assessment for determining a resident's fall risk. a. The risk assessment categorizes residents according to low, moderate, or high risk. b. For program identification purposes, the facility utilizes high risk and low/moderate risk, using the scoring method designated on the risk assessment. Low/Moderate Risk Protocols: a. Implement universal environmental interventions that decrease the risk of resident falling,including, but not limited to: i. A clear pathway to the bathroom and bedroom doors. ii. The bed is locked and lowered to a level that allows the resident's feet to be flat on the floor when the resident is sitting on the edge of the bed. iii.Call light and frequently used items are within reach. iv. Adequate lighting. v. Wheelchairs and assistive devices are in good repair. b. Implement routine rounding schedule. c. Monitor for changes in resident's cognition, gait, ability to rise/sit, and balance. d.Encourage residents to wear shoes or slippers with non-slip soles when ambulating. e.Ensure eye glasses, if applicable, are clean and the resident wears them when ambulating. f.Monitor vital signs in accordance with facility policy. g.Complete a fall risk assessment every 90 days and as indicated when the resident's condition changes. High Risk Protocols: a. The resident will be placed on the facility's Fall Prevention Program. i. Indicate fall risk on care plan. b. Implement interventions from Low/Moderate Risk Protocols. c. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. d. Provide additional interventions as directed by the resident's assessment, including but not limited to: i. Assistive devices ii. Increased frequency of rounds iii. Sitter, if indicated iv. Medication regimen review v. Low bed vi. Alternate call system access vii.Scheduled ambulation or toileting assistance viii.Family/caregiver or resident education ix. Therapy services referral Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed. When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify the physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of injury. II. Resident #5 A. Resident status Resident #5, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), the diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, vascular dementia, unspecified severity, with other behavioral disturbance, and unspecified symptoms and signs involving cognitive functions and awareness. The 2/2/26 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for a mental status score of zero out of 15. She required partial/moderate assistance with activities of daily living (ADL). The MDS assessment revealed the resident exhibited wandering behaviors on one to three days during the assessment look-back period. The MDS assessment revealed the resident had two or more falls without injury and one fall with injury since her time of admission to the facility. B. Observations During a continuous observation on 2/5/26, starting at 12:15 p.m. and ending at 1:02 p.m., the following were observed: At 12:15 p.m. Resident #5 was assisted to her room from lunch, and assisted to her bed. Resident #5 was left sitting on the side of her bed with her call light in reach.Resident #5 was not wearing a helmet during the observation. At 12:22 p.m. Resident #5 began to stand up and reach out for the blanket that was in her wheelchair. Resident #5 sat back down on the edge of the bed and placed the blanket on her bed. Resident #5 stood back up from the bed and reached out for her bedside table that was not within reach of her. Resident #5 sat back down on the edge of the bed and began to unlock the brakes on her wheelchair that was placed in front of her. Resident #5 stood up from the bed and placed one hand on her transfer pole while using her free hand to continue to unlock the wheelchair. Resident #5 was unstable on her feet. At 12:25 p.m. licensed practical nurse (LPN) #4 was prompted that Resident #5 was walking without assistance. LPN #4 entered Resident #5's room and assisted her to the bathroom. LPN #4 placed Resident #5's wheelchair in the doorway of the bathroom and told Resident #5 to call when she was done on the toilet. LPN #4 exited the room and did not return. Facility staff congregated in the hall near the nurses station, however no one came back to check on Resident #5. At 12:32 p.m. Resident #5 did not push her call light for assistance Resident #5 self transferred from the toilet to her wheelchair and began backing herself out of the bathroom getting her wheelchair stuck on the transfer pole in her room. At 12:46 p.m. Resident #5 self propelled to the bathroom and self transferred from the wheelchair to the toilet. Facility staff were sitting at the nurses' station and talking with each other in the hallway. At 12:54 p.m. Resident #5 self transferred from the toilet back to her wheelchair and continued to self propel out into the hallway. At 1:02 p.m. Resident #5 was assisted back to her room, where staff left Resident #5 sitting in the middle of her room. Resident #5 self propelled back out into the hallway. On 2/9/26 at 9:32 a.m. Resident #5 was sitting in her wheelchair in the hallway by the nurses' station. Resident #5 began to stand up from her wheelchair. LPN #3 intervened and asked Resident #5 if she would like to take a shower. Resident #5 agreed to the shower and attended activities after. C. Record review 1. Care plan The fall care plan, revised on 11/27/24, identified Resident #5 was a high risk for falls related to a history of frequent falls, impaired safety awareness, left sided weakness secondary to history of a cerebrovascular accident (stroke), seizure disorder and medication use. Pertinent interventions (revised on 12/1/25) included placing anti-rollbacks to the resident's wheelchair, applying anti tippers to the resident's wheelchair, applying grip tape and bright pink reflective tape to restroom floor, apply grip tape next to bed to help prevent falls/injuries, assisting Resident #5 with toileting every two hours for fall prevention, giving Resident #5 a soft touch call light to make it easier for her to call for assistance, ordering a helmet to try and prevent injury with future falls and moving the resident's room closer to nurses' station to increase line of sight. The fall care plan, revised on 11/27/24, identified Resident #5 had sustained multiple falls prior to her long term care stay and during her stay related to poor safety awareness, unsteady gait, impulsivity, and poor cognition. The care plan documented Resident #5 falls were unavoidable. Pertinent interventions (revised on 1/2/26) included placing belongings within reach of Resident #5. -However during observations revealed person centered fall interventions were not consistently implemented for Resident #5 (see observations above). 2. Fall on 12/25/25 - unwitnessed The 12/25/25 nursing progress note documented at 10:50 a.m. revealed Resident #5 had an unwitnessed fall. Staff heard a noise from Resident #5's room and immediately responded. Resident #5 was found on the floor next to her bedside and wheelchair. Resident #5 was assessed and assisted from the floor. No injuries noted. 3. Falls on 12/29/25 - unwitnessed The 12/29/25 nursing progress note documented at 12:11 p.m. revealed the nurse was notified that Resident #5 had fallen in the bathroom while brushing her hair. The note documented no injuries were noted. The 12/29/25 nursing progress note documented at 6:03 p.m. revealed the nurse made aware that Resident #5 was found by a certified nurse aide (CNA). Resident #5's wheelchair was at the door of the bathroom. Resident #5 was on the floor at the sink on her left side attempting to get up independently. No injuries were noted. The 12/30/25 interdisciplinary team (IDT) progress note was documented at 10:04 a.m. revealed the IDT met to discuss Resident #5's fall on 12/29/25. A new intervention was put in place to use a communication board to aide in providing care for Resident #5's basic needs in attempt to decrease Resident #5's frustration while trying to communicate her needs. Resident #5 became angry when staff was unable to understand Resident #5. The note documented Resident #5 would get up out of her wheelchair and attempt to ambulate while being unsteady. Resident #5's care plan was reviewed and updated. -However during observations made on 2/5/26 staff were not observed using a communication board with Resident #5 (see observations above). 4. Fall on 1/1/26 - unwitnessed The 1/1/26 nursing progress noted documented at 6:31 a.m. revealed Resident #5 was found sitting on the floor in her room at 4:30 a.m. Resident #5 was attempting to get out of bed for a drink of water and slipped. Resident #5 was wearing regular socks. The note documented the resident may need non-skid footwear while in bed. Resident #5's tray table was moved closer to Resident #5's bedside. Resident #5 was kept in the common area for better visualization until she requested to go back to bed. The 1/2/26 nursing progress note documented at 1:10 a.m. was struck out in error but revealed Resident #5 had an unwitnessed fall with injury. Staff heard a loud noise coming from Resident #5's room. Resident #5 was found on her hands and knees in front of the bathroom door. Resident #5 was wearing proper footwear. The note documented the resident was transferring without her wheelchair and without staff assistance. The note documented blood was observed dripping from Resident #5's chin. A laceration was identified on the right backside of Resident #5's head. The registered nurse (RN) was notified to perform an assessment and emergency services were notified. The 1/2/26 nursing progress note documented at 3:20 a.m. revealed Resident #5 returned to the facility from the hospital after receiving five stitches to the laceration. Resident #5 was alert and oriented to the room. The 1/2/26 hospital summary revealed Resident #5 was treated for head injury involving a laceration that required stitches or staples. The 1/7/26 physician's progress note documented Resident #5 had repeated falls. The note documented the staff were ordering the resident a low bed. The resident denied pain. The note documented the staff reported agitation and most of the resident's falls occurred when she was attempting to use the bathroom. The note documented the hospice nurse indicated the resident was constipated and a laxative was ordered. -However, observations revealed the resident's bed was not in a low position (see observations above). 5. Fall on 1/19/26 - unwitnessed The 1/19/26 nursing progress note documented at 12:06 a.m. revealed the nurse heard a loud thud and found Resident #5 sitting on the floor in her room next to the bed and her wheelchair. Resident #5 got herself into her wheelchair and declined to be assessed. Resident #5 continued to assist herself to the bathroom. The nurse provided a stand by assist while Resident #5 toileted. Resident #5 continued to deny the physical assessment. No injuries were observed. Neurological checks were implemented. D. Staff interviews CNA #4 was interviewed on 2/9/26 at 9:45 a.m. CNA #4 said she used the Kardex (staff directive tool) to determine if a resident was at risk for falls. CNA #4 said fall interventions were also included on the Kardex. CNA #4 said good practice in general for anyone who was at a high fall risk was to ensure she was rounding timely. CNA #4 said she typically rounded every hour unless specified. CNA #4 said if she found a resident on the floor she would ensure the resident was safe and then notify the nurse immediately. CNA #4 said they then began 15-minute vital sign checks and documented them. CNA #4 said if the vital signs were not within normal limits, she would notify the nurse immediately. LPN #3 was interviewed on 2/9/26 at 10:30 a.m. LPN #3 said she gave Resident #5 activities to do, including a fidget board that she can play with or watching movies in her room. LPN #3 said Resident #5 could tell the staff what movie she wanted to watch. LPN #3 said Resident #5 also attended activities and the hospice staff came every other day. LPN #3 said hospice staff would l provide one-to-one with Resident #3 for up to three hours. LPN #3 said Resident #5 also enjoyed taking showers. LPN #3 said the showers helped relax Resident #5, however LPN #3 said Resident #5 was a private person so she also did not like to be watched especially when she was in the bathroom. LPN #3 said Resident #5 was capable of standing on her own, but was not stable enough to walk. LPN #3 said Resident #5 could show signs of aggression by reaching for the staff's ID badge or reaching for the staff's hair. LPN #3 said when a resident fell, the nurse would assess the resident and then notify family, provider. She said since Resident #5, she would also contact the hospice staff to inform them of the fall. LPN #3 said she would assess the residents vital signs and if the fall was unwitnessed she would begin a neurological assessments. The director of nursing (DON) was interviewed on 2/9/26 at 12:33 p.m. The DON said the facility would implement a plan to ensure Resident #5 was not left alone while toileting. The NHA and the DON were interviewed together on 2/9/26 at 3:04 p.m. The NHA said the staff needed to do more training on purposeful rounding. She said purposeful rounding would be beneficial in regards to the high amount of falls in the facility. The DON said getting ahead of the residents' needs before they tried to do things on their own would help reduce the amount of falls. The DON said in order to tell if an intervention was successful the DON said a big portion would be through feedback from the nursing staff. The NHA said they also discussed falls during their team leadership rounds, after morning meetings, and during each shift change a huddle at each nurses' station to be able to provide training. III. Resident #2 A. Resident status Resident #2, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included dementia, protein-calorie malnutrition and a history of falling. The 1/15/26 MDS assessment documented the resident was severely cognitively impaired with a BIMS score of zero out of 15. The resident required substantial/maximum assistance for chair to bed or bed to chair transfers, partial/moderate assistance for dressing including footwear, hygiene and bed mobility, and set up assistance at meals. The assessment documented the resident had a fall with injury and did not refuse care. B. Observations On 2/4/26 a continuous observation was conducted from 2:36 p.m. to 3:40 p.m. At 2:36 p.m. Resident #2 was in bed in her room. The resident's wheelchair was next to her bed. The resident remained in bed until 3:40 p.m. A fall mat was not placed next to the bed while the resident was in bed and the bed was not in the lowest position. The fall mat was folded in half next to the wall in the residents's room. On 2/5/26 Resident at 11:15 a.m. Resident #2 was observed in her room in her wheelchair sitting next to her bed. Resident #2 self transferred from her wheelchair into her bed, leaving the wheelchair at her bedside. The resident's red locking pedal under the bed was up and the green pedal was down. On 2/5/26 at 11:30 p.m. the resident remained in bed. A fall mat was not on the floor next to the resident's bed. On 2/5/26 at 11:54 p.m. the resident remained in bed. A fall mat was not on the floor next to the resident's bed. On 2/5/26 at 12:13 p.m. an unidentified staff member entered Resident #2's room. The unidentified staff member looked at Resident #2, asked where the resident's roommate was and then exited the room. The unidentified staff member did not place a fall mat next to the resident's bed, or ensure the resident's bed was in a locked position (see CNA #2 interview below). On 2/5/26 at 12:30 p.m. Resident #2 remained in her bed. There was no fall mat on the floor by the bed and the bed remained in an unlocked position. On 2/9/26 at 10:17 a.m. Resident #2 was observed sitting in her wheelchair in her room. The resident had on regular socks and no shoes. The resident's red locking pedal under the bed was up and the green pedal was down. (see CNA #2 interview below). C. Record review Resident #2's care plan, revised 1/15/25, documented the resident was at moderate risk for falls as related to her poor safety awareness secondary to dementia disease progression. Pertinent interventions included to be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed and the resident needed prompt response to all requests for assistance (10/18/23); provide the resident with tennis shoes to help with ambulation (12/18/23); provide the resident wheelchair education to lock brakes prior to self transfer (revised 12/01/25); the resident was able to transfer independently, however, benefited from contact guard assist (CGA) to promote safety as she allowed (revised 12/01/25). Additional fall interventions added after the resident's fall on 12/31/26 included to ensure the resident had proper footwear (1/2/26), a fall mat to be placed when the resident was in bed (1/12/26) and for the bed to be in the lowest position (1/20/26). -The resident's care plan did not document the resident refused care planned interventions for falls. A review of the resident's progress notes revealed the resident's sustained falls on 12/28/25, 12/31/25, 1/10/26 and 1/20/26: A 12/28/25 nursing progress note documented at 4:20 a.m. the nurse was notified at 4:15 a.m. that the resident stated that she had fallen. The resident claimed to have fallen on her bottom after returning to her bed from using the restroom. The resident stated that she had used the walker to transfer herself, and the resident was noted to be wearing non-slip socks. The resident stated she had pain in her left leg. A 12/29/25 nursing note at documented 7:08 a.m the resident had Xrays that showed moderately displaced fractures of the right superior and inferior pubic rami (pelvis). No dislocation was identified. There were moderate degenerative changes and bones were osteopenic. The physician was notified and orders were placed to send the resident to the ED. A 12/29/25 nursing progress note documented at 3:41 p.m. the facility received a call from the hospital that stated the resident received pelvis imaging and only found old fractures, no new fractures were identified. A 12/31/25 nursing progress note documented at 11:50 a.m. that the resident was found on the floor. A post-fall assessment was completed. There were no obvious deformities noted to any extremities. A neurological assessment was performed and the resident noted to be at her baseline. When asked if she struck her head, the resident shook her head no. The resident was observed yelling out in pain and guarding right hip and the nurse practitioner (NP) at the resident's bedside to complete an assessment. New orders were received to transfer the resident to the emergency department for further evaluation and to rule out an injury to the right hip. A 1/1/26 nursing progress note documented at 12:19 a.m. that the resident returned from the hospital at 6:35 p.m. via a stretcher with a diagnosis of hypokalemia, a stable pelvic fracture and weight bearing as tolerated. A 1/10/26 nursing progress note documented at 2:20 a.m. the resident was assessed for a fall with head involvement. The resident was observed while still on the floor and her baseline physical and cognitive function was intact. There were no new limb deformities, bruising or bleeding. A small hematoma was noted at the back of the head. No spinal tenderness was noted but the resident endorsed pain. A 1/10/26 nursing progress note documented at 2:30 a.m. that a CNA opened the door to the residents room to answer a call light at 2:15 a.m. and observed the resident fall out of bed onto her head. A RN assessed the resident. A hematoma was noted to the back of the resident's head, and her right shin had a small skin tear with bruising. The nurse practitioner (NP) was notified with a recommendation to follow up with imaging later in the morning as the resident declined to go to the hospital. A 1/10/26 nursing progress note documented 4:35 a.m. an intervention was implemented to place a fall mat at the resident's bedside while the resident was in bed. A 1/10/26 nursing progress note documented at 11:40 p.m. the nurse assessed the resident and the resident's pupil response was non-reactive and the resident was unable to follow commands. The resident was observed to have altered mental status, the physician was notified and an order was placed to have the resident sent to the emergency department for further evaluation. -The nursing progress notes failed to document the date the resident returned to the facility or results of the emergency department evaluation. A 1/20/26 nurses note documented at 3:14 a.m. the staff heard the resident calling out and observed the resident sitting on her bottom on a fall mat next to her bed. The resident reported she was trying to roll over and get into a better position and rolled out of bed. The resident denied hitting her head and denied pain. The resident was assessed by an RN. An immediate intervention to replace the resident's bed with a high/low bed that lowered to the floor was implemented. D. Staff interviews CNA #2 was interviewed on 2/9/26 at 10:18 a.m. CNA #2 said when the green pedal on a resident's bed was pushed down the bed was not locked. CNA #2 said Resident #2's bed should be locked. -CNA #2 then used her food to push down on the red pedal under the bed to lock the bed. The DON, the NHA and regional clinical resource #2 were interviewed together on 2/9/26 at 3:05 p.m. The DON said Resident #2 could answer yes and no questions and was able to state her needs. The DON said the resident had a fall mat added to her care plan but did not know the resident self transferred and did not remember the self transfers being part of the facility's IDT discussion for Resident #2's falls. Regional clinical resource #2 said the facility did review Resident #2's falls and her care plan including her fall mat intervention and talked further on 2/9/26 about Resident #2. The NHA said she did not know if the Resident #2's bed was checked and locked at the time of the resident's fall (on 12/31/25). Regional clinical resource #2 said the facility staff checked all the beds in the facility on 2/9/26 to ensure the beds were locked. She said the ordered a new bed from hospice for Resident #2 that included a specialty mattress and a remote control. She said the staff assisted Resident #2 in putting on non-skid socks in the morning (2/9/26 after the resident was observed without appropriate footwear per the resident's care planned interventions). She said Resident #2 used contact guard assist in her care plan to assist and was able to transfer by herself. The DON said when the facility did fall investigations, if the staff were unable to gather the needed information from the fall reports they further discussed the resident's falls with the staff during their daily meetings. The DON said the facility had provided education to the staff on purposeful rounding of the residents with the staff to look for improvement on getting ahead of residents needs before the residents tried to do things on their own. The DON said staff feedback was a good portion of the fall interventions and they discussed as a team if a fall intervention was not working.

Based on record review and interviews, the facility failed to ensure two (#1 and #10) of four residents reviewed, out of a total sample of 22 residents, remained free of significant medication errors. Specifically, the facility failed to:-Ensure staff timely and accurately updated Resident #1's Methadone dose and indicated use in his electronic medical record (EMR) per external provider orders; -Ensure staff accurately administered and documented the dose of Methadone Resident #1 received in his medication administration record (MAR); -Ensure staff implemented and documented care interventions to identify, assess, monitor, or treat Resident #1's specific triggering/craving behaviors related to his documented history of substance use disorder (SUD); -Ensure staff obtained a standing order to administer Narcan to Resident #1, who had a history of SUD and was currently prescribed opioid medications; and,-Ensure Resident #10's antibiotic was administered per the provider's order.Cross-reference F842: the facility failed to ensure staff maintained a complete and accurate medical record. Findings include: I. Facility policy and procedure The Medication Administration policy and procedure, revised 11/6/25, was provided by the nursing home administrator (NHA) on 2/5/26 at 3:07 p.m. It read in pertinent part: 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 Medication Orders policy and procedure, dated 12/1/25, was provided by the NHA on 2/5/26 at 3:07 p.m. It read in pertinent part, Medications should be administered only upon the signed order of a person lawfully authorized to prescribe. Verbal orders should be received only by licensed nurses, or pharmacists, and confirmed in writing by the physician, on the next visit to the facility (See Verbal Orders Policy). Documentation of Medication Orders: -Each medication order should be documented with the date, time, and signature of the person receiving the order. The order should be recorded on the physician order sheet, and the Medication Administration Record (MAR). -Clarify the order. -Enter the order on the medication order and receipt record. -If using electronic medication records, input the medication order according to the electronic health record (EHR) instructions and facility policy. -Call or fax the medication order to the provider pharmacy. -Transcribe newly prescribed medications on the MAR or treatment record or ensure the order is in the electronic MAR. -When a new order changes the dosage of a previously prescribed medication, discontinue previous entry by writing DC'd and the date, or discontinue the order as per the electronic software instructions and retype the new order. -Enter the new order on the MAR or ensure the new order is in the electronic MAR. -Notify resident's sponsor/family of new medication order. II. Methadone failures A. Resident #1 status Resident #1, age less than [AGE] years old, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), the diagnoses included displaced fracture of fifth cervical (neck) vertebrae, functional quadriplegia (paralysis), post traumatic stress disorder (PTSD), schizophrenia, chronic pain due to trauma, and neuromuscular dysfunction of bladder. The 11/18/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. He required partial assistance with bed mobility and transfers, and required substantial assistance with sit to stand transfers and toileting. The resident did not exhibit verbal or physical behaviors toward others during the assessment period. He did not have any episodes of rejecting care. B. Record review A 12/18/25 addiction provider visit note was provided by the NHA on 2/4/26 at 1:28 p.m. It documented Resident #1 reported still experiencing cravings while taking Methadone 40 milligrams (mg) daily. It documented the treatment plan for Resident #1's relapse prevention was increasing his Methadone dose to 50mg daily. A review of Resident #1's December 2025, January 2026 and February 2026 CPO revealed the following physician orders: Methadone oral concentrate 10 mg per 10 milliliters (mL). Give 40 mg by mouth in the morning for pain. Start date 9/19/25. Discontinue date 1/20/26. Methadone oral concentrate 10mg/mL. Give 50 mg by mouth in the morning for pain. Start date 1/20/26. Discontinue date 2/2/26. Monitor for nausea, constipation, itchiness, drowsiness, slowed breathing, or euphoria every shift for opioid/narcotic medication use. Start date 8/21/25. -However, a review of Resident #1's addiction provider's note (see above) documented Resident #1's Methadone dose was increased to 50 mg orally daily after his visit on 12/18/25, over one month before the dose was updated in Resident #1's EMR. -Additionally, the 12/18/25 provider's note (see above) documented the indicated use for Resident #1's Methadone was relapse prevention. However, a review of Resident #1's December 2025, January 2026, or February 2026 CPO revealed pain was the indicated use documented for Resident #1's Methadone. -Review of Resident #1's February 2026 CPO revealed no documented orders to identify/monitor/assess/document the resident's triggers and/or cravings related to his history of SUD or relapse prevention. -A review of Resident #1's February 2026 CPOs revealed no documented diagnoses addressing the resident's history of SUD. Resident #1's Methadone narcotic count sheets, dated from 12/26/25 to 1/23/26, were provided by the NHA on 2/3/26 at 3:46 p.m. and revealed the following: The narcotic count sheet, dated 12/26/25 to 1/2/26, documented the facility received seven bottles of Methadone on 12/26/25. The count sheet contained handwritten documentation, including the resident's name, the medication, and the administration route. It documented Resident #1 was administered Methadone orally on 12/27/25, 12/28/25, 12/29/25, 12/30/25, 12/31/25, 1/1/26, and 1/2/26. -Review of the 12/26/25 to 1/2/26 narcotic count sheet revealed facility staff failed to document the strength of Methadone received from the pharmacy for Resident #1. Additionally, Resident #1's December 2025 and January 2026 MAR documented the resident was administered Methadone 40 mg on 12/27/25, 12/28/25, 12/29/25, 12/30/25, and 12/31/25, 1/1/26, and 1/2/26. This was against Resident #1's addiction provider's order to administer Methadone 50 mg daily (see provider note above). The narcotic count sheet, dated 1/2/26 to 1/9/26, documented the facility received seven bottles of Methadone on 1/2/26. The count sheet included the following sections to be filled out by facility staff: resident name, room number, medication name, dose and route of administration, prescribing physician, starting count, and signature of nurse receiving the medication. The count sheet documented Resident #1's name, room number, medication name, route of administration, starting count, and the signature of the nurse receiving the medication. The count sheet documented Resident #1 was administered Methadone on 1/3/26, 1/4/26, 1/5/26, 1/6/26, 1/7/26, 1/8/26, and 1/9/26. -Review of the 1/2/26 to 1/9/26 narcotic count sheet revealed facility staff failed to document the strength of Methadone received from the pharmacy for Resident #1, as the count sheet indicated. Additionally, Resident #1's January 2026 MAR documented the resident was administered Methadone 40mg on 1/3/26, 1/4/26, 1/5/26, 1/6/26, 1/7/26, 1/8/26, and 1/9/26. This was against Resident #1's addiction provider's order to administer Methadone 50 mg daily (see provider note above). The narcotic count sheet, dated 1/10/26 to 1/16/26, documented the facility received seven bottles of Methadone 50 mg on 1/10/26. The count sheet documented Resident #1 was administered Methadone 50 mg on 1/10/26, 1/11/26, 1/12/26, 1/13/26, 1/14/26, 1/15/26, and 1/16/26. -However, Resident #1's January 2026 MAR documented the resident received Methadone 40 mg orally on 1/10/26, 1/11/26, 1/12/26, 1/13/26, 1/14/26, 1/15/26, and 1/16/26. This was against Resident #1's addiction provider's order to administer Methadone 50 mg daily (see provider note above). The narcotic count sheet, dated 1/16/26 to 1/23/26, documented the facility received seven bottles of Methadone 50mg on 1/16/26. The count sheet documented Resident #1 was administered Methadone 50mg on 1/17/26, 1/18/26, 1/19/26, 1/20/26, 1/21/26, 1/22/26, and 1/23/26. -However, review of Resident #1's January 2026 MAR documented the resident received Methadone 40 mg orally on 1/17/26, 1/18/26, 1/19/26, and 1/20/26. This was against Resident #1's addiction provider's order to administer Methadone 50 mg daily (see provider note above). -Additionally, a review of Resident #1's January 2026 CPO revealed orders to discontinue Methadone 40 mg daily and start Methadone 50 mg daily, both entered on 1/20/26 (see above). This was over one month after Resident #1's addiction provider visit on 12/18/25 (see provider note above), where his Methadone dose was increased to 50mg daily. The substance abuse care plan, revised 11/27/25, documented Resident #1 had a history of methamphetamine substance abuse. Interventions included: encouraging the resident to discuss his feelings and concerns (initiated 8/19/25), inviting the resident to activities to divert attention (initiated 8/19/25), and offering the resident mental health services (initiated 8/19/25). The psychosocial care plan, revised 11/27/25, documented Resident #1 had a psychosocial well-being problem related to previous homelessness, dependent behavior, pain in his back and legs, and a history of alcohol and substance abuse. Interventions included: allowing the resident time to answer questions and verbalize feelings (revised 12/1/25), increasing communication between resident/family/caregivers about care and living environment (initiated 8/20/25), and providing opportunities for the resident and family to participate in care (initiated 8/20/25). -A review of Resident #1's care plan revealed no documented care interventions to identify/address/monitor/document the resident's Methadone use, or his triggers/cravings related to his history of SUD. III. Narcan failures A. Record review A nurse note, dated 1/26/26 at 8:09 p.m., documented at approximately 5:00 p.m. Resident #1 was found unresponsive. It documented that upon assessment, Resident #1's respiratory rate was 11 breaths per minute. It documented the nurse administered one spray of Narcan into each of Resident #1's nostrils with immediate results. It documented emergency medical services (EMS) were activated, and Resident #1 was transferred to the hospital. It documented Resident #1's provider was notified. A nurse note, dated 1/26/26 at 9:09 p.m., documented Resident #1's addiction clinic was contacted to schedule an appointment for increased lethargy, disorientation, and sedation after the resident's Methadone dose was increased. It documented a meeting was requested to discuss lowering Resident #1's Methadone dose from 50 mg back to 40 mg daily per the resident's primary provider's recommendation. It documented staff were awaiting a call back from Resident #1's addiction provider. -A review of Resident #1's progress notes revealed no documentation the resident was experiencing increased lethargy, disorientation, or sedation before the incident on 1/26/26, when he was administered Narcan. A review of Resident #1's January 2026 CPO revealed a physician's orders for Narcan nasal liquid 4 milligram (mg) per 0.1 milliliters (mL). Spray one spray to alternating nostrils as needed for opioid overdose. May Repeat in five minutes if needed up to one dose. Start date 1/30/26. -However, review of the resident's CPO revealed no documented orders to administer Narcan to Resident #1 on 1/26/26, or standing orders to administer Narcan to Resident #1 as needed for potential opioid overdose before 1/30/26 (four days after the resident was administered Narcan without a physician's order). Additionally, a review of Resident #1's January 2026 MAR revealed no documented administration of Narcan to Resident #1 on 1/26/26. D. Staff interviews Licensed practical nurse (LPN #1) was interviewed on 2/3/26 at 4:27 p.m. LPN #1 reviewed Resident #1's EMR and said the resident's Methadone dose was increased to 50 mg on 1/20/26. LPN #1 said he was unsure why the resident's dose was increased. LPN #1 said Resident #1's Methadone dose was managed and adjusted by an external provider. LPN #1 said a few days before the incident on 1/26/26, Resident #1 was exhibiting increased lethargy and difficulty arousing. LPN #1 said he reported this to Resident #1's primary provider, who advised staff to notify Resident #1's pain provider. -However, review of Resident #1's progress notes revealed no documentation of Resident #1's symptoms or provider notification before the incident involving Narcan administration on 1/26/26. LPN #1 said on 1/26/26 at approximately 5:00 p.m., he was alerted that Resident #1 was unresponsive. LPN #1 said upon initial assessment, Resident #1's respiratory rate was 12 breaths per minute. LPN #1 said he reported Resident #1's change in condition to the director of nursing (DON), and was advised to contact the resident's provider and prepare to administer Narcan. LPN #1 said upon returning to Resident #1's side, he observed the resident's respiratory rate to be 10 breaths per minute. LPN #1 said he administered Narcan to Resident #1, and the resident's eyes opened immediately. LPN #1 said he was unsure why Resident #1 did not have a standing order for Narcan on file before the incident on 1/26/26. LPN #1 said he spoke with Resident #1's nurse practitioner about not having an order, which prompted the Narcan order entered on 1/30/26. -However, the standing order to administer Narcan to Resident #1 as needed was entered four days after Resident #1 required Narcan administration on 1/26/26. Additionally, the facility failed to have a standing order for Narcan in place for Resident #1, who had a known history of SUD, and orders for Methadone and Oxycodone. The DON was interviewed on 2/4/26 at 11:05 a.m. The DON said upon being alerted of Resident #1's change in condition, she went to the resident's side. The DON said she performed a sternal rub, and Resident #1 moved. The DON said she advised LPN #1 to notify Resident #1's provider due to her concern the resident needed a higher level of care and/or Narcan. The DON said she was not present when LPN #1 administered Narcan to Resident #1. The DON said Resident #1's provider was notified before LPN #1 administered Narcan to the resident. The DON said LPN #1 would need to confirm the medication order and dose with the resident's provider to ensure accurate medication administration. The DON said she was unsure why Resident #1's Methadone dose was increased or when his increased lethargy symptoms started. The DON said if a resident's external provider changed any orders, facility staff should fill out a physician communication form, review the orders with the resident's primary provider, and update the resident's EMR as needed. The DON said the facility's health information manager ceased working at the facility on 1/26/26. The DON said she was unsure what the complete process was for reviewing external provider notes and updating the resident's EMR. The ADON was interviewed on 2/4/26 at 11:14 a.m. The ADON said when residents returned from external provider visits, transportation staff would hand a copy of the physician communication form to the resident's floor nurse, unit manager (UM), or ADON. The ADON said the resident's nurse or nurse managers were responsible for reviewing the orders and updating them in the EMR. LPN #1 was interviewed a second time on 2/4/26 at 11:33 a.m. LPN #1 confirmed he spoke with the DON regarding the resident's change in condition on 1/26/26 and then returned to Resident #1's side. LPN #1 said he observed Resident #1's respiratory rate to be 10 breaths per minute. LPN #1 said because of Resident #1's lowered respiratory rate, he took the initiative and administered Narcan to the resident. LPN #1 said he did not have a chance to notify the provider and obtain an order before he administered the Narcan to Resident #1. LPN #1 confirmed he did not document the Narcan administration in Resident #1's MAR. The DON and regional clinical resource #1 were interviewed on 2/5/26 at 11:05 a.m. The DON said no emergency medications were kept in the facility's emergency response cart, and the facility did not have standing orders to administer Narcan to residents as needed. The DON said she was unsure why Resident #1 did not have a standing order for Narcan. The DON said if a resident experienced a change in condition, the nurse should gather information, notify the resident's provider, and implement orders received. The DON said for any new treatments, the nurse needed to obtain an order from the physician before performing a treatment to ensure accurate ordering and resident safety. The DON said all treatments and medication administrations should be documented in the MAR. The DON said she was unaware LPN #1 did not contact Resident #1's provider, obtain an order before administering Narcan to the resident, or document the Narcan administration in the resident's MAR. The DON said after reviewing any external provider orders and updating the resident's EMR, the nursing staff should place communication forms into the medical records box to be uploaded into the resident's EMR. The DON said she was unsure if there was a backlog of resident records needing to be uploaded and/or how long one had been present. The DON said it was important to maintain an accurate medical record to ensure accurate treatment and continuity of care. The DON said a potential risk of not maintaining accurate medical records was the potential for untimely updates to resident care orders, which could lead to adverse resident care outcomes. The DON confirmed Resident #1 was taking Methadone due to his history of SUD. The DON also confirmed, as per Resident #1's February 2026 CPOs, that the documented indicated use for Methadone was pain. The RCR said Resident #1's pain provider note documented the indicated reason for Methadone use was pain. -However, [NAME] clinical resource #1 was unable to confirm whether Resident #1 was being seen by his addiction provider for pain management or his history of SUD and cravings management. The DON confirmed Resident #1's indicated use for Methadone should be SUD and cravings management, not specifically pain relief, based on a review of Resident #1's 12/18/25 visit note. The DON said the communication form was not received from his addiction provider on 12/18/25, which led to the delay in his Methadone dose being updated in Resident #1's EMR. The DON said it was important for Resident #1's methadone use and his substance use triggers and cravings to be identified on the care plan to assist staff in monitoring for signs and symptoms of adverse effects, effectiveness of interventions, and any potential change in condition related to the resident's Methadone use. Resident #1's primary care physician (PCP) was interviewed on 2/9/26 at 1:39 p.m. The PCP said Resident #1 was vague about his history of SUD. The PCP said Resident #1 would admit to having a history of SUD, however, the PCP was unsure what specific substances the resident had taken in the past. The PCP said he assumed Resident #1's substance abuse history was related to narcotic and/or opioid pain medication use. The PCP said Resident #1's Methadone dose was increased approximately two to three weeks before, and he was unsure why the resident's dose was increased. The PCP said he was not aware Resident #1 was administered Narcan on 1/26/26. The PCP said he saw Resident #1 on 1/26/26, and the resident was lethargic but responsive. The PCP said he had exited the building before Resident #1's change in condition on 1/26/26, and after hours calls were answered by an on-call answering service. The PCP said facility staff contacted him recently regarding Narcan orders, however, he was unable to specify the date. The PCP said it was his understanding that the facility was asking for a standing Narcan order for any resident receiving Methadone or opioid pain medication, not specifically for Resident #1. The PCP said he expected facility staff to notify him if a resident experienced a change in condition. The PCP said it was important because a delay in notification could lead to critical results or consequences to the resident. -In a follow-up message received from the PCP on 2/9/26 at 2:28 p.m., the PCP said he went through the on-call notes for 1/26/26 and found a note reporting the incident and administration of Narcan. However, there was no mention an order to administer Narcan being given before the administration to Resident #1 on 1/26/26. A. Resident #10 status Resident #10, age less than 65, was admitted on [DATE]. According to the February 2026 CPO, the diagnoses included neuronal ceroid lipofuscinosis (the accumulation of auto fluorescent lipopigment in neurons, leading to vision loss, seizures, cognitive decline, motor skill loss, and frequently, a shortened lifespan), pervasive developmental disorder unspecified, acute respiratory failure with hypoxia, and personal history of pneumonia (recurrent). The 10/30/25 MDS assessment revealed the resident had short term and long term memory impairment and had moderate impairment in making daily decisions. The resident was unable to recall the current season, staff's names or faces, or where her room was located. She was completely dependent on staff for all activities of daily living (ADLs). B. Record review The December 2025 MAR revealed the physician ordered Doxycycline Hyclate tablet 100 mg by mouth two times a day for an infection. Ordered on 12/24/25 and discontinued on 12/31/25. However, blanks on the MAR revealed Resident #10 did not receive the medication on the evening shift on 12/24/25 and the morning shift on 12/25/25. The evening shift on 12/25/25 documented a 9, which indicated there was a corresponding progress note. -However the resident's EMR did not include a progress note to provide an explanation as to why Resident #10 was not administered the medication The 12/26/25 nursing progress note documented at 1:12 a.m. revealed the antibiotic had not arrived from the pharmacy, however the MAR documented the medication was administered even though it had not arrived from the pharmacy. The 12/26/25 nursing progress note documented at 4:48 p.m. revealed Resident #10 was on continued monitoring for the start of doxycycline. C. Staff interviews LPN #3 was interviewed on 2/4/26 at 12:47 p.m. LPN #3 said the administration of medications was documented on the MAR. She said she was unsure if blank boxes on the MAR meant the resident was not administered a medication. The DON was interviewed on 2/4/25 at 1:13 p.m. The DON said the blank spaces on the MAR indicated that the medication was not administered to the resident. She confirmed Resident #10 was not administered doxycycline on the days which had a corresponding black space on the December 2025 MAR. The DON said Resident #10's medical record did not contain a progress note on the evening shift on 12/25/25 indicating the reason the resident was not administered doxycycline. The DON said the medication was delivered from the pharmacy on 12/26/25 and was administered on 12/26/25. She confirmed Resident #10 did not receive three doses of doxycycline.

Based on record review and interviews, the facility failed to maintain accurate and complete medical records for one resident (#1), of four residents reviewed out of a sample of 22 residents. Specifically, the facility failed to ensure Resident #1's addiction provider notes were obtained and uploaded into the resident's electronic medical record (EMR). Findings include:I. Facility policy and procedureThe Documentation In Medical Record policy and procedure, dated 12/1/25, was provided by the nursing home administrator (NHA) on 2/5/26 at 3:07 p.m. It read in pertinent part: 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.II. Resident statusResident #1, age less than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), the diagnoses included displaced fracture of fifth cervical (neck) vertebrae, functional quadriplegia (paralysis), post traumatic stress disorder (PTSD), schizophrenia, chronic pain due to trauma, and neuromuscular dysfunction of bladder.The 11/18/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. He required partial assistance with bed mobility and transfers. He required substantial assistance with sit to stand and toileting. transfers. B. Record reviewA review of Resident #1's February 2026 electronic medical record (EMR) revealed no documentation regarding the resident's visits to the addiction provider visit notes since the resident's admission to the facility on 8/18/25. Upon request, the NHA obtained and provided addiction provider visit notes for Resident #1, on 2/4/26 at 1:28 p.m., for the dates 9/18/25, 12/18/25, and 1/27/26. The provider visit notes documented the following:The 9/18/25 addiction provider note documented Resident #1 was seen for methadone dose optimization. It documented Resident #1 was currently taking methadone 30 milligram (mg) daily. It documented Resident #1 reported intense cravings and drug dreams. It documented the treatment plan was to increase Resident #1's methadone to 40 mg daily.The 12/18/25 addiction provider note documented Resident #1 was seen for a dose adjustment of his methadone. It documented Resident #1 reported continued cravings while taking methadone 40 mg daily. It documented the treatment plan was to increase Resident #1's methadone to 50 mg daily. The 1/27/26 addiction provider note documented Resident #1 was seen for a dose adjustment of his methadone. It documented Resident #1 reported sedation while taking Methadone 50 mg. It documented Resident #1 requested a dose decrease. It documented the treatment plan was to decrease Resident #1's Methadone from 50 mg to 40 mg daily. Cross-referenced to F760 failure to prevent significant medication errors. III. Staff interviewsThe director of nursing (DON) was interviewed on 2/4/26 at 11:05 a.m. The DON said if a resident's external provider changed any orders, facility staff should fill out a physician communication form, review the orders with the resident's primary provider, and update the resident's EMR as needed. The DON said the facility's health information manager ceased working at the facility on 1/26/26. The DON said she was unsure what the complete process was for reviewing external provider notes and updating the resident's EMR.The assistant director of nursing (ADON) was interviewed on 2/4/26 at 11:14 a.m. The ADON said when residents returned from external provider visits, transportation staff would hand a copy of the physician communication form to the resident's floor nurse, unit manager, or ADON. The ADON said the resident's nurse or nurse managers were responsible for reviewing the orders and updating them in the EMR. The DON was interviewed on 2/5/26 at 11:05 a.m. The DON said after reviewing any external provider orders and updating the resident's EMR, the nursing staff should place communication forms into the medical records box to be uploaded in the resident's EMR. The DON said she was unsure if there was a backlog of resident records needing to be uploaded and/or how long one had been present. The DON said it was important to maintain an accurate medical record to ensure accurate treatment and continuity of care. The DON said a potential risk of not maintaining accurate medical records was the potential for untimely updates to resident care orders, which could lead to adverse resident care outcomes.

Based on record review and interviews, the facility failed to ensure prompt action was taken upon the filing of a grievance of a group. Specifically, the facility failed to make prompt efforts to resolve resident grievances brought up by the resident council. Findings include: I. Facility policy and procedure The Grievance policy, reviewed 5/13/25, was provided by the nursing home administrator (NHA) on 6/3/25 at 6:51 a.m. It read in pertinent part, All grievances are forwarded to the grievance official and a written acknowledgment is provided to the complainant within three calendar days of receipt. The grievance official conducts a prompt investigation. Written resolution is provided within 14 calendar days. If more time is needed, interim updates are provided, with justification for delay. II. Resident group interview Five alert and oriented residents (#65, #33, #18, #76 and #39) who regularly attended the resident council meetings were interviewed on 6/2/25 at 1:00 p.m. The residents were identified as alert and oriented through facility and assessment. The group of residents said the facility did not follow up on grievances brought up in the resident council meetings. Resident #76 said when a grievance came up in the resident council meeting the department head tried to address it during the meeting but the manager did not complete a grievance form. Resident #65 said if it was an individual grievance, the department head would follow-up with the individual resident. Resident #65 said if it was a group grievance a resolution was not consistently brought back to the next resident council meeting by the facility. III. Record review A review of the resident council meeting minutes, dated 3/6/25, revealed the residents brought up concerns regarding the men's section of the building needing increased heat, an individual resident needing a call light, short staffing, lazy night staff and requests for increased activities. -Review of the March 2025 resident council minutes did not reveal documentation indicating the facility had addressed the residents' concern. A review of the resident council meeting minutes, dated 4/3/25, revealed the residents brought up concerns regarding long call light times, cold shower water, short nursing staff, adding more vegetarian options for meals, limited snack options, increased lighting outside of the building, an individual resident's complaint of low toilets and an individual residents complaint regarding problems with wheelchair wheels. -Review of the April 2025 resident council minutes did not reveal documentation indicating the facility had addressed the residents' concerns. A review of the resident council meeting minutes, dated 5/1/25, revealed the residents brought up concerns regarding the need for improvements in taking resident's food orders, ensuring personal items, like newspapers, were not thrown away by housekeeping, requests for maintenance to install locks on drawers for individual residents, and and an individual residents complaint regarding problems with wheelchair wheels. -Review of the May 2025 resident council minutes did not reveal documentation indicating the facility had addressed the residents' concern. IV. Staff interviews The social services director (SSD) was interviewed on 6/2/25 at 3:15 p.m. The SSD said she facilitated the resident council meetings and the facility had a process for addressing individual resident grievances but there was not a process for following up on group grievances generated during resident council. She said the manager present at the meeting whose department would be responsible for the grievance, would talk about how they planned to resolve it in the meeting. The SSD said if the concern involved a maintenance issue, the maintenance director would initiate a work order to resolve the concern. V. Facility follow up The NHA sent an email on 6/3/25 at 10:03 a.m. with evidence of work orders as follows; A work order, dated 3/6/25, for the individual resident who needed a call light and had complaints regarding a low toilet. A work order, dated 4/3/25, for the individual resident with wheelchair wheel complaints. A work order, dated 5/2/25, for lock installation on drawers for the residents who requested the locks and housekeeping education regarding disposing of resident items like newspapers. -No grievances or evidence of resolution was provided for any other resident council grievances.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Ensure housekeeping staff followed appropriate infection control guidelines when cleaning residents' bathrooms; -Ensure housekeeping staff applied alcohol-based hand sanitizer per guidelines when cleaning residents' rooms; -Ensure staff donned appropriate personal protective equipment (PPE) when providing direct care for Resident #45, who was on enhanced barrier precautions (EBP); and, -Ensure staff donned appropriate PPE when providing wound care for Resident #16, who was on EBP. Findings include: I. Housekeeping failures A. Professional reference The Centers for Disease Control and Prevention's (CDC) Environment Cleaning Procedures, (revised 3/19/24) was retrieved on 6/5/25 from https://www.cdc.gov/healthcare-associated- infections/hcp/cleaning-global/procedures.html?CDC_AAref_Val=https://www.cdc.gov/hai/pre ent/resource-limited/cleaning-procedures.html#cdc_generic_section_2-4-1-general-environmental-cleaning-techniques. It read in pertinent part, Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during terminal cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones) before patient toilets, within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. According to the CDC's Hand Sanitizer Guidelines and Recommendations (3/12/24), retrieved from https://www.cdc.gov/clean-hands/about/hand-sanitizer.html#:~:text=Apply%20the%20gel%20product%20to,should%20take%20around%2020%20seconds., on 6/10/25, Cleaning hands at key times with soap and water or hand sanitizer that contains at least 60% alcohol is one of the most important steps you can take to avoid getting sick and spreading germs to those around you. Apply the gel product to the palm of one hand; Cover all surfaces of hands; and, Rub your hands and fingers together until they are dry. This should take around 20 seconds. Don't rinse or wipe off the hand sanitizer before it's dry; it may not work well against germs. B. Facility policy and procedure The Housekeeping and Environmental Cleanliness policy, revised 11/13/24, was provided by the nursing home administrator (NHA) on 5/29/25 at 10:33 a.m. It read in pertinent part, To ensure that the facility is maintained in a clean, sanitary, and orderly condition to promote resident safety and comfort. Resident rooms are cleaned daily and as needed, and bathrooms disinfected with approved products. All housekeeping staff are trained upon hire and annually in infection control practices, safe chemical handling and proper cleaning techniques. C. Observations During a continuous observation on 6/3/25 at 8:50 a.m., housekeeper (HK) #1 was observed cleaning room [ROOM NUMBER] and room [ROOM NUMBER]. HK #1 pushed the cleaning cart to the entrance of room [ROOM NUMBER]. She opened the cart and donned (put on gloves), entered the room and emptied two trash cans. She returned to the cart, removed her gloves, applied alcohol-based hand sanitizer and immediately donned a pair of gloves. She struggled to put on the gloves due to her hands being visibly wet with the alcohol-based hand sanitizer. HK #1 entered room [ROOM NUMBER] again and cleaned the high-touch areas, including the door knobs, bed controller, call light, and bedside table. She returned to her cart, removed a blue rag and disinfectant solution from the cart and entered the resident's bathroom. HK #1 sprayed a blue disinfectant solution onto the bathroom sink and cleaned the bathroom mirror. She used the blue rag to clean the mirror and the sink. HK #1 returned to the cleaning cart and placed the disinfectant solution on the cart. She removed her gloves, applied alcohol-based hand sanitizer and immediately applied clean gloves without allowing her hands to dry. HK #1 returned to room [ROOM NUMBER]'s bathroom with the blue disinfectant solution and a scrubbing brush. She sprayed the toilet with the disinfectant solution and allowed it to sit for approximately one minute. She used the blue rag to wipe the seat of the toilet, the rim of the toilet and around the toilet bowl. She wiped the side of the toilet again,the side of the toilet tank, the front of the toilet tank and the top of the toilet tank with the same blue rag. She sprayed the grab bar on the right side of the toilet wall with the disinfectant solution and wiped it with the same blue rag. HK #1 swept and mopped the floor in room [ROOM NUMBER] before pushing the cleaning cart to the entrance of room [ROOM NUMBER]. -HK #1 did not rub her hands with the hand sanitizer until they were dry before applying gloves. -HK #1 failed to clean the bathroom from a cleaner area to a dirtier area HK #1 used hand sanitizer, immediately donned gloves without allowing the hand sanitizer to dry and entered room [ROOM NUMBER]. She emptied two trash cans and proceeded to the cleaning cart to discard the trash from the resident's room. She took off her gloves, applied hand sanitizer, and immediately donned new gloves, again without rubbing her hands until the hand sanitizer was dry. She removed the container of disinfectant solution and a blue rag from her cart and washed the inside of the sink, the mirror and the surface of the sink in the resident's bathroom. She returned the container to the cart. HK #1 removed a toilet brush, a new blue rag and the disinfectant solution spray from the cleaning cart and proceeded to room [ROOM NUMBER]'s bathroom. The toilet seat had splashes of urine on the surface. She sprayed the disinfectant solution onto the surface of the toilet seat and the inside of the toilet bowl and scrubbed it with the toilet brush. She placed the toilet brush into the brush holder, which she placed on the dirty floor beside the toilet bowl. HK #1 picked up the scrubbing brush holder from the floor and placed it on the cleaned surface of the bathroom sink. HK #1 then sprayed the toilet with the disinfectant solution spray bottle and used the blue rag to wipe the toilet seat, the rim of the toilet, the back of the toilet, both sides of the toilet, the top of the toilet tank, around the toilet tank and finished by wiping the toilet seat again. -HK #1 failed to clean the bathroom from cleaner to dirtier areas to avoid spreading dirt and microorganisms. -HK #1 failed to avoid contaminating clean surfaces by placing a dirty toilet brush container on the cleaned sink surface. -HK #1 did not rub her hands with hand sanitizer until they were dry before applying gloves. D. Staff interviews HK #1 was interviewed on 6/3/25 at 9:22 a.m. HK #1 said she found it difficult to don gloves because her hands were wet with the hand sanitizer. She said it would have been easier to apply gloves if she had allowed her hands to dry before applying gloves. She said hand sanitizers were less effective if not used properly. She said she should not have placed the scrubbing brush from the toilet on the cleaned surface of the sink in the bathroom to prevent cross-contamination of microorganisms. She said the residents' toilets should have been cleaned from top to bottom. She said she forgot not to use the same cleaning rag for the toilet and the grab bar in the room [ROOM NUMBER]'s bathroom. The housekeeping supervisor (HKS) was interviewed on 6/3/25 at 9:30 a.m. The HKS said the toilet brush should never be placed on any clean surface after using it to clean the toilet. She said the toilet should be cleaned with a clean rag from top to bottom. She said HK #1 should not have used the same rag to clean the toilet and the grab bar in room [ROOM NUMBER]'s bathroom. The HKS said HK #1 should have allowed her hands to dry before applying gloves for the hand sanitizer to be effective She said she would immediately re-educate HK #1 and all housekeeping staff on proper cleaning procedures. II. EBP failures A. Professional reference According to The Centers for Disease Control and Prevention's (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDROs) (4/2/24), retrieved on 6/4/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, EBP are an infection control intervention, designed to reduce transmission of resistant organisms, that employ targeted gown and glove use during high contact resident care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization, as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for enhanced barrier precautions include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and wound care, any skin opening requiring a dressing. B. Facility policy and procedure The Infection Control policy, revised 11/13/24, was provided by the NHA on 5/29/25 at 10:33 a.m. It read in pertinent part, Enhanced barrier precautions are used for residents with wounds, indwelling devices such as catheters, tracheostomies or those at high risk of multidrug-resistant organisms (MDROs) colonization, even if they are not known to be infected. Used for residents in high-risk categories in nursing homes, especially during MDRO outbreaks or colonization events, requirements include gloves and gowns during high-contact resident care activities such as dressing, bathing, toileting and device care. Enhanced signage and personal protective equipment (PPE) in the resident care area, staff education and competency validation on all isolation practices, monitoring and auditing compliance through direct observation. All staff are trained and regularly audited to ensure adherence to these guidelines and to protect the health and safety of all individuals in the facility. C. Resident #45 1. Observations On 5/29/25 at 1:40 p.m. Resident #45 was lying in bed. He turned his call light on and certified nurse aide (CNA) #2 responded to the resident's call light. CNA #2 entered the resident's room and asked the resident what she could do to assist him. Resident #45 asked to be repositioned in bed. CNA #2 removed both of the resident's feet from his pressure injury boots (bunny boots) and held the resident's legs and feet to adjust them. Resident #45 had a diabetic wound on his right second toe, a diabetic foot ulcer with wounds to his left heel and wounds on his sacrum (buttocks). CNA #2 held Resident #45's feet without gloves, applied the bunny boots to the resident's feet and repositioned the resident using a wedge cushion. -CNA #2 failed to put on gloves or a gown before assisting Resident #45, who had wounds which required the use of EBP, to reposition. On 6/2/25 at 11:25 a.m., a restorative nurse aide (RNA) #6 arrived at Resident #45's bedroom to provide range of motion (ROM) exercises in the resident's bed. RNA #6 applied gloves but did not don a protective gown. He touched the resident's right hand and aligned it with his hands to provide ROM. RNA #6 removed the bunny boots from the resident's feet and held the resident's feet from below the heel area with his left hand. RNA #6 began providing ROM to Resident #45's feet. RNA #6 held the resident's feet close to the area of his diabetic wounds while providing ROM. -RNA #6 failed to put on a protective gown before providing ROM to Resident #45. On 6/2/25 at approximately 1:15 p.m. CNA #1 responded to Resident #45's call light and the resident requested to be changed. CNA #45 applied gloves, lifted the resident's bed and removed the resident's bed linens and started changing the resident. -CNA #1 failed to don a protective gown while changing Resident #45. D. Resident #16 1. Observations On 5/29/25 at 11:22 a.m. a sign on Resident #16's door indicated the resident was on EBP. The sign on the resident's door indicated gloves and a gown must be worn for resident care activities, including dressing, bathing/showering, transferring, linen changes, providing hygiene, changing briefs or assisting with toileting and device care or use, such as central lines, urinary catheters, feeding tubes, tracheostomies and wound care. Gloves and blue gowns were observed in Resident #16's room in clear plastic bins. On 5/29/25 at 11:24 a.m. licensed practical nurse (LPN) #1 was completing wound care with a dressing change for Resident #16, who had a pressure wound on her sacral area. The wound was observed in the sacral area with clear, yellow tinged drainage. LPN #1 had gloves on. -However, LPN #1 failed to put on a gown prior to performing wound care with the resident. 2. Resident interview Resident #16 was interviewed on 5/29/25 at 11:30 a.m.Resident #16 said when the nurses were changing her wound dressing, the nurses would put on gloves but they never wore a gown. E. Staff interviews LPN #1 was interviewed on 5/29/25 11:38 a.m. LPN #1 said Resident #16 was on EBP because the resident had an indwelling foley catheter foley and colostomy. LPN #1 said she never wore a gown for Resident #16 when she completed her wound dressing changes. LPN #1 said she was now aware of the requirement to wear a gown with wound dressing changes. LPN #1 said now that she knew the correct PPE to don, she would make sure she always wore a gown and gloves with wound care in the future. CNA #6 was interviewed on 5/29/25 at 12:35 p.m. CNA #6 said when she was providing care for any resident on EBP, she would don gloves and a gown. CNA #6 said if she was going to assist the resident with transfers, using the bathroom or helping the nurse with colostomy care, she would put on a gown and gloves to ensure the resident would not get an infection. CNA #6 said she was provided education and instruction on PPE by the facility. RN #3 was interviewed on 6/2/25 at 11:22 a.m. RN #3 said whenever she provided Resident #16 with wound care, cleaning or emptying her foley catheter or changing the resident's colostomy bag, she would wear gloves and a gown because that was the facility's protocol. RN #3 said the EBP was in place to prevent Resident #16 from getting an infection. She said all nursing staff should wear gloves and a gown with high contact care such as transfers, providing incontinence care and wound care. CNA #2 was interviewed on 6/2/25 at 1:45 p.m. CNA #2 said she did not know she had to put on a protective gown when providing care for Resident #45. CNA #2 said the only time that she applied PPE was when there was an isolation cart in front of the resident's room. She said she had received training on all isolation precautions, but she did not know to wear gloves and a protective gown before repositioning Resident #45. She said the sign posted in front of Resident #45's room should have reminded her to follow the procedure for EBP. Registered nurse (RN) #1 was interviewed on 6/2/25 at 1:55 p.m. RN #1 said there were signs posted at the entrance of each resident's room who was on EBP. She said PPE should be worn when performing personal care as indicated on the resident's care plan. The director of nursing (DON) was interviewed on 6/3/25 at 12:45 p.m. The DON said residents on EBP had signage posted at the entrance of their rooms and also indicated on their care plans. She said EBP required the use of gloves, a protective gown and in some cases a face shield, depending on the task being performed. The DON said all nursing staff were trained on isolation precautions and should know to put on the proper PPE before performing any personal care to avoid the spread of infections. The DON said she did not know why the staff failed to follow the proper infection control procedures. She said she would ensure all nursing staff were re-educated on isolation procedures, including EBP. The NHA and the DON were interviewed together on 6/3/25 at 4:02 p.m. The NHA said the facility nursing staff were provided education and training on correct EBP policy and procedure from the DON. The DON said she provided education to staff upon hire and annually thereafter, on how and when to properly use PPE when a resident was on EBP. The DON said EBP was used for high-contact interaction between staff and residents. The DON said a resident would be placed on EBP if they had an ostomy (surgical incision in the abdomen), wounds or a foley catheter. The DON said the staff should wear PPE, including a gown and gloves, when assisting residents who were on EBP with activities of daily living (ADL). The NHA said she would have the DON provide re-education to staff on proper EBP protocol.

Based on observations and interviews, the facility failed to provide adequate outside ventilation by means of windows and/or mechanical ventilation for one of two shower rooms and nine of 16 resident bathrooms. Specifically, the facility failed to ensure the exhaust fans in the north shower room and nine resident rooms were working properly. Findings include: I. Facility policy and procedure The Ventilation and Environmental Condition policy, revised 11/13/24, was provided by the nursing home administrator (NHA) on 6/3/25 at 5:22 p.m. It read in pertinent part, This facility shall maintain ventilation, lighting, and indoor environmental conditions that are safe, functional, and comfortable for residents, staff, and visitors. This policy applies to all maintenance and environmental services personnel responsible for managing heating, ventilation and air conditioning (HVAC), lighting and general facility comfort. Ventilation system requirements include operating HVAC systems in accordance with manufacturer instructions and American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) standards, ensuring that airflow does not compromise infection control and maintaining adequate natural and mechanical ventilation in all resident-use areas. II. Observations An observation of the residents' environment was completed with the maintenance director (MTD) on 6/3/25 at 10:40 a.m. There were exhaust fans installed in the ceiling of each resident's bathroom and the two main shower rooms (north and south shower rooms). The exhaust fan in the north shower room was not working and it was dirty with lint hanging from the surface of the vent. The exhaust fans in the bathrooms of room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER] did not generate air movement with the switch turned on. As a measure of checking the function of each exhaust fan, a small square of single-ply toilet paper was placed against the vent. The exhaust fans were unable to hold the toilet tissue in place, which indicated the fans were not functioning at that moment. The vents in the bathrooms of room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER] had large holes around the vents, exposing the electrical wires. The bathroom exhaust fans of room [ROOM NUMBER] and room [ROOM NUMBER] were missing. III. Staff interviews The maintenance director (MTD) was interviewed on 6/3/25 at 11:40 a.m. The MTD said the exhaust fan vents in the facility were old and needed to be replaced. He said monitoring was completed once a month for all the facility's exhaust fans. He said he repaired the fans that were broken but he said he had not come across the missing exhaust fans in room [ROOM NUMBER] and room [ROOM NUMBER] during his monitoring. The MTD said he did not know how and why the exhaust fans were missing from some of the bathrooms. He said the dirty vents would be cleaned immediately and new exhaust fans would be ordered to replace the missing ones. The NHA was interviewed on 6/3/25 at 1:08 p.m. The NHA said the proper functioning of the exhaust fan vents in the facility was important to promote air quality in the building. She said the maintenance monitoring form should be updated to include more specific checks of the ventilation system. She said orders had been placed for new vents and they would be installed as soon as they arrived. The NHA said she would reeducate the MTD and the maintenance staff on the importance of the ventilation system.

Based on interviews and record review, the facility failed to coordinate changes to the preadmission screening and resident review (PASRR) Level II determination and evaluation report promptly with the State Mental Health Agency in the case of residents with serious mental illness or a related condition for one (#38) of two residents reviewed for PASRR out of 35 sample residents. Specifically, the facility failed to notify the State Mental Health Agency when a resident received a new diagnosis (bipolar disorder) of a serious mental disorder for a PASRR Level II evaluation. Findings include: I. Facility policy and procedure The PASRR Evaluation and Screening policy, reviewed 1/29/25, was provided by the nursing home administrator (NHA) on 6/3/25 at 6:51 a.m. It read in pertinent part, Re-screening is required for; a new or changed psychiatric diagnoses, addition or change in psychotropic medication, or worsening behavioral or cognitive symptoms. II. Resident status Resident #38, age [AGE], was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included unspecified dementia with behavioral disturbances (dated 1/14/22) and bipolar disorder (dated 7/18/24). The 4/17/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 11 out of 15. The MDS condition list indicated the resident did not have a PASRR Level II diagnosis of major mental illness. III. Resident interview Resident #38 was interviewed on 5/28/25 at 10:35 a.m. She said she was unaware she had been diagnosed with bipolar disorder. IV. Record review The mood care plan, revised 1/23/25, revealed the resident used psychotropic medications related to dementia with behaviors. Interventions, dated 11/14/24, included administering medication as ordered, providing education to the resident on risks and benefits of the medication, and monitoring behaviors and interventions. The May 2025 CPO revealed the following physician orders: -Olanzapine (an antipsychotic medication) 10 milligrams (mg). Give one tablet by mouth at bedtime for dementia with behaviors, ordered on 3/27/25. A nurse practitioner visit note, dated 12/8/23, revealed a new diagnosis of unspecified bipolar disorder. The NP visited the resident at the residents request related to a urinary tract infection (UTI). -Review of Resident #38's electronic medical record (EMR) did not reveal documentation for the basis of the new diagnosis V. Staff interviews The social services director (SSD) was interviewed on 6/2/25 at 3:15 p.m. The SSD said she had not been able to find supportive documentation for the physician's diagnosis of bipolar disorder on 12/8/23 or the addition of bipolar disorder to Resident #38's EMR on 7/18/24. The SSD said when she reviewed the care plans for each resident quarterly, she also reviewed the diagnosis list. She said Resident #28's care plan was reviewed on 8/4/24, 10/28/24, 1/28/25, 2/4/25 and 4/30/25, however she said she had not identified the resident's new diagnosis during those reviews or completed an updated PASRR screening. VI. Facility follow up The NHA provided documentation pertaining to Resident #38's bipolar disorder diagnosis on 6/2/25 at 5:12 p.m. (during the survey). The documentation provided included the following: -An authorization to clarify diagnosis, dated 5/30/25 (during the survey), signed by the physician striking out bipolar disorder from Resident #38's EMR due to lack of history; A submission of a new PASRR screening, dated 5/30/25 (during the survey); and, -An automated notice of determination response to the PASRR screening, dated 5/30/25 (during the survey), revealing she did not trigger for a major mental illness or Level II condition.

IV. Resident #133 A. Resident status Resident #133, age [AGE], was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbances and attention-deficit hyperactivity disorder. The 5/22/25 minimum data set (MDS) assessment revealed that Resident #133 was severely cognitively impaired and unable to participate in the brief interview for mental status (BIMS) assessment. According to the staff assessment for mental status, Resident #133 had short term and long term memory deficits, severely impaired decision making skills and continuous disorganized thinking. Resident #133 was not cognitively orientated to staff names and faces, where his room was or what type of facility he was in. He was independent in his activities of daily living (ADL) and ambulated independently. The MDS assessment indicated Resident #133 had not displayed any wandering behaviors within the seven day assessment look back period. -However, Resident #133 eloped from the facility on 5/19/25 (see record review and interviews below). B. Resident interview and observation Several attempts were made to interview Resident #133 on 5/29/25, however the resident became frustrated when questioned and was only able to answer questions related to how his day was going. He was ambulatory and wandering the hallways aimlessly. On 6/2/25 at approximately 4:30 p.m. Resident #133 was in his room. He was not wearing a wanderguard on either of his wrists or on his ankles. The resident did not understand what the wanderguard was and could not say where his wanderguard had gone. C. Record review The cognition care plan, dated 5/29/25 (during the survey), revealed Resident #133 was at high risk for exploitation, neglect or harm related to an inability to advocate for himself. Resident #133 was highly vulnerable due to significant cognitive impairments. He had difficulty understanding or responding to social cues, making him more vulnerable to inappropriate behavior by others. Interventions, dated 5/29/25 (during the survey), included to ensure the room and common areas were arranged to promote safety, assign consistent caregivers as much as possible, and ensure the resident had a clear way to report concerns. The elopement care plan, revised 5/29/25 (during the survey), revealed Resident #133 was an elopement/wanderer risk due to being disorientated to place and a decreased safety awareness. Interventions, revised 5/19/25, included assessing the resident for falls, providing distraction by offering pleasant distractions, and applying a wander alert (wanderguard) to the resident's right hand. Review of Resident #133's May 2025 CPO revealed the following physician orders: Wanderguard to the right hand. Monitor for functioning and placement two times a day for wandering, ordered 5/15/25 and discontinued 6/3/25 (during the survey). A narrative progress note, dated 6/3/25 (during the survey), revealed Resident #133 had a wanderguard device on 6/2/25 and removed it. The device was replaced at 6:00 p.m. (on 6/2/25). At 7:00 a.m. on 6/3/25, it was discovered that Resident #133 had cut his wanderguard device off a second time. The wanderguard was discontinued and 15-minute checks were started, per the resident's preference. -There was no documentation to indicate the resident had gone to an exit door, requiring him to be redirected from attempting to leave by staff, after removing his wanderguard device on 6/2/25 (see RN) #2 interview below). -Additionally, the progress note failed to identify how the 15-minute checks would be effective in keeping the resident safe. An exit seeking/elopement assessment, dated 5/19/25, revealed Resident #133 had requested to take a walk and then stated he was leaving the facility. An unidentified staff member followed him outside and was able to converse with him about general topics. The staff member was unable to redirect Resident #133 back to the facility, and he began walking towards the main road. The staff member walked with him and was finally able to redirect Resident #133 to a nearby store and then back to the facility. The social services director (SSD) reached out to Resident #133's sister to discuss filing for guardianship and completing a health care proxy (a document giving health care decisions to a designated individual after a physician determines the individual to lack capacity to make decisions). The 5/19/25 exit seeking/elopement assessment scored Resident #133 as a low risk for elopement. -However, the resident physically eloped from the facility on 5/19/25. -Review of Resident #133's EMR failed to reveal any additional exit seeking/elopement assessments, despite the fact that the resident removed his wanderguard device twice, once on 6/2/25 and again on 6/3/25, and declined to allow staff to replace the device on 6/3/25 (see above). Review of the CNA behavior charting for Resident #133, from 5/14/25 to 6/3/25, failed to reveal documentation of the resident wandering on 5/19/25 or 6/2/25. -However, Resident #133 actually exited the facility on 5/19/25 and was redirected away from an exit door by facility staff on 6/2/25 (see record review above and RN #2 interview below). D. Staff interviews RN #2 was interviewed on 6/2/25 at 9:45 a.m. RN #2 said Resident #133 had behaviors of wandering aimlessly. She said he would go to the exit doors but the sound of the wanderguard alarm deterred him from trying to leave. She said Resident #133 would stand by the door daily and could be redirected momentarily but would return to the door and was confused as to why he was living in the facility. RN #2 said the nurses checked his wanderguard device twice a shift to ensure it was functional and in place. CNA #3 was interviewed on 6/2/25 at 11:31 a.m. CNA #3 said Resident #133 had behaviors of wandering aimlessly but was pleasant and redirectable. The SSD was interviewed on 6/2/25 at 3:15 p.m. The SSD said Resident #133 had behaviors of exit seeking and attempting to go out of the front door so he had a wanderguard device. The SSD said Resident #133 wandered aimlessly and had severely impaired cognition. RN #2 was interviewed again on 6/3/25 at 11:22 a.m. RN #2 said Resident #133 had removed his wanderguard the previous day (6/2/25) and had gone to one of the exit doors where staff had to redirect him from attempting to leave. RN #2 said he did not want the wanderguard back on so he was placed on 15-minute checks. She said she did not know if a new exit seeking/elopement assessment should be completed because she was new to the facility. The DON was interviewed on 6/3/25 at 3:00 p.m. The DON said Resident #133 had a wanderguard placed on him initially when he was admitted on [DATE] because the hospital had advised the facility that he might have difficulty adjusting to placement, he had been living at home alone after his spouse passed away and then was evicted. She said he was only cognitively orientated to himself and could not tell the facility very much information. The DON said if Resident #133 were to leave the facility, he would be at high risk of becoming lost due to his cognitive impairment. The DON said 6/2/25 was the first time Resident #133 had removed his wanderguard but the facility was not sure how that occurred. The DON said she thought he might have figured out how to cut it off when he was out of the facility with the activities staff on a shopping trip. She said she did not know what the long term interventions were going to be for Resident #133's wandering. She said the immediate intervention was 15-minute checks but she said the facility had not assessed him for alternative interventions. The DON and the NHA were interviewed together on 6/3/25 at 6:30 p.m. The DON said Resident #133 would become overstimulated and confused at times. She said Resident #133 had gone out to the store with the activities staff and found a way to cut off his wanderguard while at the store. The DON said Resident #133 wandered the facility aimlessly and if he continued to show exit seeking behaviors, the facility would have to discharge him to a secure long term care facility. The NHA said Resident #133 had initially perseverated on leaving the facility when he first admitted , but recently had told staff the facility was his home. She said Resident #133 let the facility place a wanderguard on his wrist again on 6/2/25 after removing it, but then he took it off again. The NHA said Resident #133 told her, on 6/3/25, that he would not wear his wanderguard. She said she did not know how he was able to remove his wanderguard the second time. The NHA said the facility did not complete a new exit seeking/elopement assessment after the resident's removal of his wanderguard or his attempt to leave on 6/2/25 because they initiated 15-minute checks. The NHA could not explain how the 15-minute checks were effective or why the facility initiated 15-minute checks instead of completing a new assessment to determine what effective supervision would work best for Resident #133 in order to keep the resident safe from further elopements. III. Resident #9 A. Resident status Resident #9, age greater than 65, was admitted on [DATE]. According to the June 2025 computerized physician orders (CPO), diagnoses included multiple sclerosis (MS), obstructive sleep apnea, seizures, major depressive disorder, dementia, age related osteoporosis and contracture of muscle. The 2/25/25 minimum data set (MDS) assessment revealed the resident had a memory problem, moderately impaired-decisions poor and required cues/supervision. The resident was dependent on staff for all activities of daily living (ADL). B. Resident representative interview The resident's representative was interviewed on 5/29/25 at 9:13 a.m. The representative said Resident #9 was a fall risk and that she needed lifting and transfer assistance. C. Observations During a continuous observation on 5/29/25 beginning at 12:37 p.m. and ending at 2:05 p.m., the following observations were made: Resident #9 was in bed without the fall mat beside her bed throughout the entire continuous observation. -Several unidentified staff members entered Resident #9's room on five separate occasions throughout the observation and failed to ensure Resident #9's fall mat was in place on the floor next to her bed. -Three unidentified staff members walked by Resident #9's room while the door was open and failed to ensure Resident #9's fall mat was in place on the floor next to her bed. During a continuous observation on 6/2/25, beginning at 3:15 p.m. and ending at 4:00 p.m. Resident #9 was in her bed and the fall mat was not in place on the floor next to her bed. D. Record review Resident #9's fall care plan, revised 8/9/23, documented she was at moderate risk for falls and injury secondary to progressive MS with mobility and positioning deficits and seizure disorder. A Broda chair was used for positioning the resident and as her primary mode of mobility. Pertinent interventions included a fall mat (initiated 5/31/22). Resident #9's seizure care plan, revised 5/31/22, documented she had a seizure disorder and potential for injury. Pertinent interventions included a high low bed and a fall mat (initiated 5/31/22). Resident #9's 5/8/25 fall assessment documented the resident was disoriented, at moderate risk for falls due to progressive multiple sclerosis with mobility and positioning deficits with seizure disorder and had three or more diagnoses that could contribute to falls. The assessment documented the resident had had one to two falls in the last 90 days. E. Staff interviews Licensed practical nurse (LPN) #1 and LPN #2 were interviewed together on 6/3/25 at 11:08 a.m. LPN #1 and LPN #2 said it was the responsibility of the CNAs to place the fall mat on the floor if they put Resident #9 back in bed. LPN #1 said the fall mat intervention was not in the resident's treatment administration record (TAR) and she was not sure if the facility still used the fall mat as an intervention for Resident #9. CNA #7 was interviewed on 6/3/25 at 11:15 a.m. CNA #7 said she looked at residents' care plans to see fall interventions. CNA #7 said she did not remember if Resident #9 used a fall mat but would check the care plan for interventions. The DON was interviewed on 6/3/25 at 6:00 p.m. The DON said Resident #9 could move slightly but she did not have purposeful movements. The DON said the fall mat intervention was more appropriate as a seizure activity intervention versus a fall intervention. The DON said if the fall mat was on the care plan as an intervention then the fall mat should have been used.Based on observations, record review and interviews, the facility failed to ensure three (#63, #9 and #133) of seven residents reviewed for accidents out of 35 sample residents received adequate supervision to decrease and/or prevent risk for accident hazards. Specifically, the facility failed to: -Ensure fall interventions were consistently implemented and reviewed for effectiveness for Resident #63 who sustained 14 falls in less than six months; -Ensure care planned fall and seizure activity interventions, specifically a fall mat, were implemented consistently for Resident #9; -Accurately assess Resident #133's initial elopement risk following the resident's elopement on 5/19/25; and, -Reassess Resident #133's elopement risk in order to identify appropriate and effective interventions to ensure the resident would be kept safe from elopement after he removed his wanderguard device on 6/2/25 and on 6/3/25 and refused to allow staff to put the device back on. Findings include: I. Facility policy and procedure The Neurological Assessments and Fall Follow-Up Documentation policy, reviewed 5/13/25, was provided by the nursing home administrator (NHA) on 6/3/25 at 5:20 p.m. It read in pertinent part, It is the policy of this facility that all residents who experience a fall with head involvement or a head injury without a fall receive a 72-hour neurological assessment and documented fall follow-up order to ensure proper monitoring and early detection of complications. All fall-related injuries must be assessed and addressed immediately, and fall interventions must be implemented immediately to reduce the risk of recurrence. Licensed nurses are responsible for conducting, documenting, and following up on all fall-related neurological assessments, interventions and pain monitoring. CNAs (certified nurse aide) and caregivers must report any resident changes, assist in implementing interventions, and monitor pain levels. II. Resident #63 A. Resident status Resident #63, age [AGE], was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included history of falling, pain in his right hip and dementia. The 4/19/25 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. He required supervision assistance with transferring, toileting and personal hygiene. The MDS assessment indicated the resident had a history of two or more falls prior to admission B. Observations on 5/28/25 at 3:50 p.m. Resident #63 was in his room lying in his bed watching television. The resident's call light was on the resident's wheelchair at the foot of the resident's bed. Resident #63 was unable to reach his call light. The resident had socks on both of his feet that did not have anti-slip material on the bottom of them. No floor mat was noted next to his bed and his bed was not in the lowest position close to the floor. C. Resident interview Resident #63 was interviewed on 5/29/25 at 9:39 a.m. Resident #63 said he had fallen at the facility. Resident #63 said he did not think he needed help from the nursing staff. D. Record review Review of Resident #63's fall care plan, created on 6/17/24 and revised 1/29/25, revealed the resident was at risk for falls related to muscle weakness and dementia. Interventions included ensuring the resident's call light was within reach and encouraging the resident to use it for assistance as needed (initiated 6/17/24), promptly responding to all requests for assistance (initiated 6/17/24), anticipating and meeting the resident's needs (initiated 6/17/24), ensuring that the resident was wearing appropriate footwear (sneakers) when ambulating with a four-wheel walker (initiated 8/22/24), moving the resident to a room closer to the nurse's station to help prevent falls/injuries (initiated 12/30/24) providing staff education that the resident could not be left alone on the toilet (initiated 1/2/25) and providing the resident with standby assist to get to bed (initiated 1/2/25). -However, the care plan was not updated after each fall to reflect that the care planned fall interventions were reviewed for effectiveness or when a new intervention was put into place (see falls below). Review of Resident #63's electronic medical record (EMR) revealed the resident sustained the following falls from 12/10/24 to 5/13/25: 1. Fall incident on 12/10/24 - unwitnessed A nurse's note, dated 12/10/24 documented nursing staff heard the loud noise of residents screaming at each other and went to the activity area to check on them. Resident #63 was sitting on the floor. There was a slight redness to the skin on the back of the resident's neck without any open injuries. The residents were separated and the other resident was placed on one-to-one supervision. The other resident reported Resident #63 pushed the other resident's walker first and the other resident responded by pushing Resident #63 to the floor because he was not able to cope with Resident #63 touching his walker with anger first. The interdisciplinary team (IDT) review note, dated 12/16/24, revealed the IDT met and discussed the resident's 12/10/24 fall. The note indicated the new intervention for the resident was to have a referral to behavioral health services (BHS) for evaluation and treatment of the resident's angry outbursts. -However, the IDT's review of the fall was not completed until six days after the fall and after Resident #63 had sustained another fall on 12/14/24 (see below). 2. Fall incident on 12/14/24 - witnessed A nurse's note, dated 12/14/24 documented that the activities assistant called the facility and reported Resident #63 fell while on a facility shopping outing after feeling weak and wobbly in the knees. Resident #63 fell on his right hip and elbow. The resident stated he was in severe pain and the activities assistant did not feel comfortable helping him up. An ambulance was called and the resident was taken to the hospital for further assessment. The fall resulted in a right hip fracture for Resident #63. A nurse's note, dated 12/19/24, documented Resident #63 was readmitted to the facility from the hospital. The resident was reoriented to his room and his call light. The resident's bed was in the lowest position and all of his personal belongings were within reach. His vital signs were stable and he was reporting pain of 6 out of 10 on a 1-10 pain scale in his right hip. The resident was unable to bear any weight to bilateral lower extremities. -However, there was no documentation to indicate additional fall interventions were put into place due to the resident's new inability to bear weight on his lower extremities. -Additionally, there was no documentation in Resident #63's EMR to indicate the IDT had reviewed the resident's 12/14/24 fall to determine the effectiveness of the resident's care planned fall interventions or to determine if there was a need for additional interventions. 3. Fall incident on 12/19/24 - unwitnessed A nurse's note, dated 12/19/24, documented that at approximately 9:20 p.m. staff were notified by Resident #63's roommate that the resident was on the floor. The nurses found Resident #63 lying in a supine position (lying face upward) on the floor, parallel to his bed. The resident reported he was trying to get into his recliner and was unable to stand up and fell to the floor. Neurological assessments were initiated per protocol and were within normal limits. Three staff members used a mechanical lift to assist the resident back to bed and he was assisted with raising the head of his bed to sit up in bed rather than being in his recliner, as he was attempting to do when he fell. The resident was satisfied with the option. Fluids, call light and personal items were all placed at the resident's bedside within reach. Resident #63 denied new/worsening pain. The physician and the resident's representative were notified. An IDT note, dated 12/20/24, documented the IDT met and discussed the 12/19/24fall. The root cause of the fall was determined to be Resident #63's new impulsivity and not using his call light for help. Interventions included moving the resident to a room closer to the nurses' station. 4. Fall incident on 12/20/24 - unwitnessed A nurse's note, dated 12/20/24, documented Resident #63 was observed lying on the floor next to his bed. There was bruising from his previous fall noted to his right thigh. The resident was assisted to bed with three staff members and a mechanical lift. He was moaning with pain to his right hip. There were no new skin injuries noted. -There was no documentation in Resident #63's EMR to indicate the IDT had reviewed the resident's 12/20/24 fall to determine the effectiveness of the resident's care planned fall interventions or to determine if there was a need for additional interventions. 5. Fall incident on 12/25/24 - unwitnessed A nurse's note, dated 12/25/24 documented Resident #63 had an unwitnessed fall at around 10:00 a.m. A certified nurse aide (CNA) reported Resident #63 was found lying on his back on the floor. The resident said he was trying to grab his walker to go to the bathroom but he slid off the bed. The resident was assessed and no new injuries were noted. The resident denied hitting/bumping his head during the fall. Resident #63 was helped to his bed with assistance from two staff members and education was provided to always call using his call light for assistance. The resident was reminded to utilize his urinal that was present at his bedside. The resident's bed was placed in the lowest position and a floor mat was in-place. Frequent checks were maintained to ensure the resident's needs were met due to some mild confusion noted. Neurological assessments and vital signs were initiated and the physician and the resident's representative were notified. -There was no documentation in Resident #63's EMR to indicate the IDT had reviewed the resident's 12/25/24 fall to determine the effectiveness of the resident's care planned fall interventions or to determine if there was a need for additional interventions. 6. Fall incident on 12/27/24 - unwitnessed A nurse's note, dated 12/27/24, documented nursing staff was alerted to come to Resident #63's bathroom as he had an unwitnessed fall. The resident had attempted to stand up from the toilet without calling for assistance. The resident was sitting next to the toilet when the nurse arrived, his range of motion (ROM) was at baseline, he denied hitting his head, there were no red marks or bumps on his head and no abrasions or redness to his back.The resident had bruises that were fading from his previous falls and he had weakness from not walking because of his previous falls. Resident #63 was assisted to a standing position with assistance from a CNA, put back in bed, neurological checks were initiated and the physician was notified. An IDT note, dated 12/30/24 documented the IDT met and discussed the 12/27/24 fall. The new intervention was to educate staff that the resident could not be left on the toilet alone because he would attempt to walk back to bed without assistance and he was unable to walk alone at that time. -However, the intervention to not leave the resident unattended on the toilet was not updated on the care plan to alert staff of the new intervention. 7. Fall incident on 1/17/25 - unwitnessed A nurse's note, dated 1/17/25, documented Resident #63 was sitting on the floor on his fall mat. There was no skin injury noted and the resident was able to move all of his extremities without pain or change in ROM. He was confused and when asked how he got to the floor, he did not respond. The resident's bed was placed in the lowest position at this time. The physician and the nurse on-call were notified of the fall. -There was no documentation in Resident #63's EMR to indicate the IDT had reviewed the resident's 1/17/25 fall to determine the effectiveness of the resident's care planned fall interventions or to determine if there was a need for additional interventions. 8. Three fall incidents on 1/20/25 (eighth, ninth and tenth falls) - unwitnessed A nurse's note, dated 1/20/25 at 9:11 a.m., documented Resident #63 had three unwitnessed falls that morning at 6:40 am and 8:30 am. The note documented a CNA found the resident sitting on his floor mat. This nurse went to the resident's room and found him in a sitting position with both of his legs folded and a smile on his face. The resident was confused and unable to say how he fell. The resident's bed was in the lowest position and his call light was within reach during the incident. The nurse assessed the resident for any injuries and no injuries were noted. The resident was educated to call for help or press the call light. The physician, the resident's representative and the director of nursing (DON) were notified. -The progress note referenced three falls, however the progress note only documented the times for two of the falls and there were no additional progress notes documented for the 6:40 a.m. fall or the 8:30 a.m. fall referenced in the note. A progress note, dated 1/20/25, documented Resident #63 was to be sent to the hospital for increased falls/confusion and agitation. The resident had appeared confused for a few days and he appeared to be more aggressive and agitated with confusion. He had a fall times three today (1/20/25). The physician was aware and provided an order to send him to the hospital for further evaluation. A pharmacy medication review note, dated 1/23/25, documented medications that may have contributed to Resident #63's fall on 1/20/25 or may increase risk of future falls included methocarbamol (muscle relaxant) , oxycodone (pain medication). Other medications included the resident's antihypertensive medications and antidiabetic medication, however the pharmacist indicated those medications did not seem likely considering the circumstances of the resident's fall. The pharmacist's recommendations, based upon the resident's increased frequency of falls and description of the resident being confused, were to reduce the dose of the resident's oxycodone and/or the methocarbamol to reduce confusion, especially if the resident's pain was controlled. A nurse's note, dated 1/24/25, documented Resident #63 was readmitted to the facility from the hospital with a diagnosis of a urinary tract infection(UTI). The resident's mental status was super confused. -However, there was no documentation to indicate additional fall interventions were put into place due to the resident's new diagnosis of a UTI and his increased confusion. -Additionally, there was no documentation in Resident #63's EMR to indicate the IDT had reviewed the resident's three falls on 1/20/25 to determine the effectiveness of the resident's care planned fall interventions or to determine if there was a need for additional interventions. 9. Fall incident on 1/29/25 - unwitnessed A nurse's note, dated 1/29/25, documented nursing staff heard a loud thump from Resident #63's room. Staff rushed into the resident's room and found the resident lying on the floor on his right side. The resident was reporting pain to his left hip. The resident was assisted off the floor and back into his recliner chair. His neurological status was at baseline and the physician, the resident's representative and the DON were notified. The physician gave an order to obtain a pelvic Xray. A therapy note, dated 1/30/25, documented Resident #63 fell while attempting to sit in his wheelchair without locking the brakes first. Therapy would be installing an anti-rollback device this date in order to decrease the resident's fall risk and the resident would continue with therapy services. An IDT note, dated 1/30/25 documented the IDT had reviewed #63's 1/29/25 fall. The IDT implemented a new intervention to apply anti-rollback devices to the resident's wheelchair. -However, the intervention for the anti-rollback devices was not updated on the care plan to alert staff of the new intervention. 10. Fall incident on 3/12/25 - unwitnessed A nurse's note, dated 3/12/25, documented nursing staff found Resident #63 on the floor in his bathroom sitting upright. He was not a good historian and was unable to give an account of how he got on the floor. A head to toe assessment was completed and the resident had no noted physical injury. Resident #63 was helped back to his feet and back to bed. The physician, the resident's representative and the on-call nurse were notified. A therapy note, dated 3/12/25, documented Resident #63 was participating in physical therapy (PT) for fall prevention, functional strength training and to return the resident to his prior level of functioning. The resident was actively participating and making progress towards the established therapy goals. The resident was currently on a toileting program every two hours from 8:00 a.m. to 8:00 p.m., as was recommended by occupational therapy (OT). The note indicated the IDT had added a toileting schedule for the middle of the night in order to decrease the resident's risk for falling in the bathroom again. -However, the intervention for the toileting program was not updated on the care plan to alert staff of the new intervention. -Additionally, there was no documentation in the resident's EMR to indicate staff was following the toileting program schedule for Resident #63. 11. Fall incident on 4/30/25 - unwitnessed A nurse's note, dated 4/30/25, documented Resident #63 had a small amount of blood on the top of his head. The resident said he did not fall, but he bumped his head on the dresser. The area to the right side top of his head was cleansed with wound cleanser and left open to air. Neurological checks were started. The resident had no complaints of pain/discomfort. The physician, the resident's representative, the DON and the on-call nurse were notified. An IDT note, dated 5/1/25, documented the IDT had reviewed Resident #63's 4/30/25 fall. The resident was offered padding for his dresser, however, he declined to allow staff to put any padding on his furniture. The resident said he would be more careful when putting clothes away in his room. 12. Fall incident on 5/13/25 - unwitnessed A nurse's note, dated 5/13/25, documented Resident #63 had an unwitnessed fall. Resident #63 reported he was getting in his chair and the dresser moved. An assessment was completed and there was no injury noted. Neurological checks and ROM were within normal limits for the resident. The resident had no complaints of pain/discomfort. The physician and the resident's representative were notified. Staff offered to move the furniture in the room but the resident declined. The resident's dresser was being secured to the floor to prevent it from moving when the resident transferred. -There was no documentation in Resident #63's [TRUNCATED]

Based on observations, record review and interviews, the facility failed to ensure one (#184) of two residents who required respiratory care received care consistent with professional standards of practice out of 35 sample residents. Specifically, the facility failed to ensure oxygen was administered as ordered by the physician for Resident #184. Findings include: I. Facility policy and procedure The Respiratory Care and Oxygen Administration policy and procedure, revised 5/13/25, was provided by the nursing home administrator (NHA) on 6/3/25 at 5:22 p.m. It read in pertinent part, The facility provides respiratory care, including the administration of oxygen, in accordance with medical orders and based on residents' clinical needs. Care shall be safe and evidence-based. Procedures, including respiratory care, must be ordered by a physician, nurse practitioner, or physician's assistant. Nursing staff will assess residents for signs of respiratory distress upon admission and routinely thereafter. Respiratory orders must specify oxygen flow rate, delivery method and frequency. Verify the physician's order prior to administration. Observe respiratory rate, oxygen saturation, breath sounds, and effort at least every shift. II. Resident #184 A. Resident status Resident #184, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included cardiac arrest (when the heart stops beating suddenly), acute respiratory failure with hypoxia, anoxic brain damage (when the brain is deprived of oxygen for a period, leading to damage or death of brain cells), cerebrovascular disease, dependence on supplementary oxygen and seizures. The 4/15/25 minimum data set (MDS) assessment revealed the resident was unable to complete a brief interview for mental status (BIMS) assessment. According to the staff assessment for mental status, the resident had short-term and long-term memory deficits, severely impaired decision making and continuous disorganized thinking. Resident #184 was not cognitively oriented to staff names and faces. He was dependent on staff for all of his activities of daily living (ADLs). According to the MDS assessment, the resident had a debilitating cardiorespiratory condition and respiratory failure. The MDS assessment identified the resident required oxygen therapy, suctioning and tracheostomy care. B. Observations On 5/28/25 at 2:14 p.m. Resident #184 was lying in bed. Resident #184 had a tracheostomy inserted through the center of his throat, with oxygen running through the tracheostomy. His oxygen concentrator was turned on and set at approximately 4.8 liters per minute (LPM) of oxygen. Resident #184 was partially awake and was taking deep breaths. The resident would open his eyes momentarily, take a deep breath, and close his eyes. On 5/29/25 at approximately 9:44 a.m. Resident #184 was in bed, lying flat with his face pointed up toward the ceiling. His tracheostomy was attached to his trachea with an oxygen tube connected to the tracheostomy. His oxygen concentrator was set at 4.8 LPM of oxygen. On 6/2/25 at approximately 11:40 a.m. registered nurse (RN) #1 entered Resident #184's room to set up a formula for the resident's tube feeding. RN #1 donned (put on) a protective gown and gloves. RN #1 performed tracheostomy care, administered medications via the resident's gastrostomy tube, checked the resident's pulse oximetry and then left the resident's room after disposing of the gown and gloves. -RN #1 failed to check the liter flow of oxygen for Resident #184 or identify that the resident was receiving 4.8 LPM of oxygen instead of the continuous 4 LPM of oxygen that was specified by the resident's physician's order for oxygen (see physician's order below). C. Record review A review of Resident #184's May 2025 CPO revealed the following physician's order: Resident on 4 LPM of oxygen via trach (tracheostomy) every shift for shortness of breath (SOB), ordered 3/6/25. Further review of the resident's physician order history revealed Resident #184 had a physician's order for 6 LPM of oxygen via tracheostomy that was discontinued on 3/6/25. The oxygen care plan, revised 1/29/25, revealed Resident #184 received oxygen therapy related to respiratory failure with hypoxia. -The care plan did not include that Resident #184 required oxygen at 4 LPM via tracheostomy. The May 2025 oxygen saturation log, between 5/1/25 and 5/31/25, documented Resident #184's oxygen saturation levels (level of oxygen in the blood) were checked two to three times a day and ranged between 91 percent (%) and 97%. D. Staff interviews RN #1 was interviewed on 6/2/25 at 11:46 a.m. RN #1 said Resident #184 had a physician's order for 4 LPM of oxygen via tracheostomy. RN #1 confirmed the resident was receiving 4.8 LPM of oxygen instead of 4 LPM. RN #1 said she did not know why the resident' oxygen concentrator was set to 4.8 LPM. RN #1 said she did not check the resident's oxygen settings at the start of her shift and she was not aware that Resident #184 was receiving more oxygen than the physician's order specified he should receive. She said only nurses were allowed to adjust oxygen settings on the concentrators. RN #1 said there was no titration order (order that includes a target oxygen saturation level and instructions for gradually adjusting the oxygen flow rate to maintain that oxygen saturation level target) with the resident's order and the concentrator should be left at 4 LPM. RN #1 said Resident #184 was not physically able to adjust the oxygen setting himself. Licensed practical nurse (LPN) #3 was interviewed on 6/2/25 at 2:05 p.m. LPN #3 said Resident #184 had a physician's order for 4 LPM of oxygen via tracheostomy with no titration order. LPN #3 said oxygen was a medication and required a physician's order to initiate oxygen therapy. LPN #3 said a physician's order for the use of oxygen should be followed to avoid complications associated with high levels of oxygen in the blood. The director of nursing (DON) and the NHA were interviewed together on 6/3/25 at 12:45 p.m. The DON said all nursing staff were responsible for ensuring that oxygen was administered according to the physician's orders. The DON said only nurses were permitted to set, titrate and initiate oxygen therapy. The DON said nurses should check the settings of each residents' oxygen concentrator at least once every shift. The NHA said a physician's order for oxygen should include the diagnosis explaining the reason oxygen was needed, the flow rate for the oxygen, duration of use and the delivery method for the oxygen. The NHA said nursing staff would be re-educated immediately on the need to ensure oxygen orders were followed. E. Facility follow-up On 6/4/25 at 2:15 p.m., following the survey exit, the NHA provided the following information via email: The NHA's email revealed the facility's respiratory therapist (RT) was consulted to reassess the appropriateness of Resident #184's existing oxygen order. According to the NHA, the facility's RT concluded that, based on Resident #184's chronic tracheostomy and fluctuating respiratory status, a titrated oxygen range order was more clinically appropriate for the resident than a continuous fixed flow rate of oxygen. The information submitted by the NHA revealed Resident #184's physician's order for 4 liters LPM of oxygen was discontinued on 6/4/25 at 1:15 p.m. and the following physician's order was obtained: -Oxygen delivery via tracheostomy cannula: administer oxygen via a humidified tracheostomy. Flow rate range: 4 LPM to 10 LPM, maintain oxygen saturation between 88% and 100% every shift for altered respiratory status. If SpO2 (oxygen saturation level) falls below 88%, increase flow by 1 LPM every 5 (five) minutes up to a maximum of 10 LPM. Notify the physician if oxygen requirement exceeds 10 LPM or if signs of respiratory distress are observed.

Based on record review and interviews, the facility failed to ensure residents were free from significant medication errors for one (#55) of six residents reviewed for medications errors out of 35 sample residents. Specifically the facility failed to ensure Resident #55 was administered Percocet (pain medication) per physician's orders. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), E.[NAME], St. Louis Missouri, pp. 606-607. Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication. II. Resident #55 A. Resident status Resident #55, age greater than 65, was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included acute myocardial infarction (heart attack), chronic obstructive pulmonary disease (lung disease), acute and chronic respiratory failure, fractured thoracic vertebra (12 bones of the vertebrae), heart failure and chronic respiratory failure. The 4/22/25 minimum data set assessment (MDS) revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required substantial assistance bathing, moderate assistance with dressing and hygiene, and set-up assistance for meals. The assessment documented the resident was on a scheduled pain medication regimen, received as needed pain medication and received non-medication intervention for pain. The assessment revealed the resident frequently had pain that frequently affected her sleep and day-to-day activities and pain intensity was seven out of 10. B. Resident interview Resident #55 was interviewed on 5/28/25 at 11:00 a.m. Resident #55 said she did not feel like the facility effectively managed her pain and her pain medication needed to be adjusted. III. Record review Resident #55's pain care plan, revised 12/18/24, documented she was at risk for pain due to diagnoses of heart failure, history of myocardial infarction, chronic obstructive pulmonary disease,and a history of fractured thoracic vertebra, muscle spasms, and chronic kidney disease. Pertinent interventions, initiated 10/2/24, included to anticipate the resident's need for pain relief and respond immediately to any complaint of pain, to identify and record previous pain history and management of that pain and impact on function, to monitor/document for probable cause of each pain episode and remove/limit causes where possible and to notify the physician if interventions are unsuccessful or if current complaint was a significant change from residents past experience of pain. The resident's pain medication care plan, revised 8/17/24, documented the resident was on pain medication therapy due to back pain. Pertinent interventions included to administer analgesic medications as ordered by the physician and monitor and document the side effects every shift, asking the physician to review medication if the side effects persist and assessing whether the pain intensity was acceptable to the resident The resident's care plan documented she had a history of fracture to her thoracic vertebrae and diagnosis. She was at risk for pain, fracture, and falls, and generalized weakness, revised 10/10/24. Pertinent interventions included to give pain and anti-inflammatory medications as ordered and monitor the side effects and handle gently when moving or positioning. A review of Resident #55's May 2025 CPO revealed the resident had physician's orders for the following medications: -Oxycodone 5 milligrams (mg) by mouth, one tablet by mouth every 12 hours as needed for pain management, ordered 5/13/25. -Percocet 325 milligrams (mg) by mouth three times a day for chronic pain, ordered 5/13/25. Resident #55's May 2025 Medication administration record (MAR) revealed the resident did not receive her percocet as ordered for two of two opportunities on 5/15/25. A 5/15/25 nurses progress note documented at 1:47 a.m. the resident was being monitored for a decrease in oxycodone and added Percocet. The resident stated that the change in medication was not helping and that she wanted it switched back. A 5/15/25 administration note documented at 12:15 the Percocet was on order and not administered to the resident. A 5/15/25 administration note documented at 12:16 p.m. Resident #55 requested oxycodone for pain level of 8 out of 10. A 5/15/25 administration note documented at 4:45 p.m. the Percocet was on order and not administered to the resident. A 5/15/25 administration note documented at 4:52 p.m. the oxycodone pain administration was ineffective and the follow-up pain scale was an 8 out of 10. A 5/15/25 administration note documented at 6:15 p.m. revealed the resident was on follow-up monitoring for a decrease in dosage of oxycodone and addition of Percocet. The resident reported she was never notified of the change in dosage and addition of percocet. -However, there were no progress note documented to indicate the resident's physician had been notified Resident #55's pain medication was not available and not administered to the resident, and the resident's medication was ineffective in treating her pain. IV. Staff interviews The director of nursing (DON) was interviewed on 6/3/25 at 1:10 p.m. The DON said Resident #55 was previously on scheduled oxycodone that had been changed to as needed on 5/13/25 and scheduled Percocet was added. The DON said on 5/15/25 the Percocet was prescribed and nothing else was given to the resident except the as needed oxycodone. The DON said the nurse should notify the physician if a medication was not available to administer. The DON said the pharmacy could tell the facility when a medication was being delivered to the facility. The DON said the Percocet was an added prescription and not a change in the order. The DON said if the facility did not have the Percocet the nurses could pull something from the ekit (a medical supply kit). The DON said the nurse should have called and notified the physician the medication was not available

Based on record review, observation, and interviews, the facility failed to create an environment that protected the right of eight (#1, #2 #3, #4, #5, #6, #7, #8) of eight residents reviewed for abuse out of eight sample residents to be free from abuse. The facility's failure contributed to repeated incidents of abuse and actual harm. Record review and interview revealed Resident #1, under age 35, was blind, nonverbal, non-interviewable, severely cognitively impaired, and dependent on care. On 10/14/24 at 9:39 a.m., a housekeeper observed Resident #2 sexually abusing Resident #1 in her bed. Resident #1 had blood in her incontinence brief and was actively bleeding. A review of the facility's investigation of the 10/14/24 incident revealed Resident #2 had previously engaged in inappropriate sexual behavior toward other male and female residents in the facility. Resident #2 grabbed male Resident #4's breast/chest and torso about a year ago and grabbed male Resident #3's buttocks around a month ago. In addition, Resident #2, known to wander into residents' rooms, entered the room of Resident #5, a female with a history of physical and emotional trauma, on 10/14/24 around midnight (before the incident involving Resident #1), making her feel uncomfortable and leaving when she yelled at him. The facility failed to protect Resident #1 from sexual abuse by Resident #2, protect Resident #3 and #4 from unwanted sexual contact by Resident #2, and protect Resident #5 from Resident #2 entering her room in the middle of the night. The facility conducted training regarding the prevention and detection of sexual assault on 10/16/24 following the incident with Resident #1 and implemented a number of measures to promote resident safety. However, record review and resident interviews revealed abusive incidents continued in the facility after 10/14/24. On 10/23/24, Resident #7 threatened and hit Resident #6 and on 12/10/24, Resident #7 pushed Resident #8 to the ground. Measures taken by the facility after 10/14/24 failed to create an environment that protected residents' right to be free from abuse. This failure created a situation of immediate jeopardy with actual, serious harm for Resident #1 and the likelihood of serious harm for other facility residents if the failure was not immediately corrected. Cross-reference F727 - failure to have a director of nursing (DON) serve on a full-time (40 hrs +) basis when the facility had an average daily occupancy of over 60 residents. Cross-reference F867 - failure to ensure an effective quality assurance program to identify and address facility compliance concerns. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy The facility failed to develop and implement effective interventions to prevent resident-to-resident abuse. Resident #2, with moderate cognitive impairment, had a history of exhibiting inappropriate sexual behavior towards other residents. On 10/14/24 at 9:39 a.m., a housekeeper observed Resident #2 sexually abusing Resident #1, who was blind, nonverbal, non-interviewable, severely cognitively impaired, and dependent on care. A review of the facility's investigation of the 10/14/24 incident revealed Resident #2 had previously engaged in unwanted sexual behavior toward other male and female residents in the facility. Resident #2 grabbed male Resident #4's breast/chest and torso about a year ago and grabbed male Resident #3's buttocks around a month ago. In addition, Resident #2, known to wander into residents' rooms, entered the room of female Resident #5, who had a history of physical and emotional trauma, on 10/14/24 around midnight (before the incident with Resident #1), making her feel uncomfortable and leaving when she yelled at him. The facility conducted training regarding the prevention and detection of sexual assault on 10/16/24 following the incident with Resident #1 and implemented a number of measures to promote resident safety. However, record review and resident interviews revealed abusive incidents continued in the facility after 10/14/24. On 10/23/24, Resident #7 threatened and hit Resident #6, and on 12/10/24, Resident #7 pushed Resident #8 to the ground. Measures taken by the facility after 10/14/24 failed to create an environment that protected residents' right to be free from all types of abuse. This failure created a situation of immediate jeopardy with actual, serious harm for Resident #1 and the likelihood of serious harm for facility residents if the failure was not immediately corrected. On 12/30/24 at 6:35 p.m., the nursing home administrator (NHA) was notified the facility's failure created an immediate jeopardy situation. B. Facility plan to remove immediate jeopardy On 12/31/24 at 2:48 p.m., the facility submitted a plan to remove the immediate jeopardy. The plan read: Immediate Action: All facility employees were immediately re-educated on abuse training. Training was initiated on 12/30/24 at approximately 7:30 p.m. and would continue until complete on or before 12/31/24. Any facility staff unable to complete the training due to pre-approved leave would complete training prior to their next scheduled shift. Abuse training with all residents and their responsible parties would be completed with residents currently in the facility. Training was initiated on 12/30/24 and completed on 12/31/24. Any resident not at the facility would receive abuse training on the same day of their return. The facility temporarily increased resident monitoring. Monitoring was implemented on 12/30/24 and completed on 12/31/24. Increased signage instructing staff how to identify abuse and who/how to report potential signs of abuse were hung throughout the facility. Increased signage was initiated on 12/31/24. The facility's abuse coordinators would complete additional training on occurrence reporting guidelines and investigations. This training was completed on 12/31/24. The facility created and distributed personalized reminder cards to staff that contained the definitions of abuse when to report abuse, who a mandated reporter is, resident rights, and abuse coordinators. This was completed on 12/31/24. C. Removal of immediate jeopardy On 12/31/24 at 2:48 p.m., the NHA was notified that the facility's plan to remove the immediate jeopardy was accepted based on the facility's plan and evidence of implementation of the measures outlined in the plan. However, the deficient practice remained at a G level, isolated, actual harm. II. Facility policy The facility's Abuse policy, revised April 2021, was received from the nursing home administrator (NHA) on 12/30/24 at 5:15 p.m. It read in pertinent part: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Interpretation and implementation: If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Immediately is defined as: -Within two hours of an allegation involving abuse or result in serious bodily injury; or, -Within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. All allegations are thoroughly investigated. The administrator initiates the investigation. Investigations may be assigned to an individual trained in reviewing, investigation, and reporting such allegations. The individual conducting the investigation as a minimum: -Reviews the documentation and evidence; -Reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; -Observes the alleged victim, including his or her interactions with staff and other residents; -Interviews the person(s) reporting the incident; -Interviews any witnesses to the incident; -Interviews the resident (as medically appropriate) or the resident's representative; -Interviews the resident's attending physician as needed to determine the resident's condition; -Interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; -Interviews the resident's roommate, family members, and visitors; -Interviews other residents to whom the accused employee provides care or services; -Reviews all events leading up to the alleged incident; and, -Documents the investigation completely and thoroughly. The administrator, or his/her designee, provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident. The resident and/or representative are notified of the outcome immediately upon conclusion of the investigation. III. Sexual abuse of Resident #1 by Resident #2 A. Facility investigation of the 10/14/24 sexual abuse of Resident #1 by Resident #2 The social services director (SSD) provided the facility's investigation of the 10/14/24 incident of sexual abuse on 12/30/24 at 11:50 a.m. The abuse investigation, dated 10/14/24, documented the sexual abuse occurred on 10/14/24. It read that registered nurse (RN) #1 was called into Resident #1's room by housekeeping staff, where she found Resident #2 on top of Resident #1 with his pants down by his knees, not wearing underwear, and penetrating Resident #1's vagina with his penis. It was documented that RN #1 immediately separated both residents and took Resident #2 out of the room so she could assess Resident #1. 1. Timeline of events on 10/14/24 -At 9:39 a.m., Resident #2 was seen entering Resident #1's room (per security camera review). -At 9:44 a.m., housekeeping staff went into Resident #1's room to take out trash and found Resident #2 on top of Resident #1. -At 9:45 a.m., RN #1 removed Resident #2 from being on top of Resident #1. -At 9:45 a.m. Resident #2 was placed on one-to-one supervision. -At 9:50 a.m., RN #1 brought Resident #2 to the NHA, the director of nursing (DON), assistant director of nursing (ADON), and the facility's psychiatric nurse practitioner (NP), who were meeting, and informed them she found Resident #2 on top of Resident #1 having sexual relations. -At 10:00 a.m., the investigation was opened and police were notified. -At 10:05 a.m., the facility called emergency medical services (EMS) to take Resident #1 to the hospital for a sexual assault nurse examiner (SANE) examination. -At 10:11 a.m., EMS arrived to take Resident #1 to the hospital. -At 10:23 a.m., the police department arrived to begin an investigation. The police took over supervision of Resident #2 in the facility upon their arrival, at 10:23 a.m. Resident #2 was not left without a police escort, and EMS required the police department to follow them to the hospital. -At 10:38 a.m., police officers took Resident #2 into the facility's conference room for questioning. -At 10:48 a.m., the police left the room and stated Resident #2 was unable to talk to the police, therefore, they could not arrest him. -At 10:54 a.m., the facility's psychiatric NP provided her clinical presentation of Resident #2 to the police and stated Resident #2 knew what he was doing, and that he knew right from wrong. She also contacted the overseeing psychiatrist who agreed that Resident #2 could identify if he had done something wrong. -At approximately 11:30 a.m., police officers informed the facility's staff that they were not going to arrest Resident #2 and that the NHA and the DON were responsible for changing the safety plan to protect the residents. -At (time undocumented) the psychiatric NP ordered an M1 (mental health) hold for Resident #2. -At (time undocumented) EMS arrived at the facility to transport Resident #2 to the hospital for an M1 hold. A formal interview on 10/14/24 at 2:00 p.m. with RN #1 revealed that RN #1 observed Resident #2's penis was in Resident #1's vagina. The facility investigation documented the facility's social services director (SSD) was unable to interview Resident #1 on 10/14/24, time undocumented, due to Resident #1 being cognitively impaired and non-verbal. The investigation documented the facility's SSD was unable to interview Resident #2 on 10/14/24 due to Resident #2 declining to answer questions. 2. Interviews The facility conducted interviews with other residents in the facility during the abuse investigation, starting on 10/14/24, and found an additional three residents (#3, #4, and #5) who reported being subjected to inappropriate/non-consensual encounters perpetrated by Resident #2. -The investigation documented an interview with Resident #3 on 10/14/24. The interview revealed Resident #3 said he was touched on his butt, one month ago by Resident #2, and that he had to tell Resident #2 to stop touching him. The facility's SSD followed up with Resident #3 who said he did feel safe in the facility. Resident #3 did not report the incident to staff when it first occurred but said he would tell staff if something happened in the future. The investigation documented an interview with Resident #4 on 10/14/24. The interview revealed Resident #4 said that one year ago, Resident #2 told him he wanted to have sex with him. Resident #4 said he reported the incident to staff when it occurred but staff did not do anything. Resident #4 told the interviewer that he did not trust Resident #2, however, he did feel safe in the facility. The investigation documented an interview with Resident #5 on 10/15/24. The interview revealed Resident #2 had entered Resident #5's room in the middle of the night on 10/14/24 and she felt uncomfortable. No documentation was found that Resident #5 reported the incident to staff before she was interviewed on 10/15/24. 3. Facility response The investigation concluded the allegation that Resident #1 was sexually abused by Resident #2 was substantiated, and documented the following follow-up actions were put into place: -The assailant was immediately discharged from the facility; -The facility's medical director/ primary care provider (PCP) was replaced on 10/16/24 (see staff interview below; one person was filling the roles of medical director and PCP in the facility); -The facility conducted room moves to separate male and female residents on separate hallways and the shower rooms were separated and divided by gender; -Vulnerability and risk of aggression screening tools were created on 10/16/24, and assessments were conducted on all residents on 10/17/24; -15-minute checks were initiated on residents deemed vulnerable using the new screening tool. -All residents had a standardized safety plan added to their care plans addressing both vulnerability and risk of aggression scenarios; -All residents, and/or their responsible parties, were notified of the incident and safety measures were put into place to help minimize the risk of occurrence; -The facility requested authorization to run background checks on all residents, as a recommendation from the police department; -Staff training was provided on 10/16/24 that covered signs of sexual assault and abuse; and -The facility's policies were updated to reflect new male and female cohorting and a standardized safety policy. 4. Failures in facility response a. The facility's investigation failed to reveal evidence the facility attempted to investigate or address the additional allegations of Resident #2's inappropriate behavior reported during the investigation of the sexual abuse perpetrated on Resident #1 to identify gaps in the facility's ability to protect residents from abuse and to develop effective abuse prevention interventions. -Resident #4, legally blind, said in an interview on 12/30/24 at 1:58 p.m., that there were a lot of aggressive behaviors between residents in the facility. And, when he notified staff of his incident with Resident #2, staff told him only that the two residents should stay away from each other. (See Resident #4's interview below.) -Cross-reference F867; QAPI (quality assurance and performance improvement). The NHA was interviewed on 12/31/24 at 4:33 p.m. The NHA said the QAPI committee had not previously identified concerns related to abuse and the topic of abuse would be a new addition to QAPI meetings moving forward. She said abuse had been cited on the prior recertification survey on 11/30/23 but the action plan was completed and discussed with QAPI. The NHA said the facility finished its plan of correction monitoring for the previously cited abuse citation in January 2024. She said abuse had not been identified by the facility as a concern since that time. b. The facility's investigation documented Resident #2 was experiencing an increase in inappropriate behaviors before and at the time he sexually abused Resident #1. The investigation read the increase in inappropriate behaviors aligned with a prescribed gradual dose reduction (GDR) of his psychotropic medications, first initiated in January 2024. See the interviews below. An interview with the NHA, the DON, and the SSD on 12/30/24 at 4:13 p.m. revealed that Resident #2 had been acting weird for months and that he had six or seven medication changes over the previous six months. The DON said the PCP would review behavior changes with the psychiatry team and continued to make medication changes without the addition of other interventions. The NHA, DON, and SSD agreed that when Resident #2 started exhibiting more behaviors, the GDR was not stopped. A review of Resident #2's record revealed there had been no additional interventions initiated to address the resident's known increase in inappropriate behaviors. B. Resident #2 - perpetrator of sexual abuse involving Resident #1, unwanted sexual contact involving Resident #3, and #4, and entry into Resident #5's room in the middle of the night. 1. Resident status Resident #2, age under 65, was readmitted on [DATE] and discharged on [DATE]. According to the October 2024 computerized physician orders CPO, the resident's diagnoses included unspecified personality disorder, other impulse disorders, inhalant use with inhalant-induced persisting dementia, and generalized anxiety disorder. The 9/12/24 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 10 out of 15. He was independent with eating, toileting and toileting hygiene, dressing, bed mobility, and transfers. He required moderate assistance with oral and personal hygiene. No coded behaviors were documented. The resident's behavior care plan, initiated on 8/9/22, documented Resident #2 had a behavior of inappropriately touching staff and other residents in the community related to a diagnosis of impulse disorder. It documented Resident #2 had the potential to be physically aggressive and his triggers were delusions secondary to water intoxication, poor sleep patterns, and peers, and aggression could occur impulsively without warning. -Pertinent interventions included anticipating and meeting Resident #2's needs (initiated 8/9/22), intervening as necessary to protect the rights and safety of others by: approaching/speaking in a calm manner, diverting attention, removing resident from the situation and taking him to an alternate location as needed (initiated 8/9/22), and monitoring Resident #2's location frequently (initiated 8/9/22). The care plan documented staff was to ensure the safety of person(s) who have or have the potential to receive unwanted/unasked-for inappropriate touch, and when the situation warrants, to separate resident(s) and ensure safety with 15-minute checks (initiated 9/30/22). It also documented to report incidents to the authorities/police if, and when, warranted (initiated 10/6/22). The behavior care plan was not updated to include the resident's weird behavior, increase in behaviors, or GDR. The resident's elopement care plan, initiated on 9/8/22, documented Resident #2 was an elopement risk/wanderer related to impaired safety awareness. It documented Resident #2 wanders into others' rooms to look for soda, money, or cigarettes. -Pertinent interventions included distracting the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or books (initiated 9/8/22), and by by utilizing 15-minute tracking to provide increased monitoring (initiated 9/8/22) Resident #2 also had a behavior care plan initiated on 2/21/18 that was documented as resolved on 9/9/22. This care plan documented Resident #2 could be socially inappropriate at times, could be sexual in nature and he could be seen hugging or kissing other female residents or staff. -Pertinent interventions documented were to provide one-to-one supervision as needed to educate Resident #2 on appropriate behaviors with staff and other female residents and to place him on 15-minute tracking for safety if concerns of unsafe sex practices were observed. 2. Documentation on 10/14/24 A nurse's note, dated 10/14/24 at 1:49 a.m., documented Resident #2 was being monitored for a medication change from Depakote (anti-convulsant medication) to Valproic acid (anti-convulsant medication). It documented Resident #2 took his scheduled medications yet refused his blood sugar check and insulin. It read that Resident #2 had some difficulty falling and staying asleep again that night. The note did not document Resident #2 had entered Resident #5's room around midnight, leaving when yelled at by Resident #5, or document 15-minute checks were initiated because of the inappropriate encounter. A nurse's note, dated 10/14/24 at 12:59 p.m., documented the nurse was called into Resident #1's room by housekeeping where she found Resident #2 on top of Resident #1 with his pants down toward his knees and not wearing underwear. It documented Resident #1's incontinence brief was open. It read the nurse separated both residents and Resident #2 was placed on one-to-one supervision. A psychiatry follow-up note, dated 10/14/24 at 5:15 p.m., documented Resident #2 had a diagnosed psychotic disorder with hallucinations, and he had been non-compliant with his prescribed psychiatric medications. It documented that since the incident on 10/14/24, Resident #2 continued to exhibit episodes of irritability and agitation, making him a continued risk to other residents in the facility. Due to the risk of immediate safety to other residents, an M1 mental health hold was initiated on Resident #2. C. Resident #1 - victim of sexual abuse 1. Resident status Resident #1, under age 65, was admitted on [DATE] and readmitted on [DATE]. According to the December 2024 CPO, the resident's diagnoses included neuronal ceroid lipofuscinosis (nerve cell disorder), autistic disorder, legal blindness, aphasia (the loss of understanding/expressing speech), and major depressive disorder. The 11/7/24 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of zero out of 15. She was dependent on staff for all activities of daily living (ADLs). She had adequate hearing but was unable to speak, rarely able to express her needs and wants (both verbally and non-verbally), and had severely impaired vision. She was sometimes able to understand verbal content. The resident's activities of daily living (ADL) care plan, initiated on 8/31/2020 and revised on 8/25/23, revealed Resident #1 had an ADL self-care performance deficit related to neurological deficits. -Pertinent interventions revealed that Resident #1 was totally dependent on two staff to perform all ADL care. The resident's vulnerability care plan, developed after the 10/14/24 incident, was initiated on 10/17/24 and revised on 11/25/24. It read Resident #1 was at high risk of vulnerability due to significant cognitive impairment, physical disability, and dependence on staff for most or all personal care. It documented that Resident #1 had difficulty understanding or responding to social cues, making Resident #1 more vulnerable to inappropriate behavior by others, with a greater risk for exploitation, neglect, or harm due to an inability to self-advocate. -Pertinent interventions included: ensuring Resident #1's room and common areas were arranged to promote safety, including reducing hazards and ensuring easy access to staff (initiated 10/17/24); checking on the resident every 30 minutes, especially during personal care or social interactions to ensure their needs were being met respectfully (initiated 10/17/24); and assigning a consistent caregiver to minimize confusion and ensure familiarity with the resident's preferences and needs (initiated 10/17/24). 2. Documentation on 10/14/24 A change in condition note, dated 10/14/24 at 10:41 a.m., documented that a housekeeper called the floor nurse to Resident #1's room after finding Resident #2 on top of Resident #1 sexually assaulting her. The nurse separated the residents. Resident #1 was then sent to the hospital emergency room for a sexual assault nurse examiner (SANE) exam and treatment for injuries and potentially sexually transmitted diseases. A nurse's note, dated 10/14/24 at 1:13 p.m., documented the nurse on duty was called into Resident #1's room by a housekeeper. It read the nurse found Resident #2 on top of Resident #1 with his pants down towards his knees and he was not wearing underwear. It documented Resident #1's incontinence brief was open. It documented the nurse separated Resident #2 from Resident #1 and took him out of the room, and Resident #1's provider, responsible party, the police, and the facility's NHA, DON, and assistant director of nursing (ADON) were notified. A late entry progress note, dated 10/14/24 at 1:39 p.m. documented Resident #2's penis penetrated Resident #1's vagina during the sexual assault. A late entry nurse's note, dated 10/14/24 at 7:50 p.m., documented Resident #1 returned from the hospital and her vital signs were stable. An orders administration note, dated 10/17/24 at 3:05 p.m., documented Resident #1 was screaming and restless, and she was given Oxycodone 5mg ordered as needed for pain. An orders administration note, dated 10/17/24 at 10:30 p.m., documented Resident #1 was given Oxycodone 5mg due to her screaming, moaning, and facial grimacing. A physician note, dated 10/23/24, documented Resident #1's primary care physician (PCP) rounded on her for follow-up after confirmed sexual abuse. It documented Resident #1 seemed uncomfortable for a few days after the assault occurred which was treated with pain medications. IV. Residents subjected to unwanted sexual contact or the unwanted presence of Resident #2 A. Resident #3 - victim of unwanted sexual contact 1. Resident status Resident #3, age under 60, was admitted on [DATE] and readmitted on [DATE]. According to the December 2024 CPO, the resident's diagnoses included paranoid schizophrenia (mental disorder), chronic obstructive pulmonary disease (COPD, a lung disorder), and generalized anxiety disorder. The 8/22/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He was independent with most ADL tasks or needed set-up assistance No coded behaviors were documented. 2. Resident interview Resident #3 was interviewed on 12/30/24 at 1:28 p.m. Resident #3 said A few months ago, he was walking around a corner in the facility, and Resident #2 grabbed his butt. Resident #3 said he felt angry when it occurred, and I wanted to punch him in the face. He said he did not report the incident to staff when it happened because he was too angry. Resident #3 said staff asked him recently (during the facility investigation of the 10/14/24 incident) if anything happened (involving Resident #2) and he reported the incident. Resident #3 said staff did not tell him the incident would be investigated and he had not been questioned further about the incident. B. Resident #4 - victim of unwanted sexual contact 1. Resident status Resident #4, age under 70, was admitted on [DATE]. According to the December 2024 CPO, the resident's diagnoses included schizoaffective disorder (chronic mental disorder) depressive type, legal blindness, unspecified depression, and Type 2 diabetes mellitus. The 10/29/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He was independent with all ADLs. No coded behaviors were documented. 2. Resident interview Resident #4 was interviewed on 12/30/24 at 1:58 p.m. He said there were a lot of aggressive behaviors between residents in the facility and I just try and stay away. He said he had experienced issues with other residents due to his blindness; residents get mad and sometimes yell at him if he accidentally crosses into their path while walking (Resident #4 was observed ambulating with the aid of a walking stick). Resident #4 did not mention any staff intervention when this occurred. Resident #4 said two years ago, Resident #2 grabbed his chest and torso area. He said that he felt violated after it occurred. Resident #4 said he notified staff of the incident and was told by staff that he and Resident #2 should stay away from each other. Resident #4 said Resident #2's behavior was triggering because he was sexually assaulted when he was eight years old and he also protected his mother from being physically abused by his father. Resident #4 said he currently feels unsafe and uncomfortable with male caregivers. He said he would not undress or take showers if a male caregiver was present and would refuse care if a male caregiver attempted to help him dress or shower. A review of Resident #4's care plan revealed it failed to address his vulnerability until after the incident on 10/14/24. Further, Resident #4 said staff did not tell him the incident with Resident #2 would be investigated and he had not been questioned further about the incident. C. Resident #5 - victim of unwanted presence of Resident #2 1. Resident status Resident #5, age under 30, was admitted on [DATE] and discharged on [DATE]. According to the November 2024 CPO, the resident's diagnoses included unspecified protein-calorie malnutrition, post-traumatic stress disorder, recurrent major depressive disorder, and severe hypoxic-ischemic encephalopathy (brain injury). The 11/20/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. No coded behaviors were documented. The resident was independent with all ADLs. 2. Record review A trauma-informed care plan, initiated on 11/2/18, documented that Resident #5 experienced physical and emotional trauma by her father at a very young age. It read Resident #5 had a history of sexual abuse leading to mistrusting males, and that she did better with female caregivers. -Pertinent interventions included reassuring Resident #5 that she was in a safe environment (initiated 6/22/2020) and the facility would attempt to provide female caregivers when she needed assistance with care (initiated 5/5/23). The resident's vulnerability care plan, developed after the 10/14/24 incident and initiated on 10/17/24, documented that Resident #5 was generally independent but could be vulnerable due to factors such as mild cognitive declines, physical limitations, or age-related frailty. It documented Resident #5 had occasional difficulty in self-advocating or making decisions, and had minor risks of exploitation due to confusion o[TRUNCATED]

Based on record review and interviews, the facility failed to designate a registered nurse (RN) to serve as the director of nursing (DON) on a full-time basis Specifically, the facility utilized the DON as a floor nurse several times a week when the facility's average daily census was over 60 residents. Findings include: I. Facility policy and procedures The Staffing policy, dated 8/1/24, was provided by the NHA on 12/31/24 at 4:28 p.m. It read in pertinent part, The facility will maintain sufficient, competent nursing staff to provide care and services 24 hours per day, seven days per week, in alignment with the resident care needs, acuity levels, and applicable state and federal requirements. II. Record review The facility assessment, reviewed 8/8/24, was provided by the NHA on 12/31/24 at 10:57 a.m. and documented the DON was planned to work as a full-time employee as the DON. The DON position description, undated, was provided by the nursing home administrator (NHA) on 12/31/24 at 4:28 p.m. It read in pertinent part, The DON is responsible for overseeing and managing all aspects of nursing care within the facility. Plays a critical role in ensuring high-quality resident care, compliance with regulations and standards, and effective leadership of the nursing staff. The primary focus is to promote resident well-being, supervise nursing operations, and collaborate with interdisciplinary teams to achieve optimal outcomes. The resident list report was provided by the NHA on 12/30/24 at 10:39 a.m. The list of residents revealed there were currently 80 residents residing in the facility. The December time sheets provided by the NHA on 12/31/24 at 7:00 p.m. documented for the pay period of 12/1/24 through 12/15/24 the DON worked 35.91 hours on the floor and 85.97 in the office. For the pay period of 12/16/24 through 12/31/24 the time sheet documented that the DON worked a total of 47.23 hours on the floor and 91.28 hours in the office. III. Staff interviews The DON was interviewed on 12/31/24 at approximately 2:00 p.m. The DON said she was the full time DON. She said that due to her working the floor she was behind on her daily DON duties. She said that she was behind on investigating and logging falls due to working the floor.

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to freedom from abuse, reporting and investigating that rose to the level of immediate jeopardy and created a situation where a serious adverse outcome occurred and caused harm. Findings include: I. Facility policy The Quality Assurance and Performance Improvement Policy, reviewed 12/11/24, was provided by the nursing home administrator (NHA) on 12/31/24 at 7:00 p.m. It read in pertinent part, The purpose of this policy is to establish a systematic, data-driven approach to maintain and improve the quality of care and services provided to residents. This policy aligns with federal requirements and state guidelines to ensure high-quality, person-centered care. The facility will implement a comprehensive Quality Assurance and Performance Improvement (QAPI) program that integrates quality assurance (QA) and performance improvement (PI) principles to enhance resident outcomes, promote safety, and maintain regulatory compliance. The QAPI program will involve all staff, residents, families, and stakeholders in identifying opportunities for improvement and achieving sustainable quality improvements. The QAPI program will address all aspects of care and services, including but not limited to: clinical care, quality of life, resident safety, behavioral health services and infection control. The program will focus on both proactive improvement initiatives and responsive corrective actions. Design and Scope: The QAPI program will be resident-focused, considering resident preferences, needs, and goals. Quality assurance activities will monitor care and identify deviations from standards. Governance and Leadership: Facility leadership, including the administrator and director of nursing (DON), will champion the QAPI program. The governing body will allocate resources necessary to implement and sustain QAPI initiatives. Data-Driven Decision Making: The program will use quantitative and qualitative data, including incident reports, resident feedback, clinical performance indicators, and survey results. Systematic Analysis: Root cause analysis (RCA) will be conducted for adverse events to identify and address underlying system issues. II. Review of the facility's regulatory record revealed it failed to operate a QA program in a manner to prevent repeat deficiencies and initiate a plan to correct F600 Free from abuse and neglect During the recertification survey on 8/23/22 F600 was cited at an E scope and severity, a potential for more than minimal harm, isolated. During the recertification survey on 11/30/23 F600 was cited at a D scope and severity, a potential for more than minimal harm, isolated. III. Cross-reference citations Cross-reference F600: The facility failed to ensure residents were protected from resident to resident sexual and physical abuse. The facility's failure to protect residents from resident-to-resident sexual and physical abuse put residents in a situation where a serious outcome occurred and created an immediate jeopardy situation. IV. Staff interviews The NHA was interviewed on 12/31/24 at 4:33 p.m. The NHA said today (12/31/24) was the last day of work for the facility's current medical director (MD #1) and a new medical director (MD #2) started work at the facility tomorrow (1/1/25). The NHA said the QAPI committee met monthly on the second Wednesday of each month. The NHA said QAPI meetings included a full review of the previous month's activities. The NHA said the committee reviewed the reported data for the entire month, such as risk management, resident council and grievances. The NHA said standard items were reviewed, such as admissions, discharges, dietary, weight loss, therapy, restorative programs, falls (including where/why with root cause analysis), hospitalization s, infection control, recruitment/hiring and online continuing education. The NHA said the committee would review each department, such as environmental services, resident council, activities, outings, social services and ancillary. The NHA said the committee created at least one PIP (Performance improvement plan) annually, and as needed, and usually once every quarter to track and trend identified concerns. The NHA said the QAPI committee had not previously identified concerns related to abuse and the topic of abuse would be a new addition to QAPI meetings moving forward. She said abuse had been cited on the prior recertification survey on 11/30/23 (see above) but the action plan was completed and discussed with QAPI. The NHA said the facility finished their plan of correction monitoring for the previously cited abuse citation in January 2024. She said abuse had not been identified by the facility as a concern since that time.

Based on observation, record review, and interviews the facility failed to provide the necessary treatment and services to prevent a pressure injury from occurring for one (#32) of two residents out of 36 residents. Specifically, the facility failed to implement interventions to reduce pressure injury risk factors for Resident #32 who was identified by the facility as high risk for developing pressure injuries. The resident required extensive assistance for activities of daily living (ADL) and was dependent upon facility staff for bed mobility and transfers. The facility failed to ensure preventative interventions were implemented which resulted in the development of a facility acquired stage 3 pressure injury to the sacrum (base of lower back). Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 12/4/23, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy and procedure The Repositioning policy, revised 9/1/23, was provided by the nursing home administrator (NHA) on 12/5/23 at 9:34 a.m. It read in pertinent part, Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation,and providing pressure relief. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. A turning/repositioning program includes a continuous consistent program for changing the resident's position and realigning the body. A program is defined as a specific approach that is organized, planned, documented, monitored and evaluated. Residents who are in bed should be on at least an every two hour (q2 hour) repositioning schedule. If ineffective, the turning and repositioning frequency will be increased. III. Resident #32 A. Resident status Resident #32, age 82, was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO), diagnoses included vascular dementia, diabetes, heart failure, left hand contracture, and chronic obstructive pulmonary (lung) disease. The 6/20/23 minimum data set (MDS) assessment revealed the resident had a severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. It documented that the resident was at risk for the development of pressure ulcers, and he required a pressure reducing device for his chair. The resident was not using a turning/repositioning program and Resident #32 was dependent on staff for repositioning in bed, transferring, bathing and eating. B. Resident representative interview Resident #32's representative was interviewed on 11/30/23 at 10:45 a.m. He said his major concern was the sore on his father's lower back which had been present for several months. He said his mother visited Resident #32 daily since he was admitted and she told him that the resident was always resting on his back in bed prior to the wound being discovered. The representative said he also visited often and he observed Resident #32 was resting on his back whenever he was in bed (prior to the development of the pressure injury). He said the wound had gotten worse before the staff started turning him. C. Observation On 11/29/23 at 10:15 a.m., registered nurse (RN) #1 changed the dressing for the pressure injury to Resident #32's sacrum. The wound bed was pink with a granular appearance. The edges of the wound were well-defined with a small amount of serous (clear pink) drainage present. RN #1 said the pressure ulcer was 4.5 cm (centimeters) long. The resident was repositioned with a wedge to his left side. D. Record review The skin integrity care plan, initiated on 12/23/21, documented the resident had the potential for additional pressure injury related to decreased tensile strength of the previous injury site and immobility. It indicated the resident required the assistance of one to two staff members with turning and repositioning. The interventions included educating the resident/family/caregivers as to the causes of skin breakdown, including transferring and positioning requirements, importance of taking care during ambulation/mobility, good nutrition and frequent repositioning, teaching the resident/family the importance of changing positions for the prevention of pressure ulcers, encouraging small frequent position changes; keeping the bed as flat as possible to reduce shear,following facility policies for the prevent of skin breakdown, informing the resident/family/caregivers of any new area of skin breakdown, monitoring the residents nutritional status and monitoring, documenting and reporting any changes in the resident's skin status. The care plan included the addition of a stage 3 pressure ulcer to the sacrum on 7/23/23. The care plan was revised after the discovery of the pressure ulcer to include the following interventions: turning and repositioning the resident every two hours and more often as needed or requested, providing Prostat (protein nutritional supplement) three times per day and Expedite nutritional supplement, providing an up/down schedule after meals and using a wedge to offload the wound. -Cleanse with wound cleanser, pat dry and apply soaked gauze, lightly pack into wound bed. Monitor pressure injury for signs/symptoms of infection. Notify MD as indicated. Reposition per facility protocol. Off load wound. The Braden Scale for predicting pressure ulcer risk on 1/5/23 revealed the resident was identified as being at a very high risk for developing a pressure ulcer. -A Braden Scale assessment on 6/20/23 documented the resident was at moderate risk for development of a pressure ulcer, however, it also revealed the resident was completely immobile, with an inability to make even slight changes in body or extremity position without assistance. The activities of daily living (ADL) care plan, revised 4/1/22, revealed the resident required extensive assistance of two staff members to turn and reposition in bed and to move between surfaces. The weekly pressure injury assessment on 5/15/23 at 3:26 p.m. revealed Resident #32 had a stage two facility acquired pressure injury to his coccyx. The injury was noted to be resolved by weekly pressure injury assessment documented 6/7/23 at 5:47 p.m. The weekly skin assessment dated [DATE] at 9:26 a.m. revealed Resident #32's skin was intact with no treatable wounds present. On 7/23/23 at 2:35 p.m., a nursing progress note described an open sore on the coccyx area (base of lower back) of a one by one cm wound, which was cleaned and barrier cream was applied. Per the note, the manager and resident representative were notified. -There were no additional interventions or nursing notes documented between 7/23/23 and 7/26/23, however there was growth from a one centimeter open sore to a stage 3 pressure ulcer during this time period (see wound medical doctor (WMD) notes below). The wound medical doctor (WMD) assessment, dated 7/26/23, documented Resident #32 had developed a stage 3 pressure injury of the superior sacrum, which was identified as full thickness. The wound size was 3.0 cm long by 1.5 cm wide by 0.1 cm deep. Light serous (thin liquid) drainage was present and there was 60% granulation tissue (reddish connective tissue that forms on the surface of a wound when the wound is healing) present. The initial treatment ordered by WMD was a hydrocolloid sheet (thin) dressing applied every two days for a period of 30 days, and recommendations included offloading of the wound and repositioning the resident per facility protocol. On 7/26/23 at 4:56 p.m., RN #2 documented a pressure injury assessment which revealed a stage 3 facility acquired pressure injury. RN #2 documented the physician was notified and education was provided to staff about repositioning the resident. -A review of the resident's medical record did not reveal documentation that indicated the resident was placed on a turning and repositioning schedule. There was no documentation to indicate that staff had been providing repositioning to the resident every two hours. E. Staff interviews Certified nurse's aide (CNA) #1 was interviewed on 11/29/23 at 12:10 p.m. She said Resident #32 was unable to reposition himself. She said he had contractures, especially to the right arm. She said he had to be repositioned by at least two staff members. RN #1 was interviewed on 11/29/23 at 12:30 p.m. He said Resident #32 could not reposition himself. He said he was not sure how long the resident had required positioning every two hours. The wound care nurse, RN #2, was interviewed on 11/30/23 at 12:46 p.m. She said Resident #32 was still at high risk for pressure injury in June 2023 (though the Braden scale documentation showed high risk in January 2023 and moderate risk in June 2023). The RN could not identify measures put in place between 7/23/23 and 7/26/23 to prevent the worsening of the pressure injury. She said the resident was completely dependent on staff for positioning/mobility. She said the resident was not placed on a formal repositioning and turning program prior to the development of the stage 3 pressure injury on 7/23/23. The director of nursing (DON) was interviewed on 11/30/23 at 1:07 p.m. She said for residents at high risk for developing pressure ulcers, interventions included a turning (repositioning) schedule, up-down schedule (getting resident up for meals/down after), and dietitian consultations. She said the turning schedule should be every two hours for someone who was at high risk for pressure ulcer development. She said Resident #32 was on an up/down schedule prior to the pressure ulcer development, but she was not sure when the turning schedule was initiated. The DON said if a resident could not reposition themselves they should to be repositioned every two hours, not waiting until the resident developed a pressure injury. The WMD was interviewed on 11/29/23 at 11:17 a.m. She said she was notified by the facility of Resident #32's sacral wound and assessed it a few days after it was identified. She said upon initial assessment she determined that Resident #32's sacral wound was a stage 3 pressure ulcer. She said the wound had been acquired at the facility. She said the wound had deteriorated since she first assessed it and progressed to a stage IV. She said she was perplexed as to why the wound continued to progress. She said she felt the facility had followed her plan of care and provided off loading once the wound developed. She said Resident #32 was cooperative with care. She said the resident was unable to reposition himself and required staff assistance. She said the resident was very agreeable with repositioning and she had not heard from staff that they had any issues. She said the resident was unable to ambulate or propel himself in the wheelchair and was dependent upon staff for all care. She said Resident #32 was a very high risk for developing pressure injuries. She said, due to Resident #32's comorbidities, wounds could easily develop if the resident was not placed on a turning schedule as a preventative measure. She said she was not able to say that Resident #32's sacral wound was unavoidable. She said it did not appear the resident was on a preventative turning schedule prior to the development of the sacral wound.

Based on interviews and record review, the facility failed to ensure one (#18) of three residents reviewed for abuse out of 36 sample residents were kept free from abuse. Specifically, the facility failed to ensure Resident #18 was kept free from physical abuse by Resident #68. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating policy, revised April 2021, was provided by the nursing home administrator on 11/28/23 at 9:00 a.m. It read, in pertinent part: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. II. Incident of physical abuse by Resident #68 toward Resident #18 The abuse investigation, dated 11/27/23, documented certified nurse aide (CNA) #3 observed Resident #68 yell move at Resident #18 and then struck Resident #18 two to three times on her right arm. The residents were separated and Resident #18 was teary eyed, however denied being in pain. An assessment was conducted by the registered nurse (RN) with no bruising or injuries noted. Resident #68 continued to be agitated and was removed from the dining room area. The investigation showed Resident #18 was able to confirm that she was hit and the video footage confirmed the incident. The physical abuse was substantiated. III. Resident #68 A. Resident status Resident #68, age younger than 65, was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO), diagnoses included traumatic brain injury, anoxic brain damage (lack of oxygen to the brain), autistic disorder, attention deficit hyperactivity disorder, chronic pain and depression. The 10/2/23 minimum data set (MDS) assessment revealed the resident had a moderate cognitive impairment with a brief interview for mental status score of 10 out of 15. He was dependent on staff for repositioning, transferring, hygiene, and eating. He had lower extremity range of motion (ROM) impairment, but did not have ROM impairment in his upper extremities. It indicated that the resident had verbal behavioral symptoms directed toward others which occurred daily. B. Record review The behavioral care plan, revised 8/21/23, documented the resident had a history of yelling at others. The interventions included anticipating the resident ' s needs, providing an opportunity for positive interactions, intervening as necessary to protect the rights of others and non- pharmacological interventions (speak in calm manner, divert attention, remove from situation as necessary, provide one to one interaction, offer drink, fidget toy, weighted blanket, play music and TV, program of activities). -The care plan did not address the resident ' s physically aggressive behavior. The 10/25/23 nursing progress note revealed the resident was still agitated and frequently yelled out. The 10/29/23 nursing progress note documented the Trazodone (psychotropic medication) had been increased due to increased agitations and yelling out. The 11/10/23 nursing progress note revealed Resident #68 had agitation sometimes, especially when he was alone. The 11/24/23 nursing progress note documented the resident was involved in a resident to resident altercation in the dining room. It indicated the resident had struck another resident in the arm two to three times. IV. Resident #18 A. Resident status Resident #18, age younger than 65, was admitted on [DATE]. According to the November 2023 CPO, diagnoses included traumatic brain injury, epilepsy, diabetes, dementia with agitation, anxiety disorder and fractured right lower leg. The 10/16/23 MDS assessment revealed the resident had short term and long term memory impairment with impaired ability to make decisions regarding tasks of daily life. It indicated that the resident had physical behavioral symptoms directed at others that occurred four to six days out of the week and verbal behavioral symptoms directed at others that occurred one to three days out of the week. B. Record review The behavioral care plan, revised on 8/29/23, documented the resident exhibited impulsivity. The interventions included avoiding impulsive acts on others by redirecting the resident to another area, providing praise, one to one meetings and providing 15 minute trackings of the resident. The comprehensive care plan documented that the resident could be physically aggressive (documented on 11/28/23). It indicated that the resident ' s physical aggression could be a precursor to a seizure or could be caused by pain. The interventions included moving the resident to a calm and quiet environment, adjusting the temperature and removing items that the resident could throw. The 11/24/23 nursing progress note revealed that Resident #18 ' s power of attorney (POA) was told Resident #18 was the recipient of aggression from another resident and was struck two to three times on her right arm. V. Staff interviews The director of nursing (DON) was interviewed on 11/30/23 at 3:00 p.m. She said that she did not have the details of resident to resident altercation between Resident #68 and #18, but knew Resident #68 and Resident #18 did not like each other. She said the residents triggered each other when they would yell out and there had been incidents in which these residents had yelled at each other, prior to the physical altercation. CNA #3 was interviewed on 11/30/23 at 3:59 p.m. She said she observed Resident #68 hit Resident #18 on 11/24/23 at about 5:15 p.m. She said both residents were in the dining area at the end of dinner. She said Resident #68 was moving back and forth in his chair and he was next to Resident #18. She said he was trying to pass by Resident #18. CNA #3 said Resident #68 yelled at Resident #18, made a fist with his hand and then hit Resident #18 ' s arm three times. She said Resident #18 did not react or say anything initially, however, Resident #18 then became angry. CNA #3 said she took Resident #68 away from the area and reported the incident to licensed practical nurse (LPN) #2.

Based on record review and interviews, the facility failed to ensure three (#19, #34 and #49) of three residents out of 36 sample residents were free from misappropriation of resident property. Specifically, the facility failed to ensure Resident #19, #34 and #49 were reimbursed when the facility had identified that Resident #79 had stolen their cigarettes. Resident #19, #34 and #49 were required to keep their cigarettes in a facility lock box, which was controlled by facility staff. Resident #79 broke into the lock box and stole the cigarettes. When it was identified what Resident #79 had done, the facility failed to ensure Resident #19, #34 and #49 were reimbursed for their missing cigarettes. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation, Misappropriation, Reporting and Investigating policy, revised April 2021, was provided by the nursing home administrator (NHA) on 12/5/23 at 9:34 a.m. It revealed in pertinent part, If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. All allegations are thoroughly investigated. The administrator initiates investigations. Investigations may be assigned to an individual trained in reviewing, investigating and reporting such allegations. The administrator is responsible for keeping the resident and his/her representative (sponsor) informed of the progress of the investigation. The administrator ensures that the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility. Upon conclusion of the investigation, the investigator records the findings of the investigation on approved documentation forms and provides the completed documentation to the administrator. The administrator, or his/her designee, provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident. The resident and/or representative are notified of the outcome immediately upon conclusion of the investigation. II. Investigation of misappropriation of property On 11/14/23, Resident #19 reported his cigarettes were missing to the activity director (AD). The AD checked the cabinet and saw that Resident #19's cigarettes were missing, along with two other residents (Resident #34 and #49) cigarettes. The AD checked the cameras and saw Resident #79 enter into the locked box and steal the cigarettes. The social services director (SSD) and activity director spoke with Resident #79 and at first Resident #79 denied taking the cigarettes. After the SSD and AD told the resident she was seen on camera taking the cigarettes, the resident walked over to her bed and removed Resident #19's cigarettes from her walker. When asked about the other two residents (Resident #34 and #49) cigarettes she had stolen, she said that she had already smoked them. The AD moved the cigarettes to the other side of the facility and changed the code on the lock box. -The investigation did not reveal documentation of what was done to replace the cigarettes of Resident #34 and #49, which were stolen and smoked by Resident #79. III. Resident information A. Resident #79 1. Resident status Resident #79, age less than 65, was admitted on [DATE] and discharged on [DATE]. According to the November 2023 computerized physician orders (CPO), the diagnoses included malignant neoplasm (breast cancer) of unspecified site of left female breast. The 10/9/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She was independent with all activities of daily living (ADLs). 2. Record review -A review of Resident #79's medical record did not reveal documentation of the incident on 11/14/23, when the resident stole the cigarettes of three residents. B. Resident #34 1. Resident status Resident #34, age less than 65, was admitted on [DATE]. According to the November 2023 CPO, the diagnoses included anoxic brain damage. The 8/24/23 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 10 out of 15. He was independent with all ADLs. 2. Resident interview Resident #34 was interviewed on 11/30/23 at 3:48 p.m. He said his cigarettes were stolen by another resident. He said he was never told that his cigarettes would be replaced. He said he would like for his cigarettes to be replaced. 3. Record review The smoking safety screen completed on 11/01/21 documented the resident was safe to smoke with supervision. -A review of the resident's medical record did not reveal documentation of his cigarettes being stolen by another resident. C. Resident #49 1. Resident status Resident #49, age less than 65, was admitted on [DATE]. According to the November 2023 CPOs, the diagnoses included frontotemporal neurocognitive disorder. The 10/12/23 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 10 out of 15. He was independent with all ADLs. 2. Resident interview Resident #49 was interviewed on 11/30/23 at 3:25 p.m. He said his cigarettes had been stolen by another resident. He said the facility never offered to replace his stolen cigarettes. He said he would like his cigarettes replaced. 3. Record review The smoking care plan, 5/20/23, documented Resident #49 smoked and could smoke during scheduled breaks. He had a history of smoking violations for smoking in non-smoking areas and outside of scheduled smoke breaks. -A review of the resident's medical record did not reveal documentation of his cigarettes being stolen by another resident. D. Resident #19 1. Resident status Resident #19, age 65, was admitted on [DATE]. According to the November 2023 CPOs, the diagnoses included dysarthria (slurred speech) and anarthria (complete loss of speech). The 9/25/23 MDS assessment revealed the resident had short term and long term memory impairment. He was impaired in making decisions regarding tasks of daily life. He required physical assistance with bed mobility, transferring, dressing, eating, toileting and personal hygiene. 2. Record review The smoking care plan documented Resident #19 was a supervised smoker. -A review of the resident's medical record did not reveal documentation of his cigarettes being stolen by another resident. IV. Staff interview The SSD was interviewed on 11/30/23 at 3:15 p.m. She said Resident #79 had stolen the cigarettes of Resident #19, #34 and #49 on 11/14/23. She said Resident #79 had originally denied stealing the cigarettes, however it was caught on camera. The SSD said she had not replaced the cigarettes for Resident #19, #34 and #49. She said she went to the store to buy cigarettes once a month and would not be going until the third of the month. She said she had not thought to replace the cigarettes for Resident #19, #34 and #49. She said the facility would reimburse their facility accounts instead of going to the store and replacing the cigarettes. She said the money had not yet been placed in the residents' accounts.

Based on observations, record review, and interviews, the facility failed to ensure three (#46, #54 and #7) out of 36 sample residents were provided services that meet professional standards of practice. Specifically, the facility failed to: -Ensure narcotic medication was documented on the narcotic log at the time of removal from the locked narcotic drawer for Resident #46; and, -Ensure an assessment was completed by a registered nurse (RN) assessment following a fall for Resident #54 and Resident #7. Findings include: I. Failure to ensure narcotic medication was documented on the narcotic log upon removal A. Facility policy and procedure The Controlled Substances policy, revised 9/1/23, was provided by the nursing home administrator (NHA) on 11/30/23 at 5:03 p.m. It read, in pertinent part: Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. The director of nursing services investigates all discrepancies in controlled medication reconciliation to determine the cause and identify any responsible parties, and reports the findings to the administrator. B. Resident #46 status Resident #46, age 73, was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO), his diagnoses included spinal stenosis (narrowing), heart disease, diabetes, and peripheral neuropathy (nerve damage). The 9/7/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. 1. Observations On 11/28/23 at 11:38 a.m., licensed practical nurse (LPN) #2 removed Oxycodone 10 milligrams (mg) from the locked narcotic drawer for Resident #46. He did not document the removal of Oxycodone on the resident's narcotic log. He then administered the medication to Resident #46. On 11/28/23 at 1:10 p.m., the south hallway (bobcat hallway) medication cart was reviewed with LPN #2. The narcotic log for Resident #46 showed a discrepancy of Oxycodone. The card containing Oxycodone narcotic showed 38 remaining pills, and the log revealed 39 pills remained. LPN #2 said that he had not yet documented the oxycodone he administered to Resident #46 at 11:38 a.m. 2. Record review The November 2023 CPOs included an order for Oxycodone 10 mg, every six hours with a start date of 4/26/22. C. Staff interviews LPN #2 was interviewed on 11/28/23 at 1:10 p.m. He said he should have documented the removal of the oxycodone on Resident #46's narcotic log after administering the medication. -LPN #2 proceeded to document the oxycodone dose on the narcotic log at 1:15 p.m. The director of nursing (DON) was interviewed on 11/30/23 at 1:18 p.m. She said LPN #2 should have documented the Oxycodone removal on the resident's narcotic log immediately after it was removed from the locked narcotic storage drawer on the medication cart. She said she would provide education to the nursing staff. 47422 II. Failure to ensure an assessment was conducted and documented by an RN following a fall A. Resident #54 1. Resident status Resident #54, age 68, was admitted on [DATE]. According to the November 2023 CPOs, the diagnoses included anxiety, vertigo, extrapyramidal (decreased fine motor skills) and movement disorder and a history of falling. The 8/31/23 MDS assessment revealed the resident had moderate cognitive impairment with a brief interview for a mental status score of 11 out of 15. She was independent for all mobility and activities of daily living. It indicated the resident had experienced falls since the prior assessment, one with a sustained injury. 2. Record review The 3/22/23 nursing progress note documented Resident #54 sustained a witnessed fall at 9:32 p.m. The nurse responded to the resident and documented performing an assessment. -The assessment was performed and documented by a licensed practical nurse (LPN). A review of the resident's medical record did not reveal an assessment completed or documented by an RN at the time of the fall B. Resident #7 1. Resident status Resident #7, age 66, was admitted on [DATE]. According to the November 2023 CPOs, the diagnoses included dementia, post traumatic stress disorder (PTSD), tachycardia (high heart rate) and history of repeated falls. The 11/6/23 MDS assessment revealed the resident had no cognitive impairment with a brief interview for a mental status score of 15 out of 15. He required extensive assistance of one person with bed mobility, toileting and personal hygiene. He was independent for all mobility in his wheelchair and activities of daily living. 2. Record review The 7/10/23 nursing progress note documented Resident #7 sustained an unwitnessed fall at 12:35 p.m. The resident was found on his hands and knees on the floor. Resident was reaching for his television remote. It indicated the resident was assessed by an LPN, who had discovered him on the floor. -A review of the resident's medical record did not reveal an assessment was completed or documented by an RN at the time of the fall. The 11/3/23 nursing progress note documented Resident #7 sustained an unwitnessed fall at 12:35 p.m. The resident was found on his bathroom floor out of his wheelchair. The on call provider was contacted and orders were placed including neurological assessments. An LPN documented that an RN had arrived to the resident to assess, however the RN did not document that an assessment was completed in the resident's medical record. C. Staff interviews LPN #1 was interviewed on 11/30/23 at 12:58 p.m. She said all falls require a RN to assess the resident before the resident could be moved from the ground. She said the RN assessment should be documented in the resident's medical record by the RN. The director of nursing (DON) was interviewed on 11/30/23 at 1:41 p.m She said that an RN should assess any resident that experienced a fall before they were moved from where the fall occurred. She said a RN assessment should include baseline vital signs, any injuries observed and notifying the provider. She said that the facility did not require RN assessments to be documented in the electronic medical record. She said that the facility should require the assessment to be documented to ensure the accuracy of the medical record and resident status.

Based on record review, observation, and interviews the facility failed to ensure one (#8) of two out of 36 sample residents with limited range of motion received the appropriate treatment and services. Specifically, the facility failed ensure interventions identified to address Resident #8's contractures were implemented. Findings include: I. Resident #8 A. Resident status Resident #8, age 82, was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO), the diagnoses included hemiplegia and hemiparesis (weakness of one entire side of the body) following unspecified cerebrovasc ular disease (stroke) affecting the right dominant side. The 9/7/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 12 out of 15. She required extensive assistance of two people with bed mobility, transferring, bathing, and toileting. She required one person's assistance with dressing, and personal hygiene. B. Observations On 11/28/23 at 11:44 a.m. Resident #8 was observed sitting in the hallway in her wheelchair with her right hand balled up towards her torso. The resident was not able to open her right hand and had difficulty with moving her right hand. She was not wearing a splint on her right hand. -At 3:29 p.m. the resident was in her wheelchair and was sitting in the activity room watching television. She was not wearing a splint on her right hand. On 11/29/23 at 9:13 a.m. the resident's wheelchair was outside of her room, and the resident was still in bed. An unidentified staff member entered the resident's room and asked the resident if she was ready to get up. The staff member left the room, got a mechanical lift and then re-entered the room. Another unidentified staff member entered the room to assist in transferring the resident with the mechanical lift. -At 9:58 a.m. the resident was wheeled out of her room. She did not have a splint to her right hand. -At 3:32 p.m. the resident was in the hallway sitting in her wheelchair without a splint on her right hand. On 11/30/23 at 9:32 a.m. the resident was up in her wheelchair in the hallway, resident has a pillow/cushion placed under her right arm and no splint on her right hand. -At 10:45 a.m. an unidentified staff member began performing range of motion to the resident's right hand. After completing the range of motion, the staff member donned a splint to the resident's right hand. C. Resident interview Resident #8 was interviewed on 11/27/23 at 10:54 a.m. She said she was not able to move her right hand. The resident was not wearing a splint on her right hand. She said she would ask the staff to put her splint on her right hand. She said oftentimes they did not listen to her and would not put the splint on her hand. On 11/30/23 at 9:35 a.m. Resident #8 said she asked for a pillow to help elevate her right hand. She said it really helps. She said she had to ask for it; it was never just provided by the facility staff. D. Record review The physical mobility care plan documented Resident #8 has limited physical mobility related to contracture to the right hand and a history of a stroke with right sided hemiparesis (weakness). The interventions included active-assisted range of motion to upper extremity and lower extremity; administering antipasticity agents as ordered; applying right elbow splint in the morning; assessing pain level monthly by completing monthly summary; pain assessment daily, track on medication administration record (MAR); assessing right hand skin before placing splint; the certified nurse aide (CNA) will provide gentle passive range of motion (PROM) of right hand daily and before putting splint on, if resident complains of pain inform nurse; hand splint; hand wash splint and allow to air dry as needed (PRN); per resident's request, she will wear right elbow splint during the day for stretching of right arm; removing right elbow splint at bedtime; nursing rehabilitation/restorative: 3-7 times a week, passing range of motion program: right wrist/digits passive range of motion in all planes within her pain tolerance. The musculoskeletal care plan documented Resident #8 has an alteration in musculoskeletal status related to weakness, hemiplegia (severe or complete loss of strength) and contracture to the right hand. -It did not address the resident's use of splinting. The restorative progress notes documented the following: -On 7/31/23, the resident participated an average of three times per week in July. -On 8/31/23, the resident participated an average of five times per week in August. -On 10/2/23, the resident participated an average of four times per week in September. -On 11/1/23, the resident participated an average of six times per week in October. -On 11/29/23, the resident participated an average of five times per week in November. E. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 11/30/23 at 11:28 a.m. She said the restorative aide worked with Resident #8 every day. She said the restorative aide was responsible to apply the splint daily to the resident's right hand. She said when the restorative aide was not available, then the certified nurse aide (CNA) was responsible for assisting the resident with her right hand splint. She said that the resident should wear her splint every day. She said she would wear the splint for however long she was able to tolerate it and then ask staff to remove it. She said the restorative aide was responsible for documenting how often the resident wore the splint. Restorative aide (RA) #1 was interviewed on 11/30/23 at 11:37 a.m. He said Resident #8 was provided with restorative therapy for range of motion every day. He said the resident should wear the splint every day. He said prior to placing the splint, he would stretch her fingers out and massage them so when the splint was applied it did not cause her pain. He said the resident had another splint which covered her elbow to her hand, but it was missing. He said the splint had been missing for a couple of days. He said he had not reported the missing splint. CNA #2 was interviewed on 11/30/23 at 11:57 a.m. She said the restorative staff provided range of motion for Resident #8. She said she would provide massages and a splint to the resident's right hand. She said the resident was supposed to wear her splint every day. She said she did not put the splint on the resident every day. She said the CNAs put the splint on the resident when the restorative aide was not there. She said when the resident's hand hurt the resident would not wear her splint, but most of the time the resident was agreeable to wear the splint. She said she did not document when the resident refused to wear the splint. She said the resident reminded staff when she did not have her splint on. The director of nursing (DON) was interviewed on 11/30/23 at 1:45 p.m. She said the resident was on a restorative program and was working with physical therapy. She said physical therapy worked with the resident weekly and depending on their schedule. She said the resident should wear the splint every day. She said there were some days that the resident would wear the splint longer and other days would refuse to wear it. She said it was recommended that the resident wear the splint for up to eight hours per day. She said all staff were responsible for ensuring the splint was donned to the residents right hand.

Based on observations, interviews and record review, the facility failed to protect six residents (#63, #26, #30, #37, #18, and #6) of nine residents reviewed, from neglect and abuse out of 48 sample residents. NEGLECT The facility failed to provide services - implementation and monitoring of its plan to address a known rodent infestation, resulting in resident fear, disgust and actual injury. Specifically: According to the Department's records, the facility recognized rodents were entering the facility through the crawl space in late April and indicated it had a plan to address this concern. However, observations on 6/6/21 revealed the facility failed to implement a plan to prevent the mice from entering the facility and failed to have an effective plan to remove the mice once they had entered. Observations revealed many of the grates that covered the facility's crawl spaces were missing or damaged with holes at the top, bottom and sides, allowing free access of rodents into the crawl spaces and, per the maintenance director (MTD), to then travel along the heat registers to go room to room. Observations further revealed mice traps were observed without bait and residents reported delays of a week in the facility checking the traps for rodents. The pest reporting logs were reviewed and documented evidence of mice in residents' rooms. Approximately 200-300 rodent droppings and urine were observed during survey in Resident #63's room under a box on the floor. Resident #63, per interview and record review, sustained a bite from a mouse on her left middle toe on 5/25/21 which led to treatment in the emergency room and a course of antibiotics. The toe was red, painful and involved a puncture wound. Resident #26 complained a mouse had run under her legs while she was sitting on the commode and it frightened her. Resident #30 reported she was afraid of mice and said a mouse had nested and had pups (babies) in her bathroom and left mouse droppings in her clothes. Residents #37 and #18 reported seen mice in the facility and Resident #37 said it was unsanitary and disgusting. The facility's failure to implement and monitor its plan to address the rodent infestation resulted in fear, disgust and actual injury, and would likely result in further injury and distress if immediate action to address the infestation was not taken. VERBAL ABUSE The facility failed to timely investigate an allegation of verbal abuse reported by Resident #6 on 6/2/21 during the survey, and thus failed to protect the resident from potential future abuse. (Cross-reference F609 and F610) Findings include: I. Neglect-Immediate Jeopardy A. Findings of Immediate Jeopardy Review of Department records revealed the facility recognized rodents were entering the facility through the crawl space in late April 2021. At that time, the facility indicated to the Department that it had a plan to address this concern. However, observations on 6/6/21 revealed the facility failed to implement a plan to prevent the mice from entering the facility and failed to have an effective plan to remove the mice once they had entered. Observations revealed many grates that covered the crawl spaces were missing or damaged with holes at the top, bottom and sides, allowing free access of rodents into the crawl spaces and, per the maintenance director (MTD), to then travel along the heat registers to go room to room. Observations further revealed traps were observed without bait and residents reported delays of a week in the facility checking the traps for rodents. The pest control logs were reviewed and documented evidence of mice in residents' rooms. Approximately 200-300 rodent droppings and urine were observed during survey in Resident #63's room under a box on the floor. Resident #63 sustained a mouse bite that led to an emergency department visit and a course of antibiotics. The toe was red, painful and involved a puncture wound. Resident #26 complained a mouse had run under her legs while she was sitting on the commode, frightening her. Resident #30 reported she was afraid of mice and said a mouse had nested and had pups (babies) in her bathroom and left mouse droppings in her clothes. Residents #37 and #18 reported seen mice in the facility and Resident #37 said it was unsanitary and disgusting. The facility's failure to implement and monitor its plan to address the rodent infestation resulted in fear, disgust and actual injury, and would likely result in further injury and distress if immediate action to address the infestation was not taken. B. Imposition of Immediate Jeopardy On 6/7/21 at 7:18 p.m., the nursing home administrator (NHA) was informed by the Department that the facility's failure to implement and monitor its rodent infestation plan which resulted in Resident #63's injury and contributed to other residents' mental and emotional distress, represented a failure of the facility to provide residents necessary services (neglect) that required immediate correction to prevent serious harm. C. Facility Response and Removal of Immediate Jeopardy Although the NHA responded that she knew the facility was deficient, but she felt it was more of a pest control issue and not neglect, on 6/8/21 at 4:18 p.m., the facility submitted the following plan (draft #6) to remove the immediate jeopardy. The plan read: A sweep of resident #1376's (Resident #63's) room was completed on 6/7/2021, by the Maintenance Director and the Housekeeping/Laundry Supervisor, at approximately 8:00 p.m. The sweep included a visual inspection of each room, floors, traps (if in place), bathrooms and windows. No evidence of pests was identified. A facility-wide sweep (see above) of all resident rooms and common areas was completed on 6/7/2021, by the Maintenance Director and the Housekeeping/Laundry Supervisor. No evidence of pests was identified. A-1 Pest Control will complete a facility wide assessment, on 6/8/2021 to determine where pests may be entering the facility, and what can be done to prevent entry to the facility. This assessment will include resident rooms, common areas, offices, basement, and the exterior of the building. The pest Control company will be asked to identify any areas where pests may enter the facility. Any recommendations from the Pest Control company will be implemented immediately by the Maintenance Director. Summary of A-1 Pest Control visit 6/8/2021: All resident rooms, closets, drawers and bathrooms were checked, to include tin cats and RTU's. Pest activity was identified in rooms #5 and #8. The tin cats' ' and RTU's were reset/replaced in these rooms. A-1 Pest Control checked and filled all exterior bait stations, dusted for roaches and spiders, and replaced all monitors. In addition, the new exterior vents will help decrease mouse activity, and keeping resident food in plastic containers is essential for rodent control. Sanitation is also a key factor in keeping a pest-free environment, as is keeping all exterior doors closed at all times. The Maintenance Contractor will be in the facility on 6/8/2021. The Maintenance Contractor has worked with the facility for many years and is very familiar with the structure of the building. The Maintenance Contractor will make recommendations to address pest control, and these will be implemented by the Maintenance Director. Resident #1376 was interviewed by Social Services on 6/8/2021 regarding her fear of pests, and what can be done to address/alleviate her fears. The resident did not state any interventions that she felt would help address the issue. Recommendations from A-1 Pest Control and the Maintenance Contractor will be implemented for resident #1376. All interview-able residents will be interviewed, by Social Services, on 6/8/2021, to determine if they have observed pests. If residents report seeing pests, a Complaint/Concern Form will be completed and the NHA and Maintenance Director will be informed and address the issue immediately. Non-interview-able residents will have their skin monitored by the CNAs (certified nurse aides) during each shower/bath. Any skin issues will be reported to the nurse immediately. A Pest Log was created, on 6/7/2021, in order to document and address any identified pest issues. Education of all staff will be completed regarding the Pest Control policy and procedure, the pest log, and how to identify evidence of pests. This education will be conducted by NHA or designee. This was initiated 6/7/2021, and will continue until all staff have been educated prior to working their shifts. This education should be completed by 6/11/2021. NHA will ensure that all staff have received this education. A staff-wide text was sent by the NHA on 6/7/2021, informing staff that they must have this education prior to working their next shift. The facility will contract with a new Pest Control Company within 14 days. In the meantime, A-1 Pest Control will be contacted to address any identified issues immediately. The facility employs Behavior Technologists. Behavior Technologists make observations of residents every 15-minutes for a variety of safety and/or behavioral reasons. Evidence of pests has been added to the Behavior Tracking clipboard for the Behavior Techs. Behavior Techs will monitor resident rooms and common areas, on an hourly basis, for any evidence of pests. The checks will continue until the facility achieves substantial compliance. Staff will be educated on the following evidence of pests: -Mice/Rats: Damaged products/droppings/sightings of mice -Cockroaches: Sightings, fecal matter, stains -Filth Flies: Sightings -Small Flies: Sightings -Ants: Sightings, trails If evidence is observed, this will be immediately reported to the NHA, and will be documented on the Pest Control Log. The Pest Control Logs will be reviewed daily by the NHA, and any issues will be addressed immediately. The Maintenance Director and Maintenance Assistant will replace all 34 grates on the outside of the facility by 6/8/2021. These grates will help to prevent pests from entering the crawl space. Tin cats are metal traps with glue boards. There are two entrances and no exits, and pests get stuck on the glue board. Bait traps have food as bait. The food in the bait traps is poisonous and it kills the rodents. Beginning 6/7/2021, Maintenance Director, or designee, will monitor and will reset any traps on a daily basis and report any findings to the NHA. Traps and tin-cats are located in the following areas: -One in room [ROOM NUMBER] -One in room [ROOM NUMBER] -One room [ROOM NUMBER] -One room [ROOM NUMBER] -Two in room [ROOM NUMBER] -Three in room [ROOM NUMBER] -One in room [ROOM NUMBER] -One in room [ROOM NUMBER] -Eight in the Kitchen -Six Bait Stations are located in the basement. -Six Bait Stations are located on the exterior of the facility. Pest Control issues/concerns will be reviewed by the facility QA/PI Committee monthly for three months, or until substantial compliance is achieved. Action Plans/Performance Improvement Plans will be developed to address any identified issues. C. Removal of immediate jeopardy On 6/8/21 at 5:38 p.m., the NHA was notified that the immediate jeopardy had been removed based on the steps taken by the facility to begin implementation of the above plan. However, observations, interviews, and record review, deficient practice remained at a G level, actual harm that is isolated. II. The facility failed to provide services - implementation and monitoring of its plan to address a known rodent infestation - resulting in resident fear, disgust and actual injury. A. Facility policy and procedure The Pest Control policy, revised 5/2008, was received from the NHA on 6/8/21 at 11:12 a.m. The policy documented in pertinent part, the facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Pest control services by outside company. Windows are screened at all times. Only approved FDA or EPA insecticides or rodenticides are permitted in the facility and all such supplies are stored in areas away from food storage areas. Garbage and trash are not permitted to accumulate and are removed from the facility daily. Maintenance services, when appropriate and necessary in providing pest control services. The maintenance director (MTD) was interviewed on 6/3/21 at 9:20 a.m. He said the process for reporting pests was for staff to notify him or document the issue in the maintenance log or the pest control book. He said he would go to each area of concern and assess the situation. He indicated that if mice were spotted, he would set out traps (Tin Cat) in those areas. He said he would monitor the traps two to three times a week for signs of activity. Certified nurse aide (CNA) #4 was interviewed on 6/3/21 at 9:30 a.m. She said if pests were present in the residents ' room she would report to the charge nurse or director of nursing (DON). She said the nurses would document in the maintenance log or communicate with the MTD about the problem. Social service staff (SS #1) was interviewed on 6/8/21 at 2:15 p.m. She said her process when the residents notified her of mice, was to write the room number and mouse sighting in the pest book for the pest control company to investigate the next time they came out. Or, she might contact the MDT by writing the siting in the maintenance log or by putting a note in the MTD's mailbox, or just tell the MDT when she saw him in the hallway. She said she did not follow up to see if the issue was handled after giving the information to the maintenance department. B. Facility history of rodent infestation Review of the Department's database revealed an abbreviated survey was completed on 4/28/21 and identified a rodent infestation problem. The facility recognized the rodents were entering the facility through the crawl space and communicated a verbal plan to address the concern. Review of the facility's Pest Reporting Log from 2/1/21 to 5/24/21 confirmed a rodent problem with reports of mice 2/26/21 (room [ROOM NUMBER]), 4/9/21 (rooms #21, 12 and 24), 4/22 x 2 (room [ROOM NUMBER]) and 5/24/21 (rooms #20 and #21). C. Current rodent infestation - facility failure to implement a plan to prevent the mice from entering the facility and failure to have an effective plan to remove the mice once they had entered the facility. 1. Observations Observations revealed an ongoing mice problem. The observations revealed traps placed in resident rooms (but observed without bait), mouse dropping and urine in a resident's room and missing or damaged grates outside the facility that were designed to cover crawl spaces. On 6/2/21 at 10:58 a.m., a mouse trap was observed under the dresser in Resident # 63's room. There was no bait in the trap. On 6/2/21 at 4:40 p.m., a mouse trap was observed under the window near Resident # 37's bed. There was no bait in the trap. On 6/3/21 at 11:00 a.m., six mice bait stations were located on the perimeter of the building up next to the building. Each bait station was next to a crawl space. On 6/6/21 at 10:00 a.m., initial observations of the outside of the facility revealed 18 grates that covered the crawl spaces were missing or damaged with holes at the top, bottom and sides, allowing free access of rodents into the crawl spaces. On 6/8/21 at 4:25 p.m. additional observations of the outside of the facility (excluding the south side) revealed 24 crawl spaces were located on the perimeter of the building. Two of the crawl spaces did not have a grate and exposed an opening into the building. The rest of the grates were damaged and had holes in them. On 6/9/21, at 10:34 a.m., approximately 200-300 mouse droppings and urine were observed on the floor in Resident # 63's room near the heater vents. 2. Staff interviews Staff interviews revealed the maintenance director (MTD) was aware mice entered the facility through crawl spaces which he confirmed were poorly covered or not covered at all and the NHA, social service staff (SS #1) and MTD were aware mice were a problem, more than usual during the pandemic, and that the problem had not been resolved. Specifically: The MTD was interviewed on 6/3/21 at 9:20 a.m. and again at 5:50 p.m. He said mice get in through openings around the building, like a hole in a screen and the crawl spaces and then travel along the heat registers to the resident rooms. He said he thought the facility had more mice than usual due to the COVID-19 pandemic and residents eating in their rooms. He observed the wall and the curtain in the conference room which had small brown black droppings that appeared to be mouse feces. The NHA was interviewed on 6/6/21 at 11:10 a.m. and 11:32 a.m. -At 11:10 a.m., the interview was conducted outside while walking along three sides of the building while observing 18 outdoor grates. (See observations above on 6/6/21 at 10:00 a.m.) She said she had a social worker background and never knew to look at grates on the outside of a building. She said it was obvious to her how the mice had been getting in. She said they were not jumping in the traps that are set next to the open grates. She said all the mice needed to do was to come right in the building easily through the openings in the grates. She said mice are abundant and that it was so easy for them to get in that way. -She said the MTD could put down as many traps as he wanted with peanut butter but that would not stop anything if the holes all along the outside of the building were open. She said she could see that the grate holes were open with no grates or there were holes in the grates along the sides, tops and bottoms. She indicated the MTD was taking care of the situation. -At 11:32, the NHA observed the mouse droppings on the floor in Resident #63's room. (See observations above on 6/9/21, at 10:34 a.m.) She said she did not know what they were. The resident told the NHA they were mouse droppings and the NHA said she was going to inform the MTD. The MTD was interviewed on 6/6/21 at 11:30 a.m. and said he was going to the store to purchase grates today. He said he would take care of the situation, if not today, then tomorrow. He said he was surprised that the grate in the area where the staff smoked was only blocked by a big rock and some cardboard. He said it would be easy for mice to enter through all of the open holes on the outside of the building. SS #1 was interviewed on 6/8/21 at 2:15 p.m. She said she was aware of the mice problem and she notified the MTD every time a mouse was reported to her which she said occurred often. She said she had been in the facility for two years and this year, 2021, was the worst for mice being in the building. She said at times in her office, she kept her feet up off of the ground because it was just creepy how many mice were in the building. She said she interviewed all the residents today and they told her to stop asking them about the mice because it was just a problem that goes with living in the facility. The MTD was interviewed on 6/10/21 at 3:00 p.m. He said he had been at the facility for almost [AGE] years and he was sure the grates were the original and had never been replaced. He said the grates were damaged and he had just finished putting up 34 new grates to cover the outside holes in the building. D. Actual harm and potential for serious harm 1. Diseases directly transmitted by rodents - potential for harm The Centers for Disease Control and Prevention (7/5/2017), on Diseases directly transmitted by rodents, retrieved from: https://www.cdc.gov/rodents/diseases/direct.html, on 6/15/21, documented: [CONDITION(S)], virus, spreads by breathing in dust that is contaminated with rodent urine or droppings, direct contact with rodents or their urine and droppings, bite wounds, although this does not happen frequently. [CONDITION(S)], bacteria, spreads by eating food or drinking water contaminated with urine from infected animals, contact through the skin or mucous membranes (such as inside the nose) with water or soil that is contaminated with the urine from infected animals. Lymphocytic Chorio-meningitis (LCM), virus, spreads by breathing in dust that is contaminated with rodent urine or droppings, direct contact with rodents or their urine and droppings, and bite wounds, although this does not happen frequently. Additionally, Plague, salmonellosis, and [CONDITION(S)]. 2. Resident #63 - actual harm Resident #63, age 61, was admitted on [DATE]. According to the June 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/11/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. She required minimal assistance with bathing and mobility. a. Record review The care plan for Resident #63 retrieved on 6/10/21 (updates not dated) -The resident's care plan read Resident #63 kept unsecured food items in her room and noted that there was potential for pests to enter the room. -The care plan further read, Resident #63 experienced a mouse bite on her toe that was to be treated per physician orders. The resident's room will be monitored closely for pests and the pest control company will monitor the resident's room weekly for pests. (not dated). Interventions included all complaints will be followed up by the interdisciplinary team (IDT) committee and also that housekeeping will clean the resident's room daily. The care plan included the resident being educated on keeping food in plastic containers which the facility provided. (There were no dates included in the revised care plan.) Review of a progress note dated 5/25/21 at 3:44 p.m. read Resident #63 reported to the staff that a mouse came out from beside the resident's chair, bit her toe and went under a blanket. Report included the second left toe was red with a small puncture wound. The note indicated staff called the resident's physician to inform him of the incident. Review of a hospital visit for Resident #63 dated 5/26/21 read the resident was seen in the emergency department for a mouse bite to her left third toe. The wound had a small puncture and tissue swelling. No signs of infection were noted. Resident #63 was administered a [CONDITION(S)] injection and prescribed antibiotics for an animal bite. She was then released back to the facility. b. Interviews Resident # 63 was interviewed on 6/2/21 at 10:54 a.m. and again on 6/3/21 at 5:38 p.m. in her room. Observation of the room revealed the resident's food was stored in plastic bins with lids. -She said she was bitten by a mouse in her room on her left toe. She said this happened on 5/25/21. She indicated she felt a sharp pain on her toe and looked down at her foot and saw a mouse running away. She said at this point, she asked the staff to send her to the emergency room and they refused to do so. She said she called 911 on her own. She said the paramedics came and the staff talked her out of going to the hospital. She said she kept on insisting to be seen by a doctor and she was sent to the emergency department by ambulance on 5/26/21. She said she received a [CONDITION(S)] shot and antibiotics while she was at the hospital. - She said she had seen two mice two days ago in the heater in her room. She said she told a certified nurse aide (CAN) about it and no report was filed. CNA #4 was interviewed on 6/3/21 at 9:30 a.m. She said she had not seen any mice in the resident's room. However, see observations above on 6/9/21, at 10:34 a.m.; approximately 200-300 mouse droppings and urine were observed on the floor in Resident # 63's room near the heater vents. Resident #63 was interviewed again on 6/7/21 at 4:45 p.m. She said on 5/31/21 she was sitting in her chair with a blanket over her legs and a mouse ran across her lap. She said she had the maintenance assistant come to her room and a trap was set that day. She said she told the maintenance assistant that the mice were smart and very quickly learned to eat the peanut butter off of the trap and not get caught. She said the maintenance staff still had not checked her mouse trap from when the staff set it a week ago. She said she checked it and the peanut butter was gone the next day after the maintenance department set the trap. A regular visitor to the facility was interviewed on 6/8/21 at 3:10 p.m. She said she was aware of the mice problem at the facility. She said she had received a call from a resident complaining about the mice. She said she was in the facility about a month ago and spoke to Resident #63. She indicated she talked to the MTD concerning the rodent problem and suggested that he find the entry source for them and block it off. She said the MTD told her that he was at the facility for [AGE] years and there had always been a mice problem. She indicated the NHA told her that Resident #63 had a mice problem because she had food in her room. 3. Residents #30 and #26 - fear and emotional distress a. Resident #30, younger than 65, was admitted on [DATE]. According to the 4/5/21 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/5/21 annual minimum data set (MDS) assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. Resident #30 was interviewed on 6/21/21 at 11:25 a.m. She said there had been a mouse problem in 2021 and someone from the staff caught a mouse yesterday. She said around Easter, a mouse nested and had babies in her bathroom and left mouse droppings in her clothes. She said she told the staff about the mouse in her bathroom. She said it was frightening to her to know another resident was bitten by a mouse in the facility recently. c. Resident #26, age 67, was admitted on [DATE] and readmitted on [DATE]. According to the 3/11/21 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/30/21 entry minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a BIMS score of 11 out of 15. Resident #26 was interviewed on 6/2/21 at 11:40 a.m. She said she was on the commode and a mouse went behind her feet as she was going to the bathroom. She said she did not know where it came from. She said the mouse ran under her legs, behind both feet, and out the bottom of the door. She said, I about shot up in the air off the toilet with fright, it scared me good. We have a mouse problem here. This happened recently in the past week. She said she notified the staff but did not remember who she told. 4. Residents #37 and #18 a. Resident # 37, moderately cognitively impaired, was interviewed on 6/2/21 at 4:40 p.m. and 6/7/21 at 10:00 a.m. -She said there was a mice problem in her room, stating she had seen mice in her room on different occasions and pointing to the mouse trap under her room window. She said other residents in the facility had told her they had seen mice, too. Resident #37 indicated that mice were so disgusting and unsanitary. She said mice can carry so many diseases. -She said her daughter came to take her to a wedding about three weeks ago and there was an awful smell in her room. Her daughter found a trap with a decomposed mouse and got rid of it. She said they tell the maintenance guys, but they don't believe them. b. Resident #18, cognitively intact, was interviewed on 6/7/21 at 2:30 p.m. She said she had seen mice in her room and there was a mousetrap in her room by the heater vent. E. Final interviews-confirmation of a mice problem and the facility's failure to implement a plan to address the infestation. 1. The facility medical director (MD) was interviewed on 6/10/21 at 1:26 p.m. via a phone call. He said he understood pest problems but it seemed uncommon that a mouse would bite someone. He said in his [AGE] years of going to the facility, he knew mice were always a problem, an issue, but he did not know why it had gotten worse. He said the mice were not a good thing to have there. 2. The NHA was interviewed on 6/10/21 at 3:00 p.m. She said the Quality Assurance and Performance Improvement (QAPI) committee knew of the mice problem, although the problem was not necessarily reviewed in the facility's QAPI meeting. She said it should have been, because then there would be a written plan in place to address it. She said the MTD or she could have brought it forward in the meeting and had the situation handled. She said had they done that, the facility would not be dealing with the mouse problem today. III. Verbal abuse A. Facility policy The Abuse policy revised December 2016 was provided by the NHA on 6/2/21 at 10:00 a.m. It read in pertinent part: The residents have the right to be free from abuse, neglect and exploitation. As part of the abuse and neglect prevention the facility will develop and implement policies and procedures designed to protect the residents from abuse, neglect and mistreatment. The facility will enter a finding into the state nurse aide registry concerning abuse, neglect exploitation, mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] B. Resident #6 - failure to take timely steps to protect the resident from verbal abuse 1. Resident status Resident #6, age 62, was admitted on [DATE]. According to the June 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The 5/28/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. He was independent with bed mobility, transfers, dressing personal hygiene and toileting. 2. Resident Interviews Resident #6 was interviewed on 6/2/21 at 2:47 p.m. He said last week, another male resident on his hallway in room [ROOM NUMBER], called him racially inappropriate names and shook his fist at him. Resident #6 said he had gone into room [ROOM NUMBER] to talk to his friend about helping him with an issue on his phone. He said that was when his friend's roommate began to call him the racial names and shake his fist at him. He said he was afraid of his friend's roommate. Resident #6 said he did not report the event because he felt when he reported things, it always seemed to turn out to be his fault. He said most days he was afraid to leave his room as a big black man because he would get blamed for things. The allegation of verbal abuse with fear was reported to the NHA on 6/2/21 at 2:57 p.m. The NHA said she would investigate the allegation. Resident #6 was interviewed again on 6/3/21 at 10:00 a.m. He said none of the facility staff had talked to him about the verbal abuse since it was reported on 6/2/21 at 2:57 p.m. The resident's friend in room [ROOM NUMBER] was interviewed on 6/10/21. He said he knew Resident #6, and he frequently came to his room to ask for help with his cell phone. He said he recalled an incident last week when his roommate began to yell at Resident #6 and call him racial names. He said he could not see if his roommate shook his fist at Resident #6, because the privacy curtain blocked his view. He said something needs to be done to mitigate this situation, it has happened before. 3. Staff interviews - confirmation of the facility's failure to take steps to protect Resident #6 from abuse. Social worker (SW) #1 and SW #2 were interviewed on 6/10/21 at 9:40 a.m. The investigation of Resident #6's allegation was requested. SW #1 said they had interviewed the resident who was accused of making the racial comments and shaking his fist at Resident #6, and he denied doing this. She said, therefore, there was no investigation (cross reference F-610 failure to investigate allegation of abuse). The SW said she had not interview[TRUNCATED]

Based on observations, interviews and record review, the facility failed to have an effective system in place to ensure two or four residents reviewed (#45 and #35) out of seven residents, received the appropriate treatment and services to prevent complications of enteral feeding, such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. Specifically: Record review and observations on 6/2/21 at 9:20 a.m., 6/3/21 at 9:30 a.m., and 6/7/21 at 10:12 a.m., revealed the facility failed to follow facility policy, standards of practice, care plan directives and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -Resident #45 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the resident was observed on 6/2/21 at 9:20 a.m. and 6/3/21 at 9:30 a.m. during her tube feeding, with the head of her bed positioned 15 degrees (6/2/21) and flat (6/3/21). Although staff was notified of these observations on 6/3/21 at 3:21 p.m., on 6/7/21 at 10:12 a.m., during another tube feeding, the head of the resident's bed was again at 15 degrees. -Upon observation of the resident's positioning on 6/7/21 at 10:12 a.m., the assistant director of nursing (ADON) failed to raise the head of the bed to comply with facility policy, standards of practice, and the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review and observations on 6/2/21 at 10:39 a.m. and 6/7/21 at 3:50 p.m. revealed the head of Resident #35' s bed was positioned at less than 30 degrees while he was being fed through a gastric tube. He, too, had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Interviews revealed some, but not all staff, were able to state how high the bed needed to be elevated during tube feedings. Further, review of all licensed nurses and a sample of certified nurse aides (CNAs) revealed there was no evidence staff had completed training on feedings by enteral means. (Cross-reference F726) The facility's failure to have an effective system in place to ensure Residents #45 and #35 received the appropriate treatment and services to prevent complications of enteral feeding created the likelihood of serious harm, including aspiration/aspiration-related complications, if immediate action was not taken. Findings include: I. Immediate Jeopardy A. Findings of Immediate Jeopardy Observation, record review, and interviews with staff demonstrated the facility did not have an effective system in place to ensure residents fed by enteral means received appropriate treatment and services to prevent complications. Interventions were not implemented to prevent the risk of aspiration for Resident #45 and #35 who were fed by gastric tube and both of whom been hospitalized for aspiration/aspiration-related complications. When notified of the concern that Resident #45's head of bed was positioned contrary to facility policy, standards of practice, the resident's care plan and orders during a tube feeding, the facility did not take immediate action to raise the head of the bed. Additionally, the facility did not assess Resident #45 for signs of aspiration for approximately seven hours after notified of the resident's improper positioning. Staff interviews revealed not all staff were aware how high to raise the head of the bed during a gastric tube feeding. Additionally, the employee files for all licensed nurses and a sample of CNAs revealed there was no evidence staff had completed training on tube feedings. (Cross-reference F726). B. Imposition of Immediate Jeopardy On 6/7/21 at 7:18 p.m., the nursing home administrator (NHA) was informed by the Department that the facility's failure to follow facility policy, standards of practice, orders and care plans, failure to immediately respond to observations of improper positioning for Resident #45, and failure to ensure all staff were knowledgeable and trained in enteral feedings, created a situation of immediate jeopardy with the potential for serious resident harm. C. Facility Response and Removal of Immediate Jeopardy On 6/8/21 at 4:22 p.m., the facility submitted the following plan (draft #4) to remove the immediate jeopardy. The plan read: RN conducted a respiratory assessment of Resident #1240 (Resident #45) on 6/7/21 at approximately 1715. Resident was assessed to be in no respiratory distress. The physician was notified on 6/8/2021 by ADON (Assistant Director of Nursing). No additional orders given. Daily Respiratory Assessments will continue daily for the next 72 hours to ensure no symptoms of aspiration are identified. If any signs or symptoms of aspiration are identified, the physician will be notified for any orders. All residents who receive tube feedings will have respiratory assessment completed by the ADON on 6/8/2021. Any signs or symptoms of respiratory distress will be reported to the physician for recommendations/orders. The physician will be notified if any concerns are identified. The Respiratory Assessment will trigger onto the 24 hour report each time one is completed. Education will be completed, by ADON/Designee, with all licensed nursing staff (RNs/LPNs) regarding policies/procedures of residents on enteral feeding including but not limited to elevation of the head of bed (HOB) per physician orders. This education will begin on 6/7/21 during the evening shift and will continue until all nursing staff have received education prior to working on the floor by the ADON/designee. All education of licensed nurses will be completed and verified by 6/11/2021. Education will be completed, by ADON/Designee, with all licensed CNAs regarding proper positioning of the HOB for residents who receive enteral feeding. This education will begin on 6/7/21 during the evening shift and will continue until all CNAs have received education prior to working on the floor by the ADON/designee. All education of licensed nurses will be completed and verified by NHA by 6/11/2021. Tape marks were placed on the wall by the beds in order to indicate the proper angle for the beds to be positioned. The residents in these beds do not move their beds, therefore, the positioning of the HOB will not change. RN Nurse Consultant provided education to Director of Nursing (DON) and Assistant DON (ADON) regarding policies/procedures of residents on enteral feeding including but not limited to elevation of the head of bed (HOB) per physician orders. This education occurred on 6/8/2021 at 8:15 a.m. Licensed nursing staff will conduct hourly rounding on all residents requiring enteral feeding, to ensure the HOB is elevated per physician orders. Rounding will be initiated on 6/8/2021 and will be verified by ADON/Designee. A log will be developed to document these hourly rounds, and staff will be educated on the use of the log. This will be completed by RNs, LPNs, and/or CNAs. If identified that HOB is not elevated per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If resident exhibits signs/symptoms of distress or aspiration, the physician will be notified. The Respiratory Assessment will trigger onto the 24 hour report, which will be reviewed by the ADON/Designee and NHA daily, Monday through Friday. The facility utilizes Behavior Technologists that complete 15-minute checks for resident with behavioral issues, repositioning or other issues. The six residents who receive tube feeding have been placed on the behavior tracking for the Behavior Techs to ensure that the HOB is in the proper position. If the HOB is observed to not in the correct position. The HOB will be elevated and the Respiratory Assessment will be completed. The Respiratory Assessment will trigger onto the 24-hour report which will be reviewed by the NHA/DON on a daily basis. RN/Nurse Consultant audited resident charts, on 6/8/2021, that require enteral feeding to ensure the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No resident with tube feedings will be admitted until the facility is in substantial compliance with F693. Tube Feeding issues/concerns will be reviewed by the facility QA/PI Committee monthly for three months, or until substantial compliance is achieved. Action Plans/Performance Improvement Plans will be developed to address any identified issues. C. Removal of immediate jeopardy On 6/8/21 at 5:38 p.m., the NHA was notified that the immediate jeopardy had been removed based on implementation of the plan above. However, based on observations, interviews, and record review, deficient practice remained at a D level, potential for more than minimal harm at a pattern. II. Facility policy and professional reference A. Facility policies The Enteral Nutrition Policy, revised in November 2018, was provided by the ADON on 6/7/21 at 4:15 p.m. It read in part in section 14, staff caring for a resident with feeding tubes are trained on how to recognize and report complications from the use of a feeding tube: aspiration. Risk of aspiration is assessed by the nurse and can be affected by: improper positioning of the resident during feeding. The Enteral Feeding, Safety Precautions Policy, revised in November 2018, was provided by the ADON on 6/7/21 at 4:15 p.m. It read in part, preventing aspiration included elevating the head of the bed at least 30 degrees during tube feeding and at least one hour after feeding. Monitor the resident for signs and symptoms of respiratory distress. B. Professional references [NAME], L. (2019) Enteral feeding tubes: an overview of nursing care. British journal of nursing (Mark [NAME] Publishing), https://doi.org/10XXX /bjon.2019.28.12.748 retrieved on 6/16/21. It read in pertinent part, it is important for nurses in care of persons with feeding tubes are aware of safety aspects of maintenance to prevent harm. Nurses need to have appropriate training and are competent. Gavi, S. DO, MPH, [NAME] J., MD, [NAME] F., MD, Nicastri C., MD, and Fields S., MD (April 2008, last revised 2021) Management of Feeding Tube Complications in the Long-Term Care Residents, https://www.hmpgloballearningnetwork.com/site/altc/article/8614, retrieved on 6/16/21. It read in pertinent part that long term care residents who are receiving nutrition through feed tubes need to be at a minimum of a 30 to 45 degree angle to prevent aspiration pneumonia. It is a modifiable risk to decrease the complication of aspiration pneumonia and remain in that position for an hour after the feeding is completed. III. Facility failure to have an effective system in place to ensure Residents #45 and #35, fed by enteral means, received the appropriate treatment and services to prevent complications of enteral feeding, including aspiration. A. Resident #45 Resident #45, age under [AGE] years, was admitted on [DATE]. According to the June 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/22/21 minimum data set (MDS) assessment revealed the resident was of unknown cognitive impairment with a brief interview for mental status related to her inability to speak. She was totally dependent with all cares. She required tube feedings for nutrition. The June 2021 orders read Resident #45 had an enteral feeding order start date of 5/8/21 for Fibersource HN at 75 milliliters and hour through her gastric tube for 20 continuous hours. Additionally, she was ordered to receive 25 milliliters of water every hour. 1. Record review revealed a history of aspiration/aspiration-related complications, provider notes, orders and care plan to position the head of the resident's bed 45 degrees during tube feedings. a. History of aspiration/ aspiration-related complications Change in condition assessments, progress notes and hospital records revealed the resident experienced three hospital visits that involved aspiration/ aspiration-related complications. Specifically: 4/26/21: A 4/26/21 change in condition assessment was retrieved from the resident's electronic medical record (EMR) on 6/3/21. It read the resident experienced a change related to diaphoretic (sweating), a fast heart rate, low blood pressure, resident is grimacing and moaning and distended abdomen with decreased bowel sounds. She was sent by emergency ambulance to the hospital. A 4/26/21 at 2:08 p.m. progress note read the resident was admitted to the intensive care unit (ICU) for closer monitoring. The 4/30/21 hospital discharge summary, retrieved from the resident's EMR, read in part she was hospitalized from 4/26/21 until 4/30/21 due to septic shock from aspiration and decreased oxygen supply. 5/14/21: A 5/14/21 change in condition assessment read the resident was diaphoretic, audible gurgling sounds, a fast heart rate, fast respirations and low oxygen saturations. The resident possibly aspirated. The 5/14/21 emergency department visit discharge summary, retrieved from the resident's EMR on 6/3/21, read for shortness of breath due to pneumonia from COVID -19 and aspiration. 5/19/21: The 5/24/21 hospital discharge summary, retrieved from the resident's medical record on 6/3/21, read in part she was hospitalized from 5/19/21 until 5/24/21. She was diagnosed with severe [CONDITION(S)], acute hypoxemic respiratory failure (low oxygen saturations) from suspected bacterial pneumonia from aspiration. Her COVID-19 tests were negative. As well as an NSTEMI (Non-ST elevated [CONDITION(S)] infarction). b. Provider notes, orders and care plan The resident's June 2021 orders read, with an order start date of 6/28/2018, to keep the resident's head up at a 45 degree angle to prevent aspiration. The care plan for Resident #45, last revised in December 2020, read to maintain the resident's head of the bed at a 45 degree angle while she received tube feeding and 30 minutes after to prevent aspiration. A provider note dated 6/3/21 at 2:46 p.m. read the resident was required to stay upright during feeding. 2. Observations and interviews Observations revealed the facility failed to ensure the resident was positioned as ordered during tube feedings, contrary to facility policy, standards of practice, her care plan and physician orders, in order to prevent complications such as aspiration. On 6/2/21 at 9:20 a.m., Resident #45 was in bed with the head of her bed at a 15 degree angle with a gastric tube feeding running until 11:00 a.m. On 6/3/21 9:30 a.m., in Resident #45's room had a sign above the head of her bed that read to keep the head of the bed up at a 45 degree angle. However, the bed she laid in was flat while her tube feed was running. On 6/3/21 at 3:21 p.m., registered nurse (RN) #2, who was caring for Resident #45, was interviewed. She was informed the head of the resident's bed had not been elevated that morning during her tube feeding. The RN said she was aware the resident needed to have her head up when she received her tube feeding; however, she did not know the angle the resident required to be positioned while she received the tube feeding. On 6/3/21 at 3:23 p.m., RN #2 walked into Resident #45's room. The head of the resident's bed was flat and her tube feeding was running. The RN quickly walked to the resident's bed and elevated the head of the bed to about 30 degrees. She stated she had set up and begun the resident's scheduled tube feeding 10 minutes before 3:00 p.m. At that time, the head of the resident's bed was up, and she did not know why or how she had just found the head of the bed in a lower position. On 6/7/21 at 10:12 a.m., the resident laid in bed with the head of her bed up at a 15 degree angle while her tube feeding was running. The assistant director of nursing (ADON) walked into Resident #45's room and came back out. Observations thereafter revealed the resident remained in bed with her head at a 15 degree angle and her tube feedings continued to run. On 6/7/21 at 10:22 a.m., the director of nursing (DON) was interviewed. She had observed Resident #45 while in bed at 10:20 a.m. and stated Resident #45's head of the bed was at about a 25 degree angle. She said the resident needed to be up higher in bed to prevent aspiration and other complications. She asked two certified nurse aides (CNAs) to reposition the resident up higher in bed. She did not assess the resident's respiratory status, even though the resident had been improperly positioned during the tube feeding. 3. Further record review - failure to consistently monitor Resident #45's respiratory status Despite the resident's history of aspiration/ aspiration-related complications (see above), review of assessments and progress notes for Resident #45 did not reveal the resident had a respiratory assessment from 5/28/21 until 6/7/21. Furthermore, the assessment completed on 6/7/21 was completed at 5:15 p.m., seven hours after the facility was made aware the resident was lying flat during her tube feeding. The infection prevention log for the months of April and May of 2021 did not read the facility was monitoring Resident #45's pneumonia and antibiotic prescriptions. 4. Staff interviews CNA #3 was interviewed on 6/7/21 at 1:52 p.m. She said infection was a risk for people who had tube feedings and said she did not have experience with a resident who had a tube feeding. She was unsure if she had received education about residents with tube feedings. The DON was interviewed on 6/7/21 at 12:10 p.m. She stated she did not know when the nursing staff had received education, training or competencies related to tube feedings. She said education would be provided soon. The Medical Director was interviewed on 6/7/21 at 4:09 p.m. He said the resident's pneumonia episodes were caused by aspiration because she receives tube feedings. 5. Actions taken after the NHA was informed of immediate jeopardy on 6/7/21. An in-service training was conducted by the ADON beginning on 6/7/21, to nursing staff for residents with tube feedings regarding the head of the bed and angle the head of the bed was required to be at during the feedings and to date the formula and disposable equipment that were used. The ADON was interviewed on 6/10/21 at 1:15 p.m. She stated the nursing administration team had initiated a Performance Improvement Plan on 6/7/21 regarding tube feeding protocol as the team found the head of the bed was not at the proper angle while residents received tube feedings. The team initiated education to nursing staff about enteral feeding policy and procedure, conducted an audit to identify concerns regarding the head of the bed angle, and planned to complete daily respiratory assessments for residents receiving tube feedings. Further, residents receiving tube feedings would be placed on routine monitoring to ensure the resident was at the proper angle during tube feedings. B. Resident #35 1. Resident status Resident #35, age 31, was admitted on [DATE], and readmitted on [DATE]. According to the June 2021 computerized physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 4/15/21 minimum data set (MDS) assessment, the resident was unable to complete a brief interview for mental status (BIMS.) The assessment documented he was moderately cognitively impaired for daily decisions. Resident #35 required extensive two-person assistance with transfers, and extensive one person assistance with bed mobility, dressing, hygiene eating, and toileting. He had a feeding tube. 2. Record review The resident's June 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, he had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, initiated 10/15/19, was reviewed. The care plan documented the resident experiences emesis/burping with bolus feeding therefore receives continuous feelings. At risk for aspiration related to episodes of emesis. Head of bed at 30 degrees at all times. On 6/8/21 during the survey, the care plan was updated to include keep head of bed at 30-45 degrees during tube feeding. The nursing progress notes were reviewed. On 10/4/2020 at 7:15 a.m., the resident was sent to hospital after having emesis (vomiting) twice. He was returned to the facility on [DATE] at 6:18 p.m. with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital records dated 10/5/20 documented Resident #35 had a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 3. Observations Observations revealed the facility failed to ensure the resident was positioned as ordered, contrary to facility policy, standards of practice, his care plan and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/2/21 at 10:39 a.m., Resident #35 was observed lying in bed almost flat. He had a tube feeding running at 50 ml (milliliters) per hour. His head was at the end of the bed, and he was twisting the privacy curtain. On 6/7/21 at 3:50 p.m. Resident #35 was observed in bed, the head of the bed was elevated between 10 and 20 degrees. He had a tube feeding running at 50 ml per hour. 4. Interviews CNA #1 was interviewed on 6/7/21 at 1:45 p.m. with CNA #7. CNA #7 said she did not know how high the resident's bed needed to be elevated during a tube feeding. CNA #1 said maybe 60 degrees, I don't really know. RN #1 was interviewed on 6/3/21 at 2:32 p.m. She said when a resident received a tube feeding, the head of the bed should be elevated 30 degrees. She said Resident #35 did not receive tube feeding from 10 a.m. to 2:00 p.m. each day. He received it for only 20 hours per day, and the head of the bed should be elevated. III. Medical Director interview The medical director (MD) was interviewed on 6/10/21 at 1:26 p.m. The MD said he had not heard of concerns with the tube feedings in the past. He said the facility had lost some veteran staff in the last three months and it sounded like some relearning needed to occur. The MD said he was unsure if the failure to elevate the head of the bed on Resident #45 led to her pneumonia or not. He said she has had a decline recently.

Based on observations, record review and interviews the facility failed to provide care in a manner which promoted dignity and respect for two (#48, #63) of two out of 46 residents reviewed. Resident #63 who required support from staff for toileting support was not treated and provided care in a dignified manner as evidence by the staff leaving her commode for hours at a time and the resident having to eat next to a full commode with urine and feces in. Resident #63 indicated during an interview on 6/2/21 this made her feel depressed and she felt like a burden to the staff. (Resident was weeping). She said she felt uncomfortable and degraded by having to eat her food next to the commode that has not been emptied all day. She indicated that she would be happy to leave the facility. Additionally, the facility failed to offer assistance to Resident #48 when he dropped his food on his clothes and then ate off his clothes. Findings include: I. Policy The facility admission packet (undated) was received from the nursing home administrator (NHA) on 6/2/21 at 10:00 a.m. It read in pertinent part: The residents have the right to be treated courteously, fairly and with the fullest amount of dignity and receive a written statement of services provided to them on an as needed basis. The resident also has the right to receive reasonable services to accommodate his or her needs and preferences except when the health and safety of other residents would be endangered. The dignity policy was requested from the NHA on 6/8/21 at 10:30 a.m. and again on 6/10/21 at 9:30 a.m. As of 6/22/21, it had not been provided. II. Resident #63 A. Resident #63 status Resident #63, age 61, was admitted on [DATE]. According to the June 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/11/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status score of 15 out of 15. She required minimal assistance with bathing and mobility. B. Observations On 6/2/21 intermittent observations were done from 10:54 a.m to 3:50 p.m. -At 10:54 a.m. Resident #63 ' s room had a strong smell of urine. The portable toilet was next to the residents recliner chair. It was 75% full of urine. The resident said the toilet was last emptied at 5:00 a.m. that morning. -At 11:45a.m. the resident ' s toilet was 75% full of urine. -At 12:45 p.m. the toilet had not been emptied. -At 1:30 p.m.the toilet was full of urine -At 2:30 p.m. the toilet was full of urine and feces -At 3:00 p.m the toilet was full of urine and feces -At 3:50 p.m The toilet had not been emptied; it was full of urine and feces. -At 5:00 p.m. the toilet was empty On 6/3/21 at 5:38 p.m. the portable toilet was 90% full of urine and feces. The resident indicated the toilet was last emptied at 6:30 a.m. that morning and had not been emptied all day. There was a strong odor of feces and urine in the room. On 6/7/21 at 7:26 p.m.,the toilet in Resident #63 ' s room was full of fecal matter and urine.The resident stated the toilet had not been emptied all day. C. Record review The care plan, retrieved on 6/10/21, indicated the resident had a bedside commode. It included the commode was to be checked and cleaned every two hours and staff were to assist with any help she needed with toileting. The Bedside Commode Check form indicated the resident's commode was checked and cleaned on 6/2/21 at 8:06 a.m. and again at 2:16 p.m. Observations of the commode included the toilet was 75% full at 10:54 a.m. Resident #63 indicated the commode was not emptied until 4:00 p.m. on 6/2/21. The Bedside Commode Check form indicated the resident's commode was checked and cleaned on 6/3/21 at 2:53 p.m. Observation of the commode at 5:38 p.m. indicated the commode was 90% full of feces and urine. Resident #63 indicated the commode had not been emptied all day although the check form indicated that it was emptied. The Bedside Commode Check form indicated the resident's commode was checked and cleaned on 6/7/21 at 10:03 a.m., 12:15:p.m., and 3:10 p.m. Observation of the commode at 7:26 p.m. revealed the commode was almost overflowing with urine and feces. Resident #63 said no one had been in her room all day to empty the commode. Grievances dated 1/25/21, 2/3/21, 2/17/21, and 3/8/21 from Resident #63 indicated that the staff were not emptying her commode timely. A grievance from Resident #63 ' s sister dated 2/5/21 indicated she had been in the resident ' s room on that day and saw that the commode was not emptied timely. -The corrective action taken by the facility was to implement two hour checks for the certified nurse aides (CNA) to check and empty the toilet starting 1/25/21. This was signed by the director of nursing (DON) 1/25/21. The DON implemented continued education to remind the CNAs of this task.(2/5/21). The corrective action plan created by the DON indicated for the grievance dated 2/17/21, was the commode was being emptied per task assignment located in point click care (PCC). The corrective action taken for the grievance dated 3/8/21, was that the CNAs would empty the commode on a regular basis. It was not signed to indicate who was provided with this education. D. Interviews Resident #63 was interviewed again on 6/2/21 at 10:54 a.m. She said the problems with the commode had gotten worse over the last two months. She said the NHA told her that the staff would check and empty the commode every two hours and they had slacked off on doing that. She indicated this made her feel depressed and she felt like a burden to the staff. (Resident was weeping). She said she felt uncomfortable and degraded by having to eat her food next to the commode that has not been emptied all day. She indicated that she would be happy to leave the facility. CNA # 8 was interviewed on 6/3/21 at 5:52 p.m. She said she checked Resident #63 ' s toilet every two hours. She said she checked the toilet at 4:00 p.m. and the toilet was dry. She said the resident would call to have the toilet emptied if there was a fecal matter in the toilet. She indicated that she had worked at the facility for seven years. Registered nurse (RN) #1 was interviewed on 6/3/21 at 5:58 p.m. She said Resident #63 ' s toilet should be checked every two hours and emptied when needed, as well as when the resident called for assistance. The director of nursing (DON) was interviewed on 6/3/21 at 6:03 p.m.The DON said Resident #63 ' s toilet should be emptied every time it was used. She said she was not aware that the toilet was not being emptied timely. She stated that she would re-educate the staff about the toilet before she left work that day. The DON was interviewed again on 6/7/21 at 8:40 p.m. She said she had implemented every 15 minute checks for Resident #63 to have her commode emptied, which was started on 6/3/21. She did not know if the CNAs had been documenting this. The DON was informed that the toilet was almost overflowing with bowel movement (BM) and urine. She said she would go down to the resident ' s room right away and take care of the issue. Resident #63 was interviewed again on 6/8/21 at 12:46 p.m. She said the staff was checking her toilet more timely today. She indicated that she felt better when the toilet was emptied and this made her more comfortable to eat in her room. III. Resident #48 Even though Resident #48 ate his meal independently, as the observations and record review revealed, Resident #48 was not given enough support to ensure he was able to eat in a dignified manner, without spilling food all over himself, struggling with his napkin, spoon and fork at the table and with his clothes protector at the same time trying to feed himself. Also, other residents watched him eat and yell loudly enough for the resident to hear, It is too late for a bib, he ' s already a mess. A. Resident status Resident #48, age 76, was admitted on [DATE]. According to the June 2021 certified physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required a regular diet with a pureed texture. The resident began hospice on 1/22/21. The 4/23/21 quarterly MDS assessment revealed the resident had short and long term memory problems, and had severely impaired cognitive skills for decision making. The resident required limited assistance with bed mobility, locomotion on and off the unit, and with eating. The resident required extensive assistance with transfers, dressing, toilet use and personal hygiene. B. Dining room observations 1. Observations on 6/2/21 Continuous observations on 6/2/21 from 11:51 a.m.-12:34 p.m. Resident #48 was observed in his wheelchair seated at a table in the dining room. The resident was wearing a beige color blanket over his clothes as a clothing protector. He did not receive a clothing protector during the meal. The blanket covered his front and sides and was tied loosely on his back under his neck. The resident had a tray of food with four bowls of pureed food on top of the tray placed in front of him at 11:55 a.m. The bowls did not fit flatly on the tray which had compartments. Each of the four bowls had an edge resting on a compartment of the tray. The resident was not offered help from the staff. -From 11:55 a.m.-12:02 p.m. (seven minutes) the resident attempted to remove the silverware out of a napkin. He was not assisted by staff with his silverware. -At 12:03 p.m. the resident picked up one of the four bowls in his left hand and a spoon in his right hand. Both hands shook as he began to eat. -At 12:04 p.m. the resident took a spoonful of pureed barbeque pork sandwich and attempted to place the spoon in his mouth. The food dropped off of the spoon and onto the blanket which he had on as a clothing protector. The resident used his right hand that held the spoon to scrape the food off of the blanket and back onto the spoon. He then put the spoon in his mouth with the dropped food on it and ate it. -The resident repeated four more times to put the spoon full of food up to his mouth. The food dropped onto the blanket, the resident scooped the food off the blanket, back onto the spoon and back into his mouth. -No staff members offered to help the resident. -At 12:09 p.m. the resident set down the bowl of pureed pork and picked up a bowl of applesauce. The same repeated process occurred of scooping the applesauce from the bowl with a spoon, to the mouth, the sauce dropped onto the blanket, the resident then scraped the sauce off the blanket and placed it in his mouth. No one noticed his struggles or offered to help the resident. -At 12:15 p.m. the resident picked up a third bowl of pureed food, which looked like mashed potatoes, and with the same process of taking a spoon full of food to the mouth, the food dropped onto the blanket, and he then scraped it off the blanket back onto the spoon and into his mouth. No one noticed his struggles or offered to help the resident. -At 12:19 p.m. the resident took a napkin and attempted to wipe away the food stains that were on the blanket. -At 12:21 p.m. the blanket began to untie on its own from behind the resident ' s back. He held the blanket in place with his chin so that it would not fall off. He held his chin to his chest with the blanket in between. He took the fourth bowl of food in his right hand. He continued to hold his chin on his chest to keep the blanket in place and feed himself at the same time. He pushed himself back a foot from the table while he attempted to hold the blanket under his chin and feed himself at the same time. He continued until 12:27 p.m. to hold the blanket with his chin, and feed himself in the same manner of spoon to mouth, food dropped from his mouth onto his blanket, he scraped the food back onto the spoon and put the scraped food in his mouth. No one noticed his struggles to keep the blanket under his chin or offered to help him. -At 12:29 p.m. he stacked the bowls on the table, and used the blanket to wipe his face in an attempt to clean it. He had mashed potatoes on his pointer and second fingers of his right hand and he scraped the food off his fingers onto the food tray. He put the entire blanket on his lap. He tried to place the blanket onto the table but the blanket was too large. He spent three minutes trying to balance the blanket on the table and then he rolled the blanket in a ball and held it next to his body. No one noticed his struggles or offered to help him. -At 12:32 p.m. a dietary aide cleared away his tray and blanket. He was not offered to have his hands washed and was escorted out of the dining room at 12:34 p.m. 2. Observations on 6/3/21 Continuous observations on 6/3/21 from 4:56 p.m.-5:24 p.m. Resident #48 was observed in his wheelchair, in the dining room seated at the middle table, wearing a brown shirt. He was not offered any feeding assistance by the staff and was not given a clothing protector. -At 4:56 p.m. the food tray was set before him with four bowls of pureed food balancing on the tray. The bowls of pureed food did not sit flat on the tray. The bowls balanced on their side edges on the compartments of the tray. -At 4:57 p.m. the resident picked up a bowl in his left hand and a spoon in his right hand. He scooped food from the bowl with a spoon and tried to place the spoon inside his mouth. The food fell from the spoon from his mouth and dropped onto his brown shirt. He picked up the fork and the spoon and with the two utensils pushed food onto the spoon from off of his shirt. He then returned the spoon with food to his mouth and ate it. -At 5:00 p.m. he repeated this process three times which left food residue on his brown shirt. No one noticed his struggles or offered to help him. -At 5:04 p.m. he picked up the second bowl in both of his hands and brought it to his chin where he began to try and use his tongue to scoop the food into his mouth. -At 5:05 p.m. CNA#2 walked up to the resident, placed a clothing protector down the resident's chest and tied the clothing protector around the back of the resident ' s neck. He did not ask the resident if he wanted it or if he could place it around his neck. The CNA did not offer any assistance to the resident. -At 5:05 p.m. a resident in the dining room at another table said loudly, It is too late for a bib, he ' s already a mess. -At 5:07 the resident dropped food off of the spoon while he was trying to put food in his mouth three times. He scraped the dropped food off the clothing protector, brought the spoon back up to his mouth and ate the food. -At 5:09 p.m. the resident brought a spoonful of food to his mouth but it dropped onto his shirt collar, not the clothing protector. He scraped the food off of the shirt collar and put it in his mouth. He fed himself this way three bites in a row. -At 5:12 p.m. he dropped food onto the clothing protector from his mouth, scraped it back onto the spoon and returned the spoon to his mouth. -At 5:15 p.m. the resident placed the third bowl down on the table and picked up the fourth bowl which was the dessert. The resident took the bowl up to his mouth and licked the dessert out of the bowl. He licked half of the bowl ' s contents and set the bowl down on the table. No one appeared to notice his struggles or offer to help him. -He continued to stack and restack the four bowls on his table and on his tray until 5:23 p.m. -At 5:24 p.m., CNA #2 took the clothing protector off of the resident, put the clothing protector on the table, and placed the resident ' s hands in his lap. The resident was not offered to have his hands washed. CNA #2 walked away from the resident and left him at the table. The resident was seated in his wheelchair and propelled himself with his feet towards the door of the dining room. C. Record review The resident was admitted to hospice on 1/22/21. The 4/21/21 nutrition dietary progress note was reviewed and revealed, the resident followed a dysphagia/puree diet. The resident went to the main dining room for meals and averaged 75-100% food intake at meals. The activities of daily living (ADL) log was reviewed and revealed on 6/2/21 and 6/3/21, the resident ate his meals independently with no help of staff or oversight at any time. The nutrition care plan, initiated 6/7/21 (during survey) was reviewed and revealed: Resident was at nutrition risk due to potential for chewing difficulty related to choice to not wear dentures when eating and consuming lunch and dinner, only. The resident was at nutrition risk due to weight loss related to COVID-19 complications with decline in appetite and overall condition. The resident had mild [CONDITION(S)] in both eyes and nursing was to assist as needed with visual needs. D. Staff interviews CNA #9 was interviewed on 6/8/21 p.m. at 5:25 p.m. and she said sometimes staff assisted Resident #48 to eat his meals. She said he had a hard time eating. She said she would go and get him a clothing protector to protect his clothes because he dropped his food on his clothes. She explained if she got some time she would try and sit with him because he would drop his food all over the front of his clothes. She said she was aware that food on his spoon would fall from his mouth onto his clothes and he scraped it back onto the spoon and into his mouth again. The restorative consultant (RC) was interviewed on 6/9/21 at 3:35 p.m. and was familiar with his eating habits. She said they needed to figure out how to enable the resident to eat with dignity. She said occupational therapy or the speech therapist could do an evaluation of him to assess his needs. She said she did not know if he had an evaluation planned for him but she could certainly ask for this to be done. The registered dietician (RD) was interviewed on 6/9/21 at 3:00 p.m. via the phone. She said in the last several months Resident #48 had gone from eating independently to a decline in eating independently. She said his food texture had been downgraded to puree also. She said the restorative nurse would talk to her to alert her about residents who may have changed with their eating patterns. She said the restorative nurse did not alert her today that she made changes in his chart to move him to the smaller dining room for staff to be able to set up his dining tray and assist him with eating. The RD said she was unaware that his food fell off of his spoon from his mouth onto his clothes. The RD said she did not know he then scraped the food off his clothes and placed the food back into his mouth. She said no one had communicated to her about this or any changes concerning his eating habits. The nursing home administrator (NHA) was interviewed on 6/9/21 at 4:44 p.m. She said she talked with the restorative nurse and there would be no screenings for Resident #48 because he was receiving hospice care. She said he could not have his food downgraded anymore than the pureed texture. She said they were currently working on how to help him so that he did not eat off of his clothes. She said maybe they would give him a plate with a plate guard. She said, I can tell you we will work on this and help him and get this taken care of. E. Follow up The restorative nurse (RSN) added a restorative progress note on 6/9/21 at 11:07 a.m., during the survey. The note was reviewed and revealed that Resident #48 had a change to his dining room location. The note read, Care plan update, resident will now eat in the small dining room and staff will set up (a) tray and assist him with feeding as resident needs and allows. He does become upset when staff try to assist him at times.

Based on observations, record review and interviews, the facility failed to establish and maintain an effective infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including COVID-19, in four of four resident neighborhoods. The failure affected all residents present in the facility, which placed the facility in an immediate jeopardy situation. Observations, interviews and record review 7/28, 7/29 and 7/30/2020, revealed systemic failures in the facility's infection control program, specifically, multiple failures in infection source control, including personal protective equipment (PPE) use, staff and resident mask use, hand washing, social distancing and staff screening. The facility's failures, coupled with the staff's lack of knowledge and training in infection control, created the likelihood for serious harm due to potential transmission of the highly infectious COVID-19 virus to all facility residents. Findings include: I. Facility status The facility COVID-19 line listing documented three positive staff members for July 2020. The last positive staff person was identified 7/24/2020. In addition, the facility line listing documented two positive residents in July 2020. The last COVID-19 positive results for a resident was on 7/29/2020. The line listing identified two more residents with signs and symptoms of COVID-19 for July 2020. Previous month's results were not documented on the line listing. Observations revealed 11 residents were on isolation for possible symptoms or exposure to COVID-19. One resident was in isolation for positive COVID-19 test results. II. Immediate Jeopardy A. Findings of Immediate Jeopardy Multiple observations on 7/28 and 7/29/2020 revealed direct care staff failed to don personal protective equipment (PPE), gowns, mask, gloves, and eye protection when providing care for residents in isolation for confirmed and suspected COVID-19. Staff reported they were educated to wear less than full PPE when entering COVID-19 positive resident rooms. Moreover, they reported the facility did not have all the PPE required per CDC guidance when caring for residents on isolation. Further observations of direct care staff on 7/29 and 7/30/2020 revealed one staff entered the facility without a facemask and proceeded down a hallway, still without a facemask despite stopping at the screening desk. Another staff wore her facemask below her chin. A number of observations on 7/28, 7/29 and 7/30/2020 revealed residents outside their rooms without facemasks and interacting with staff who failed to encourage them to wear a face covering or to social distance. Additional observations 7/28 and 7/29/2020 revealed staff failed to encourage residents on isolation to stay in their rooms and wear face coverings when out of their rooms, failed to isolate newly admitted and/or readmitted residents with unknown COVID-19 status in different rooms, and failed to offer residents hand hygiene before meals. Finally, record review and interview revealed the facility failed to ensure staff on the isolation unit were actively screened prior to starting their shifts, and failed to ensure staff received adequate education and training in infection control. These failures created the likelihood for serious harm to all facility residents due to potential transmission of the highly infectious COVID-19 virus. B. Facility notice of immediate jeopardy On 7/30/2020 at 5:04 p.m., the NHA was notified the failure to develop and implement an effective infection control program created the likelihood of serious harm to facility residents from COVID-19. C. Facility plan to remove immediate jeopardy On 7/30/2020 at 7:47 p.m., the NHA provided a plan to remove the immediate jeopardy. The plan read: Staff will be educated using CDC guideline materials by DON (director of nursing), ADON (assistant director of nursing), Nurse Managers and/or designee at the beginning of each shift starting on July 30, 2020 about wearing full PPE including eye protection anytime staff enters an isolation room, training will be completed by August 3, 2020. Staff will be re-educated using CDC guideline materials by DON, ADON, Nurse Managers and/or designee at the beginning of each shift starting on July 30, 2020 about encouraging residents on isolation room to use a facemask to cover their mouth and nose before staff enters their room, training will be completed by August 3, 2020. Staff working COVID unit will be educated using CDC guideline materials by DON, ADON, Nurse Managers and/or designee that the outgoing nurse/CNA will screen incoming Nursing/CNA members at the entrance of COVID unit and document it on screening form starting July 30, 2020. DON or designee will monitor screening forms every morning. If the Nurse or CNA does not pass screening then the on call nurse manager will be called and the nurse and/or CNA will be sent home. Staff will be re-educated using CDC guideline materials by DON, ADON, Nurse Managers and/or designee at the beginning of each shift starting on July 30, 2020 about encouraging residents to wear masks when out of their room. Training will be completed by August 3,2020. Nurse's carts will have disposable face masks available for residents daily and as needed for soiled masks. Staff will be re-educated using CDC guideline materials by DON, ADON, Nurse Managers and/or designee at the beginning of each shift starting on July 30, 2020 about wearing surgical masks or higher grade masks upon entering the building, while in the building, and while providing resident care. Training will be completed by August 3, 2020. Staff will be re-educated using CDC guideline materials by DON, ADON, Nurse Managers and/or designee at the beginning of each shift starting on July 30, 2020 about encouraging residents to perform hand hygiene when leaving their rooms, before meals, and at other times. Training will be completed by August 3,2020. Residents will be offered hand hygiene before meals and when leaving the room. Staff will be re-educated using CDC guideline materials by DON, ADON, Nurse Managers and/or designee at the beginning of their shift starting on July 30, 2020 about encouraging residents to social distance while in common areas. Training will be completed by August 3,2020. Common areas will have floor markings that are six feet apart. The DON and all designees, will audit 50% of staff weekly to ensure compliance. A quiz will be administered by DON and designee at the end of training of topics to ensure understanding and proper knowledge of training. D. Removal of Immediate Jeopardy On 7/30/2020 at 7:53 p.m., the NHA was notified the immediate jeopardy was removed, based on the facility's education plans and audits to ensure the plans were implemented. However, deficient practice remained at F level, potential for more than minimal harm that is widespread. III. Systemic failure to establish and maintain an effective infection prevention and control program. A. Failure to ensure staff donned personal protective equipment (PPE) - gowns, mask, gloves, and eye protection - when providing care for residents in isolation for confirmed and suspected COVID-19. 1. Professional reference and facility policy and procedure According to the Centers for Disease Control and Prevention (CDC), Preparing for COVID-19: Long-term Care Facilities, Nursing Homes, updated 6/25/2020, retrieved 8/3/2020 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html All recommended PPE should be worn during care of residents under observation; this includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. According to the CDC guidance Key Strategies to Prepare for COVID-19 in Long-term Care Facilities (LTCFs), last updated 6/25/2020, retrieved 8/3/2020 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care-strategies.html Residents with known or suspected COVID-19 should be cared for using all recommended PPE, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown. The facility's COVID-19 Prevention policy, revised 6/26/2020, was received from the DON, who also identified herself as the infection preventionist, (DON/IP) on 7/30/2020 at 11:05 a.m. The policy documented in pertinent part, COVID-19 is thought to spread mainly from person to person between people who are in close contact with another (within six feet) through respiratory droplets produced when an infected person coughs or sneezes. Staff will wear appropriate PPE as per facility guidance and follow appropriate precautions. Droplet precautions will be implemented for residents with suspected or confirmed COVID-19 for 14 days after the illness onset. 2. Observations of and interviews with direct care staff providing care and services to residents on isolation for confirmed and suspected COVID-19. On 7/28/2020 at 11:43 a.m., registered nurse (RN) #3 entered room [ROOM NUMBER], a COVID-19 isolation room. She did not wear eye protection and her gown was not wrapped completely around her. She had a short sleeve gown on with long sleeve scrubs exposed. She put her gloves on first, then the gown. Certified nurse aide (CNA) #14 also went into the isolation room without eye protection and did not wear a N95 or higher respirator/mask. -RN #3 and CNA #14, interviewed following the above observation, said they did not have eye protection or long sleeve gowns available for use. CNA #14 said she dropped her N95 mask and needed a new one. She said she was called to assist with this resident and did not have time to get a new N95 mask. On 7/28/2020 at 11:52 a.m., CNA #9 was observed delivering lunch trays to residents' rooms. She delivered room trays to room [ROOM NUMBER], a COVID-19 isolation room. She wore only a mask when she entered the room; she did not put on eye protection, a gown, or gloves. CNA #9 said the DON trained her to wear PPE only if she provided direct care to residents in isolation rooms. On 7/29/2020 at 8:18 a.m., observations revealed housekeeper (HK) #1 cleaning room [ROOM NUMBER], a COVID-19 isolation room. She was not wearing eye protection. As she cleaned the isolation room, her gown broke and hung halfway off her body. She wore a short sleeve gown and a long sleeve blouse which was exposed while cleaning the room. When she finished cleaning the room, she took off her PPE then moved to clean another room. She did not perform hand hygiene after she removed her gloves. -HK #1, interviewed following the above observation, said eye protection was not available for her to use. However, the room [ROOM NUMBER] isolation cart was observed at 8:20 a.m. There were four pairs of eye protection glasses on the cart. On 7/30/2020 at 10:08 a.m., RN #6 was observed on the unit with confirmed COVID-19 positive residents. She said she wore a gown, mask and gloves to care for the residents. She said she did not wear any eye protection and had not been educated by the facility to wear goggles or a face shield when caring for residents who were positive for COVID-19. On 7/30/2020 at 9:31 a.m., CNA #2 was interviewed. He said the DON had educated him to wear a mask in isolation rooms unless he was going to come in contact with body fluids and provide direct care. He said he did not know if the facility had any eye protection such as goggles or face shields. He confirmed he had not been told to wear eye protection and he had not been wearing eye protection in isolation rooms. Later, at 11:54 a.m., CNA #2 was observed delivering lunch trays to room [ROOM NUMBER] wearing only a mask, no gown, no eye protection, and no gloves. On 7/30/2020 at 12:59 p.m., CNA #12 was interviewed. She said the DON had trained her on PPE about two weeks ago. She said she was not educated to wear eye protection in COVID-19 isolation rooms; rather, the DON educated her to wear a mask in the isolation rooms and had said she only needed to wear a gown and gloves if she was going to come in contact with body fluids 3. DON/IP and NHA interviews On 7/30/2020 at 12:38 p.m., the DON/IP was interviewed regarding the facility's supply of PPE. She said she was in contingency mode and her current supply would last three weeks. She said she had 16,000 large gloves, 13,000 medium gloves, 3000 small gloves, 13,200 surgical masks, 900 face shields, 120 sets of goggles, 2000 KN95 masks, 900 long sleeve gowns, 200 long sleeve overalls. She did not know how many cloth face coverings or tissues she had for residents. She said she had short sleeve gowns on the floor currently, but did not know how many she had. She said she has been educating the staff to conserve their supplies and only wear a gown if they were going to come in contact with body fluids. On 7/30/2020 at 2:55 p.m., the DON/IP and NHA were interviewed. The DON/IP said the staff were educated on PPE. She said they only needed to wear a mask in isolation rooms unless they were going to provide direct care, like changing a resident, and might come in contact with body fluid. She said if they were going to come in contact with body fluid, they needed to wear a gown and gloves. The DON/IP said staff did not need goggles or face protection. She did not respond when asked what would happen if a resident in isolation coughed or sneezed on a staff person who was in the room without full PPE. B. Failure to ensure staff wore face coverings while in the facility, and wore the face coverings appropriately while providing care. 1. Professional reference and facility policy and procedure According to the CDC guidance, Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19, dated 3/20/2020, retrieved 8/3/2020 from: https://www.cdc.gov/coronavirus/2019-ncov/downloads/A_FS_HCP_COVID19_PPE.pdf: -PPE must be donned correctly before entering the patient area. - PPE must remain in place and be worn correctly for the duration of work in potentially contaminated areas. PPE should not be adjusted. - Face masks should be extended under the chin. - Both your mouth and nose should be protected . The facility's COVID-19 Prevention policy, revised 6/26/2020, was received from the DON/IP on 7/30/2020 at 11:05 a.m. The policy read in pertinent part, Staff will don a facemask throughout their shift. In addition, the Personal Protective Equipment policy, dated 9/2010, was received from the DON/IP on 7/30/2020 at 11:05 a.m. This policy read in pertinent part, Be sure the mask covers the nose and mouth. 2. Observations of and interviews with direct care staff providing care and services to residents. On 7/29/2020 at 12:26 p.m., CNA #2 was observed assisting a female resident to the bathroom in the Shawnee River neighborhood. The female resident did not have a mask on. CNA #2 had a mask positioned below his chin, not covering his mouth or nose. On 7/29/2020 at 2:04 p.m., CNA #9 entered the facility through the front door without wearing a mask. She continued around the corner to the front desk to be screened by the person at the reception desk. The person at the desk screened CNA #9, but did not advise her to don a mask. At the time, an ambulatory female resident stood at the reception area, also without a mask on. The CNA continued down the hall toward the dining room, past a male resident in a wheelchair. She stated to another staff member, I need to find my mask. When interviewed, she said, I am looking for my mask and walked away, proceeding further down the hall into an office area and shutting the door. On 7/29/2020 at 2:10 p.m., the staff person at the reception desk completing screenings, CNA #4, was interviewed. She said CNA #9 should have had a mask on before coming in the facility, but my job is just to screen them. On 7/30/2020 at 9:02 a.m., licensed practical nurse (LPN) #2 was observed speaking to two staff members on the south hallway. The staff members were standing two feet apart. LPN #2 had a facemask on, but positioned below her chin and not covering her mouth or nose. CNA #2 was interviewed on 7/30/2020 at 9:31 a.m. He said a facemask should be worn over the nose and under the chin. He said the staff were supposed to have their mask on before they entered the facility. 3. DON/IP and NHA interviews On 7/30/2020 at 2:55 p.m., the DON/IP and NHA were interviewed. The DON/IP said the staff should have a facemask on before entering the facility. She said staff needed to wear the mask above their nose and below their chin at all times. C. Failure to ensure staff encouraged residents to have facemasks/face coverings while outside of their rooms, and failure to assist and encourage social distancing 1. Professional reference and facility policy and procedure The Centers for Disease and Prevention (CDC) Hand Hygiene in Healthcare Settings, last updated 6/25/2020, retrieved 8/3/2020 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care-strategies.html included the guidance that long term care facilities ensure all residents wear a cloth face covering for source control whenever they leave their room or are around others, including whenever they leave the facility for essential medical appointments. According to the CDC guidance Key Strategies to Prepare for COVID-19 in Long-term Care Facilities (LTCFs), last updated 6/25/2020, retrieved 8/3/2020 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care-strategies.html Enforce social distancing among residents. Ensure all residents wear a cloth face covering for source control whenever they leave their room or are around others. This approach is recommended because of the high risk of unrecognized infection among residents. Recent experience suggests that a substantial proportion of residents could have COVID-19 without reporting symptoms or before symptoms develop. The facility's COVID-19 Prevention policy, revised 6/26/2020, was received from the DON/IP on 7/30/2020 at 11:05 a.m. Contrary to the CDC guidance above that all residents wear a cloth face covering whenever they leave their room or are around others, the facility policy read the resident was to wear a mask if under droplet precautions and required movement or transport outside of the room, and encouraged residents with signs and symptoms of respiratory illness to wear a mask. The policy further read, COVID-19 is thought to spread mainly from person to person between people who are in close contact with one another (within six feet). 2. Observations and resident interview On 7/28/2020 at 10:53 a.m., Resident #9, who was cognitively intact, was observed with a surgical mask on that appeared brown and dirty. The mask was dated 7/8/2020. He said he had asked for a new mask but was told masks cost money and he could not have a new mask. On 7/28/2020 at 10:55 a.m., three residents sat in a common area in the Wheatfield neighborhood. Two of the residents were seated in wheelchairs with their arms almost touching. The third resident was approximately two feet from the other residents. None of the residents had a mask on. A CNA walked by the area; the CNA neither offered masks to the residents nor asked or assisted the residents to sit further apart. Additionally, there was a resident in the hallway without a mask, and another male resident being assisted to his room by a staff member. The resident was not wearing a mask. On 7/28/2020 at 10:57 a.m., a female resident in a wheelchair propelled herself down the Wheatfield hallway past the nurse at the medication cart. She did not have a mask on and the nurse did not offer her a mask. At the same time, another female resident in a black dress ambulated the opposite direction down the Wheatfield hall, past the nurse. She, too, was not wearing a mask. The nurse did not offer or assist her with a mask. On 7/28/2020 at 11:02 a.m., a resident came out of room [ROOM NUMBER] on the north side of the facility. The resident did not have a mask on. CNA #9 spoke to the resident about lunch but did not offer or assist the resident with a mask. On 7/28/2020 at 11:15 a.m., a male resident in a red shirt propelled himself down the hallway in the North Forty neighborhood, past RN #3. He did not have a mask on. The RN did not encourage or assist him with a mask. Two other residents sat in a common area in this neighborhood. The residents did not have masks on. On 7/28/2020 at 11:32 a.m., a female resident propelled herself in a wheelchair down the hallway in the Bobcat neighborhood. She did not have a mask on. She urinated through her clothing and wheelchair onto the floor. LPN #1 came and wheeled her back to her room. He did not clean up the urine, or place a wet floor sign. A female and a male resident walked through the urine and kept walking toward the north side of the facility. On 7/28/2020 at 11:40 a.m., a male resident was wheeled into the main dining room by a staff person. He was not wearing a mask. Multiple staff were assisting residents to the dining room but none offered or assisted the resident with a mask. On 7/28/2020 at 11:46 a.m., a male resident in a wheelchair propelled himself down the hallway in the Bobcat neighborhood, past the front door. He was not wearing a mask. A CNA greeted him, but did not encourage or assist him with a mask. On 7/28/2020 at 12:47 p.m., a male resident was observed leaving the main dining room without a mask. He was not encouraged by the staff to put on a mask. On 7/28/2020 at 12:57 p.m., two residents, a male and a female, sat close together in wheelchairs in the hall in the North Forty neighborhood. They did not have masks on. Staff members walked by the residents, but did not encourage them to put masks on. On 7/29/2020 at 8:04 a.m., a male resident came out of room [ROOM NUMBER] while the housekeeper was at the room door. The resident left the room without wearing a mask. The housekeeper did not encourage the resident to put on a mask. On 7/29/2020 at 8:10 a.m., a male resident sat in the common area on the south side of the facility. LPN #1 stood at the medication cart within sight of the common area. The resident was not encouraged to wear a mask. On 7/29/2020 at 8:13 a.m., five residents were observed in the north unit common area. The residents neither wore masks nor distanced at least six feet apart. On 7/29/2020 at 8:14 a.m., a male resident ambulated down the Bobcat neighborhood, not wearing a mask. CNA #12 passed the resident in the hallway. She did not encourage the resident to wear a mask. On 7/29/2020 at 8:15 a.m., a resident in a gray sweat suit stood at the front desk without a mask. The staff person at the desk did not encourage the resident to put on a mask. On 7/29/2020 at 8:17 a.m., CNA #11 escorted three residents into the common area from the smoking area on the north side of the facility. The residents did not have masks on and were not encouraged to put masks on. On 7/29/2020 at 8:24 a.m., a male resident in a tan shirt went into an activity area on the south side of the facility. He was not wearing a mask. CNA #12 walked by the resident. She did not encourage the resident to put on a mask. On 7/29/2020 at 8:25 a.m., three male residents sat in the common area on the south side of the facility. The three men were approximately four feet from one another. Two residents were in wheelchairs and one in a regular chair. The three residents did not have masks on. On 7/29/2020 at 8:26 a.m., a male resident in a blue shirt sat in a wheelchair at the nurses' medication cart in the Wheatfield neighborhood. The man spoke to the nurse who was preparing medications. He was not wearing a mask. The nurse did not encourage or offer the resident a mask. On 7/30/2020 at 9:00 a.m., a male resident ambulated down the Shawnee River neighborhood. He did not have a mask on. The NHA walked by the resident. Another male resident in a yellow shirt ambulated the opposite direction without a mask. The NHA did not encourage either resident to wear a mask. 3. Staff interviews On 7/30/2020 at 12:11 p.m., CNA #2 was interviewed. He said the residents all have their own masks. CNA #2 said they do not like to wear them because the ties do not stay tied or the earpieces are too tight. However, he said staff should have encouraged the residents to wear the masks since the facility had a resident test positive for COVID-19 yesterday; he did not know who the resident was or what unit the resident resided was on. The DON/IP and NHA were interviewed on 7/30/2020 at 2:55 p.m. The DON/IP said staff should encourage the residents to wear masks at all times. She said the only residents who should not have a mask on were those residents that could not remove the masks themselves. She further said the staff should have encouraged social distancing of the residents. D. Failure to ensure staff encouraged residents on isolation to stay in their rooms and wear face coverings when out of their rooms. 1. Professional reference and facility policy and procedure According to the CDC, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic (7/15/2020) retrieved 8/3/2020 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC Older adults with COVID-19 may not show common symptoms such as fever or respiratory symptoms. Less common symptoms can include new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell. Additionally, more than two temperatures over 99.0 degrees Fahrenheit might also be a sign of fever in this population. Identification of these symptoms should prompt isolation and further evaluation for COVID-19. HCP (health care providers) who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), gown, gloves, and eye protection. The facility policy for COVID-19 Prevention policy, revised 6/26/2020, was received from the DON/IP on 7/30/2020 at 11:05 a.m. Contrary to CDC guidance, the policy documented in pertinent part, droplet precautions will be implemented for residents with suspected or confirmed COVID-19 for 14 days after the illness onset. Residents with onset of signs and symptoms of a respiratory infection such as fever, cough or sore throat will be encouraged to self-isolate. 2. Observations On 7/28/2020 at 12:02 p.m., Residents #2 and #15, who were both on isolation due to sharing a bathroom with another resident with COVID-19 symptoms, were observed as they ambulated through the halls without a mask on. They were not encouraged to stay in their room or wear a mask. On 7/29/2020 at 8:13 a.m. Resident #2, who was on isolation for possible exposure to COVID-19, was observed smoking in the courtyard with nine other residents in close proximity to one another. 3. Interview The DON/IP and NHA were interviewed on 7/30/2020 at 2:55 p.m. The NHA said, We cannot force them to stay in their room or wear a mask. However, during the observations above, there were no attempts by staff to redirect residents on isolation to their rooms or to encourage use of a facemask. E. Failure to ensure staff assisted residents with hand hygiene prior to meals 1. Professional reference and facility policy and procedure The CDC Interim Infection Prevention and Control (3/13/2020) Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes, retrieved 8/3/2020 from: https://www.cms.gov/files/document/qso-20-14-nh-revised.pdf, reads in pertinent part, Remind residents to practice social distancing and perform frequent hand hygiene. The facility policy on Handwashing Hand Hygiene, revised 8/2019, was received from the DON/IP on 7/30/2020 at 11:05 a.m. The policy read in pertinent part, residents will be encouraged to practice hand hygiene through the use of fact sheets, pamphlets and other written material provided at admission and posted throughout the facility. 2. Observations On 7/28/2020 at 11:37 a.m., five residents were observed in the main dining room and four residents in the Quiet dining room for lunch. The residents were not offered hand hygiene prior to their lunch being served. One male resident was observed eating a slice of bread with his hands. On 7/28/2020 at 11:40 a.m., a male resident was wheeled by staff into the dining room without a mask. He began adjusting his table. No hand hygiene was offered prior to his plate of food being served. On 7/28/2020 at 11:55 a.m., CNA # 11 was pushing a metal cart in the hallway. He took a plate of food into room [ROOM NUMBER]. The resident was not offered or encouraged to wash his or her hands before lunch. On 7/28/2020 at 12:06 p.m., CNA #11 and CNA #1 were observed delivering plates of food from a metal cart to room [ROOM NUMBER]. The CNAs placed the plates in front of the two residents. No hand hygiene was offered or encouraged. On 7/29/2020 at 8:17 a.m., CNA #11 escorted three residents back into the facility from the smoking area. The residents were not encouraged to wear masks or perform hand hygiene. On 7/29/2020 at 12:09 p.m., CNA #12 took two plates into a room and set them down before the residents. Hand hygiene was not offered or encouraged. 3. Resident Interviews On 7/28/2020 at 12:10 p.m., Resident #1, #2 and #4, all alert and oriented, were interviewed. The three residents said the staff never offered or encouraged residents to perform hand hygiene. 4. Staff interviews On 7/30/2020 at 9:31 a.m., CNA #2 was interviewed. He said residents should be offered hand hygiene before meals and after using the bathroom. He said he did not know if hand hygiene was to be offered when the meal was delivered to the resident or prior to the food arriving. The DON/IP and NHA were interviewed on 7/30/2020 at 2:55 p.m. The DON/IP said hand hygiene was always encouraged for the residents. She said the residents participate in a coupon program and get a coupon when they perform hand hygiene. However, no resident hand hygiene was observed to be encouraged or offered to residents on 7/28 and 7/29/2020 (see above). Moreover, no coupons were observed being distributed. The DON/IP said she could not explain why hand hygiene was not being offered before meals and after smoking. She said she was unsure if the staff go around and offer hand hygiene to everyone before the meal or if they offer it immediately before the meal arrives. F. Failure to ensure the facility actively screened staff prior to the start of their shift for signs and symptoms of COVID-19 on the COVID-19 isolation unit. 1. Professional reference and facility policy and procedure The CDC Coronavirus 2019 COVID-19,(6/25/2020) Preparing for COVID-19 in Nursing Homes retrieved 8/3/2020 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, read, in pertinent part, Screen all HCP at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19. The facility's COVID-19 Prevention policy, revised 6/26/2020, was received from the DON/IP on 7/30/2020 at 11:05 a.m. The policy documented in pertinent part, Staff will be monitored for any onset of respiratory illness such as fever of 100 or higher, dry cough, sneezing, nausea, vomiting, body aches, shortness of breath, loss of taste or smell, nasal congestion and sore throat. If any of the following are present, staff wil(TRUNCATED)

Based on observations, interviews, and record review, the facility failed to ensure one of two residents (Resident #1) reviewed for abuse out of 15 sample residents remained free from abuse by staff. On 7/28/2020, social worker (SW#2) stopped Resident #1 in the south unit hallway as the resident attempted to return to her room from the outdoor smoking area. When the resident became upset, a male licensed practical nurse (LPN #1) put his arms up wide, stepping toward the resident and barricading the hallway. Resident #1, care planned to become overwhelmed easily and known to have behavioral issues related to difficulty following directions, pushed her walker away and leaned against the wall, frightened and crying until another staff arrived and walked with the resident, away from hallway. Resident #1, interviewed an hour later, was tearful and shaking as she described the incident with LPN #1. She stated she felt threatened and the LPN frightened her. After notice of Resident #1's fear, the facility failed to take steps to ensure Resident #1 remained free from abuse. The facility failed immediately to suspend LPN #1, contrary to facility policy. The facility failed to conduct a thorough investigation (Cross-reference F610) and therefore, failed to recognize, reinforce and ensure staff followed the resident's care planned interventions designed to de-escalate her behaviors. Further, the facility failed to train LPN #1 to ensure he knew how to react and respond to Resident #1's behaviors (Cross-reference F741). The facility's failures created a situation of serious adverse outcome - resident fear - that required immediate action to prevent reoccurrence. Findings include: I. Immediate Jeopardy A. Findings of immediate jeopardy On 7/28/2020, social worker (SW#2) stopped Resident #1 in the south unit hallway as the resident attempted to return to her room from the outdoor smoking area. When the resident became upset, a male licensed practical nurse (LPN #1) put his arms up wide, stepping toward the resident and barricading the hallway. Resident #1, care planned to become overwhelmed easily and known to have behavioral issues related to difficulty following directions, pushed her walker away and leaned against the wall, frightened and crying until another staff arrived and walked with the resident, away from hallway. Resident #1, interviewed an hour later, was tearful and shaking as she described the incident with LPN #1. She stated she felt threatened and the LPN frightened her. After notice of Resident #1's fear, the facility failed to take steps to ensure Resident #1 remained free from abuse. The facility failed immediately to suspend LPN #1, contrary to facility policy. The facility failed to conduct a thorough investigation (cross-reference F610) and therefore, failed to recognize, reinforce and ensure staff followed the resident's care planned interventions designed to de-escalate her behaviors. Further, the facility failed to train LPN #1 to ensure he knew how to react and respond to Resident #1's behaviors (cross-reference F741). The facility's failures created a situation of serious adverse outcome - resident fear - that required immediate action to prevent reoccurrence. The administrator was notified of the immediate jeopardy situation on 7/29/2020 at 11:29 a.m. B. Plan to abate immediate jeopardy On 7/29/2020 at 4:33 p.m., the director of nursing (DON) submitted a plan to abate the immediate jeopardy. It read: Surveyors with Colorado Health Facilities and Emergency Medical Services Division emailed IJ for F-600, 609, 610, 741. Investigation for abuse was re-opened by Behavioral Case Manager and will be completed by Behavioral Case Manager and then reviewed by Inter Disciplinary Team to ensure compliance. Staff development coordinator went to alleged abuser identified as LPN went and received report for cart from LPN was working and counted narcotics. LPN was suspended pending investigation for psychosocial abuse and was out of the facility premises by 1145. SDC watched LPN leave the building. (Local) Police department was contacted and awaiting call back. (Local) Police department contacted facility and officer (name) stated that due to resident not being physically harmed they would not be coming into the building and have provided a computer aided dispatch (CAD) number. Adult Protective Services and Ombudsman were contacted and occurrence report was filed. Resident was provided mental health services with psychologist via tele-medicine for psychosocial harm. Surveyors were provided with Non-violent crisis intervention foundation course participant workbook that LPN was certified of which provides education on how to de-escalate situations. LPN identified will be in serviced one on one and provided written material on different mental health disorders such as [MEDICAL CONDITIONS], depression, anxiety, and behavioral disturbances upon returning to work. Every resident has the potential for abuse. Staff will begin getting in serviced on July 29, 2020 on abuse and neglect. Educated on reporting abuse. Each staff will be in serviced before their shift. Quarterly abuse and neglect training will be performed All residents who are Alert and Oriented x4 will be interviewed by Behavioral Case Manager to determine if they have experienced any psychosocial abuse. If any issues arise a full investigation will be completed. Interviews will be completed by August 7, 2020. Any reports of abuse will be reviewed each morning Monday - Friday by Inter Disciplinary Team to ensure resident safety and that investigation was thorough and will be reviewed in QAPI monthly. Systemic change includes sending any staff member that has been reported by a resident of any type of abuse including psychosocial will be suspended pending investigation. C. Removal of the immediate jeopardy On 7/29/2020 at 4:42 p.m. the NHA was notified the facility's plan to remove the immediate jeopardy had been accepted based on systemic changes, including to suspend any staff member under investigation for abuse and education for abuse, neglect. However, deficient practice remained at a G level, actual harm. II. Incident 7/28/2020 A. Staff interviews Interviews with LPN #1 on 7/9/2020 at 9:18 a.m. and SW #2 on 8/3/2020 at 9:30 a.m. revealed on 7/28/2020 at approximately 11:30 a.m., SW #2 stopped Resident #1 in the south unit hallway as the resident attempted to return to her room. Staff said Resident #1 did not understand why the SW told her not to walk through the south unit hallway and became upset. LPN #1 then said Resident #1 could walk through the hallway but SW #2 disagreed. Thereafter, LPN #1 put his arms up wide and barricaded the hallway to prevent the resident from walking down the hall. This made Resident #1 more upset, and she pushed her walker away and leaned against the wall, crying. The maintenance director (MTD) responded to staff's call for support and walked with the Resident #1 away from the situation. Interview with the MTD on 7/29/2020 at 8:55 a.m. revealed he was the last one to arrive at the incident on 7/28/2020. He said when he arrived, Resident #1 was leaning against the wall, crying and frightened. He said there were multiple staff members surrounding her and forming a barricade to prevent her from walking through the hallway. He said when he asked staff which way the resident was supposed to go, staff members in the area pointed different directions down the hall. He said noticing how upset Resident #1 was, he walked with her one on one away from the situation to allow her to calm down. B. Resident interview Resident #1, age above 50, admitted to the facility on [DATE]. According to the August 2020 computerized physician orders [REDACTED]. The 7/17/2020 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment. Active [DIAGNOSES REDACTED]. She received antidepressant and hypnotic medications for seven days prior to the assessment. She used a walker for mobility. Resident #1 was interviewed on 7/28/2020 at 12:37 p.m., approximately an hour after the incident in the south unit hallway. Resident #1 was crying and shaking as she approached the surveyor. She said she feared a male nurse (LPN #1) who had barricaded her as she tried to walk down the south unit hall. She said she regularly walks down this hallway after smoking. She said multiple staff members pointed different directions for her to walk and she became overwhelmed and confused, stating she always walked in that unit so she did not understand why it was not okay to enter the south unit hall. She said she continued to try to walk towards her room when LPN #1 put his arms up wide, stepped towards her, barricaded the hallway and refused to allow her to walk through. She said when the LPN put his arms up to barricade the hallway and stepped towards her, she felt threatened and fearful because of her history of abuse. She further said she felt she was singled out. C. Observations and other resident interview Resident #4, a cognitively intact resident, interviewed on 7/30/2020 at 2:34 p.m., said he had never felt threatened by LPN #1 but said Resident #1 was very shaken and scared after the incident on 7/28/2020 occurred. He said he talked to her outside after the incident and she cried while telling him what happened. He said he frequently saw residents walking on a unit they did not reside on, and he, too, said Resident #1 was singled out for something that many residents do. Observations on 7/28, 7/29 and 7/30/2020 confirmed many residents walked off the unit they resided on and onto another unit. III. Facility failures A. Failure to implement facility abuse policies and procedures 1. Facility abuse policies and procedures The Abuse Investigation and Reporting policy, revised March 2019, was provided by the director of nursing (DON) on 7/30/2020 at 10:52 a.m. It read, in pertinent part, Role of the administrator and/or director of nursing: If an incident or suspected incident of resident abuse, mistreatment, or neglect is reported . suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. The Protection of Residents During Abuse Investigations policy, revised March 2019, was provided by the DON on 7/30/2020 at 10:52 a.m. It read, in pertinent part, Employees accused of participating in the alleged abuse will be immediately suspended until the findings of the investigation have been reviewed by the administrator. The Abuse Prevention Program policy, revised March 2019, was provided by the DON on 7/30/2020 at 10:52 a.m. It read, in pertinent part, As part of the resident abuse preventions, the administration will: Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbal or physically aggressive resident behavior; identify and assess all possible incidents of abuse; and protect residents during abuse investigations. 2. Failure to implement the above policy and procedures. The surveyor notified the NHA on 7/28/2020 at approximately 1:00 p.m. that Resident #1 was fearful of LPN #1. On 7/29/2020 at 8:15 a.m., the NHA provided an investigation of the 7/28/2020 incident. Review of the investigation summary revealed it included no steps to ensure Resident #1 remained free from abuse by LPN #1; specifically, contrary to facility policy and procedures, LPN #1 was not immediately suspended; he finished his shift on 7/28/2020 and was observed working the floor with residents on 7/29/2020 at 11:14 a.m. 3. The NHA and DON were interviewed on 7/29/2020 at approximately 3:50 p.m. They said LPN #1 was not working with Resident #1 so they did not know he needed to be removed from providing resident care. B. Failure to conduct a thorough investigation (cross-reference F610) and therefore, failure to recognize, reinforce and ensure staff followed the resident's care planned interventions designed to de-escalate her behaviors. 1. Review of Resident #1's record revealed she was care planned for argumentative behaviors, issues related to difficulty following redirection, and impaired cognitive function/impaired thought processes due to dementia related to her diagnoses. -Regarding her argumentative behaviors, interventions included to advise the resident to calm down and to walk away. -Regarding her difficulty following redirection, the care plan read the resident decided when she was feeling overwhelmed, she would like staff to advise and allow her to take a time out. All staff were to redirect the resident to the social worker (SW #1) to address her concerns. -Regarding her impaired cognitive function/impaired thought processes which led to moments of confusion, impulsivity, and failure to listen fully to what was being said to her, staff were to keep the resident's routine consistent and present just one thought, idea, question, or command at a time. 2. Review of investigation provided by the NHA on 7/29/2020 at 8:15 a.m. revealed the investigation identified the resident's pertinent [DIAGNOSES REDACTED]. The investigation consisted of statements from Resident #1, LPN #1, the MTD, and DON. It also included other resident interviews, a behavior progress note by SW #2, past behavior notes, smoking policies, and Resident #1's care plan. However, the investigation and summary revealed it failed to recognize, reinforce and ensure staff followed the resident's care planned interventions designed to de-escalate her behaviors to prevent another incident, such as that on 7/28/2020 when the resident was surrounded by multiple staff, given confusing directions, and was barred from progressing down the hallway by LPN #1's barricade. These circumstances left the resident feeling overwhelmed, confused and frightened. Instead, the report summary written by the behavioral care manager (BCM) read the facility identified Resident #1's behavior as attention seeking and equated the incident with past behavior tendencies. It identified the resident had some moderate cognitive impairments, but knew she was not supposed to use the south unit entrance (which the resident denied). The summary further read in part, This incident fits the pattern of behavior displayed since her admission to the facility. Further review of the investigation report revealed the report failed to identify all of the staff in the area where the incident occurred. Therefore, these staff failed to receive education on Resident #1's care plan and how to respond to Resident #1 when she was confused and/or overwhelmed. C. Failure to train LPN #1 to ensure he knew how to react and respond to Resident #1's behaviors. 1. Facility characteristics and services The facility assessment, provided by the NHA on 7/29/2020 at 9:30 a.m., revealed the facility served residents with the following list of psychiatric/mood disorders [DIAGNOSES REDACTED]. The assessment revealed an average of 64 residents had behavioral health needs in the facility. The assessment further revealed the facility offered mental health and behavior services based on resident needs. The assessment read, this included managing medical conditions and medication related issues causing psychiatric symptoms and behavior, identifying and implementing interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, traumas/[MEDICAL CONDITION] (post-traumatic stress disorder), other psychiatric diagnoses, intellectual or developmental disabilities. The assessment revealed the following person centered/direct care for psycho/social/spiritual support: Build a relationship with the resident/get to know him/her; engage the resident in conversation. Find out what the resident's preferences and routines are; what makes a good day for the resident; what upsets him/her and incorporate this information into the care planning process. Make sure staff caring for the resident have this information. Record and discuss treatment and care preferences. Prevent abuse and neglect. Identify hazards and risks for residents. 2. LPN #1 1. Review of in service training records and LPN #1's file revealed LPN #1 had a history of [REDACTED]. In service training records revealed LPN #1's most recent abuse training, related to abuse policies and procedures, was 12/18/2019. However, review of LPN #1's performance review dated 4/17/2020 revealed a performance improvement plan, designed by the DON and assistant director of nursing (ADON). The evaluation revealed the LPN failed to follow abuse policies and procedures and needed to improve on knowledge of abuse policies and procedures or seek unknown information. It further revealed he missed mandatory meetings and in-service training. The performance improvement plan was in effect for three months and signed by LPN #1 on 4/27/2020. LPN #1's file also revealed LPN #1 received a write up on 5/13/2020 for failing to complete required online training on time. Review of LPN #1's training log revealed he had not received training on major mental illness and behavioral health since his hire as an LPN in November 2019. 2. Staff interviews confirmed the deficiencies found in LPN #1's file In an interview on 7/29/2020 at 10:05 a.m., the DON confirmed LPN #1 had been written up for not following the abuse policy and procedures related to completing an incident report on a previous incident in the facility. In an interview on 7/29/2020 at 10:30 a.m. the assistant director of nursing (ADON) said LPN #1 was hired in November 2019. She confirmed that since his hire, LPN #1 had not received any training on major mental illnesses and behavioral health. There had been one mental health training since his hire, but he did not attend. She said LPN #1 completed training for dealing with combative persons; however, this training did not cover care and working with individuals with behavioral needs.

Based on record review and interviews, the facility failed to ensure staff received the appropriate competency and skills training to ensure residents with mental and psychosocial disorders maintained the highest practicable physical, mental, and psychosocial well-being, affecting one resident (#1) reviewed for mental and psychosocial disorders. Specifically, the facility failed to ensure licensed practical nurse (LPN) #1 received training on the mental and psychosocial disorders and care needs of residents admitted to the facility and identified in the facility assessment, prior to providing direct resident care. LPN #1's lack of behavioral health training was displayed in an inappropriate response to Resident #1's behaviors which contributed to Resident #1, crying and shaking, and feeling threatened and fearful of LPN #1. (Cross-reference F600) Findings include: I. Facility characteristics and services The facility assessment, provided by the nursing home administrator (NHA) on 7/29/2020 at 9:30 a.m., revealed the facility served residents with the following list of psychiatric/mood disorder [DIAGNOSES REDACTED]. The assessment revealed an average of 64 residents had behavioral health needs in the facility. The assessment further read the facility offered mental health and behavior services based on resident needs. It read this included managing medical conditions and medication related issues causing psychiatric symptoms and behavior, identifying and implementing interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, traumas/[MEDICAL CONDITION], other psychiatric diagnoses, intellectual or developmental disabilities. The assessment revealed the following person-centered/direct care for psycho/social/spiritual support: Build a relationship with the resident/get to know him/her; engage the resident in conversation. Find out what the resident's preferences and routines are; what makes a good day for the resident; what upsets him/her and incorporate this information into the care planning process. Make sure staff caring for the resident have this information. Record and discuss treatment and care preferences. Prevent abuse and neglect. Identify hazards and risks for residents. Centers of Medicare and Medicaid Services (CMS) form number CMS-672 Census and Condition form which categorizes the care that residents require while in the facility was provided by the NHA on 7/28/2020 at 11:00 a.m. The form documented there were 41 residents with behavioral healthcare needs, 44 residents with documented signs and symptoms of depression, 41 with a documented psychiatric diagnosis (excluded dementias and depression), and 31 receiving health rehabilitative services for mental illness and or intellectual disability. II. Resident #1 A. Resident status Resident #1, age above 50, admitted to the facility on [DATE]. According to the August 2020 computerized physician orders [REDACTED]. The 7/17/2020 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment. Active [DIAGNOSES REDACTED]. She received antidepressant and hypnotic medications for seven days prior to the assessment. She used a walker for mobility. B. Resident #1's care and service needs Resident #1's person-centered care plan, revised 7/28/2020, revealed the resident had argumentative behaviors and can be verbally aggressive towards staff and other residents. The care planned interventions read: -If resident becomes aggressive, advise resident when she calms down, you will assist her; -If resident continues to be aggressive, walk away and advise resident's nurse and case manager; -Allow resident time to express her feelings, thoughts, or concerns; and -Speak slowly to the resident. Additionally, the care plan read the resident had behavioral issues related to difficulty following redirection at times. It revealed she had been working with her therapist on this topic and she decided when she was feeling overwhelmed, she would like staff to advise and allow her to take a time out. The term time out was identified by Resident #1 to help her when she was overwhelmed. Interventions included: -Assist the resident to develop more appropriate methods of coping and interacting. Talk with the resident about her concern and options that might help solve the situation. Encourage the resident to express feelings appropriately; -Be specific with expectations, set boundaries, and it's ok to walk away when the resident creates a scene; and -Have one person designated as the go-to person, which it will be her social worker. All staff will redirect this resident to the social worker to address the resident's concerns. Further, the care plan revealed the resident had impaired cognitive function or impaired thought processes due to Wernicke's Korsakof's dementia. The resident had moments of confusion, she was impulsive, and did not listen fully to what was being said to her. She had repetitive anxious concerns. Interventions included: -Keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion; and -Present just one thought, idea, question, or command at a time. III. Incident 7/28/2020 (Cross-reference F600) Review of an incident on 7/28/2020 revealed staff, including LPN #1, failed to respond to Resident #1's behaviors in an appropriate manner and as set forth in her person-centered care plan. A. Staff interviews Interviews with LPN #1 on 7/9/2020 at 9:18 a.m. and social worker (SW) #2 on 8/3/2020 at 9:30 a.m. revealed on 7/28/2020 at approximately 11:30 a.m., SW #2 stopped Resident #1 in the south unit hallway as the resident attempted to return to her room. Staff said Resident #1 did not understand why the SW told her not to walk through the south unit hallway and became upset. LPN #1 then said Resident #1 could walk through the hallway but SW #2 disagreed. Thereafter, LPN #1 put his arms up wide and barricaded the hallway to prevent the resident from walking down the hall. This made Resident #1 more upset, and she pushed her walker away and leaned against the wall, crying. The maintenance director (MTD) responded to staff's call for support and walked with the Resident #1 away from the situation. Interview with the MTD on 7/29/2020 at 8:55 a.m. revealed he was the last one to arrive at the incident on 7/28/2020. He said when he arrived, Resident #1 was leaning against the wall, crying and frightened. He said there were multiple staff members surrounding her and forming a barricade to prevent her from walking through the hallway. He said when he asked staff which way the resident was supposed to go, staff members in the area pointed different directions down the hall. He said noticing how upset Resident #1 was, he walked with her one on one away from the situation to allow her to calm down. B. Resident interview Resident #1 was interviewed on 7/28/2020 at 12:37 p.m., approximately an hour after the incident in the south unit hallway. Resident #1 was crying and shaking as she approached the surveyor. She said she feared a male nurse (LPN #1) who had barricaded her as she tried to walk down the south unit hall. She said she regularly walks down this hallway after smoking. She said multiple staff members pointed different directions for her to walk and she became overwhelmed and confused, stating she always walked in that unit so she did not understand why it was not okay to enter the south unit hall. She said she continued to try to walk towards her room when LPN #1 put his arms up wide, stepped towards her, barricaded the hallway and refused to allow her to walk through. She said when the LPN put his arms up to barricade the hallway and stepped towards her, she felt threatened and fearful because of her history of abuse. IV. Failure to train LPN #1 to ensure he knew how to react and respond to Resident #1's behaviors. Review of LPN #1's training log revealed he had not received training on major mental illness and behavioral health since his hire as a LPN in November 2019. It further revealed he missed mandatory meetings and in-service training. A performance improvement plan was in effect for three months and signed by LPN #1 on 4/27/2020. LPN #1's file also revealed LPN #1 received a write up on 5/13/2020 for failing to complete required online training on time. In an interview on 7/29/2020 at 10:30 a.m. the assistant director of nursing (ADON) said LPN #1 was hired in November 2019. She confirmed that since his hire, LPN #1 had not received any training on major mental illnesses and behavioral health. There had been one mental health training since his hire, but he did not attend. She said LPN #1 completed training for dealing with combative persons; however, this training did not cover care and working with individuals with behavioral needs. She said the facility did not require behavioral health training for nursing staff prior to their working with residents.

Based on observations, record review, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This failure affected four residents (including #82) using a shared blood glucose meters on one of three medication carts; one resident (#55) using oxygen tubing; and 12 residents receiving vital signs monitoring out of 29 sample residents. BLOOD GLUCOSE METER The facility had eight blood glucose meters, which were shared among 17 residents who required routine blood sugar checks. The facility's policy and procedure for cleaning and sanitizing the blood glucose meters in between residents' use was not consistent with the manufacturer's instructions. Specifically, observations and interviews revealed the nursing staff lacked knowledge, training, and equipment to manage the residents' routine and emergency blood glucose monitoring needs. The facility's failure to monitor the blood glucose meters according to standard practice, coupled with the staff's lack of knowledge to ensure blood glucose meters were cleaned, sanitized, and stored properly in between each residents' use created the situation for serious harm likely to occur at a level of immediate jeopardy if the blood glucose meters continued to be shared among residents due to potential transmission of blood-borne pathogens. OXYGEN The facility further failed to ensure respiratory equipment was stored in a sanitary manner for one (#55) of one resident reviewed for oxygen out of 29 sample residents. NON-CRITICAL EQUIPMENT The facility further failed to ensure infection control practices were properly followed with the use of non-critical care equipment (blood pressure cuff) in between residents and proper hand hygiene was performed before and after direct care with residents when taking their blood pressure. Findings include: I. Immediate Jeopardy A. Findings of Immediate Jeopardy Resident #82 was admitted to the facility on [DATE]. Record review revealed computerized physician orders [REDACTED]. On 6/5/19 at 9:59 a.m., the acting director of nursing (DON) prepared to administer the [MEDICATION NAME]to the resident by first obtaining a blood glucose level. She entered the room with the supplies which included a basket containing the blood glucose meter, alcohol swabs, small gauzes, and a single finger stick lancet. After washing her hands, she placed the storage bin containing the supplies on top of the resident's made bed. She donned clean gloves and prepared the residents' right ring finger by wiping it with an alcohol pad. She then placed a strip into the blood glucose meter, pricked the finger using the lancet to obtain blood, used a gauze to wipe off the first drop of blood, then the remaining blood was placed on a strip that was attached to the blood glucose meter. The blood glucose result was 349 (high). She then removed the strip from the blood glucose meter. While still gloved, the DON went into the hallway with the supplies in hand, and headed to the medication cart. She then placed the used glucose strip and lancet inside the sharps container, placed the used gauze in the trash, placed the blood glucose meter and storage bin on top of the medication cart, and took off the used gloves. She donned clean gloves, unlocked the medication cart and began looking inside the drawers. She asked licensed practical nurse (LPN) #2, who was working on a nearby medication cart, for Clorox wipes and he handed the container to her. She removed two Clorox wipes from the container and proceeded to wipe the bottom of the storage bin that contained the lancets, alcohol swabs, and gauze, for less than one minute. All surfaces of the storage bin were not thoroughly wetted during the cleaning process. After wiping the bin, she placed it on top of the medication cart. She wiped off the blood glucose meter with a Clorox wipe for less than one minute and placed the meter back inside the bin. All surfaces of the blood glucose meter were not thoroughly wetted during the cleaning process. She did not clean the inside of the bin. She took the storage bin and placed it in the top drawer of the cart and removed the gloves. On 6/5/19 at 10:06 a.m., the DON was interviewed. She was asked if there was a specific dwell time the Clorox bleach wipes should be used to clean the blood glucose meter. The DON stated, What is that? The DON was provided with an explanation that the blood glucose meter should remain wet with the bleach wipes for a specific period of time. The DON was unaware the meter needed to stay wet for one minute to be effective to [MEDICAL CONDITION] and opened up the drawer of the medication cart where the meter had been stored and pointed out that it is drying. This interaction was less than one minute from the time she cleaned it and the blood glucose meter did not remain wet for one full minute. The DON did not clean and sanitize the blood glucose meter according to the Clorox bleach wipes manufacturer's instructions. She did not ensure a contact time of one minute, as was recommended, or allow all of the surfaces to remain wet to disinfect the device. Licensed practical nurse (LPN) #1 was interviewed on 6/5/19 at 12:10 p.m. She was working on the [NAME]nee Hall medication cart and said there were two blood glucose meters on the cart that were shared among four residents who received blood glucose checks. She described her process for cleaning the blood glucose meter in between each resident use was to clean it with Clorox bleach wipes for two minutes, then wrap it in another wipe and let it sit in its storage bin. She confirmed she brought the storage bin that contained the blood glucose supplies into each resident's room instead of just the individualized supplies needed, and her sanitizing process did not include cleaning the bin that contained the blood glucose supplies. Registered nurse (RN) #1 was interviewed on 6/5/19 at 12:14 p.m. She was working on the North Forty Hall medication cart and said there were two blood glucose meters on the cart that were shared among four residents who received blood glucose checks. She described her process for cleaning the blood glucose meter in between each resident use by cleaning it with Clorox bleach wipes for two minutes and then placing it back in the basket that contained the blood glucose supplies. She confirmed she takes the whole kit into resident rooms, and she said she did not know when the kit itself was cleaned, and said she did not clean it. By placing the sanitized blood glucose machine back in the unsanitized storage bin, the meter would become re-contaminated. B. Facility notice of Immediate Jeopardy On 6/5/19 at 2:11 p.m., the nursing home administrator (NHA) was notified of Immediate Jeopardy under F880, infection prevention and control. C. Facility plan to remove Immediate Jeopardy On 6/5/19 at 5:47 p.m., the NHA provided the following plan to remove the Immediate Jeopardy. The plan read: Correction plan to start on (MONTH) 5, 2019. -On 6/5/19, the policy and procedure for obtaining a fingerstick glucose level and disinfecting blood glucose meters have been updated to state: 1. blood glucose meters are assigned to individual residents, cleaned and disinfected between use. Single-resident use fingerstick devices should never be used by more than one resident. blood glucose meters will be labeled with the resident's name and their storage container (plastic or bag) will be labeled with the resident's name. 2. Place blood glucose meter, disposable lancet, alcohol wipes, and gauze wipes that are to be used one time only in a disposable bag. 3. Disinfect the resident's blood glucose meter per manufacturer's instructions with bleach wipes per manufacturer instructions after use by wiping down blood glucose meter with the bleach wipes then wrapping the bleach wipe around the blood glucose meter and setting it inside a disposable cup. Let it rest for three minutes, remove bleach wipe, place blood glucose meter in another disposable cup and allow to dry, then place blood glucose meter back in container. -On (MONTH) 5, 2019, facility staff went to (local store) and purchased blood glucose meters at 3:35 p.m. to ensure that any resident with an order for [REDACTED]. -On (MONTH) 5, 2019, any new admit or any resident that received an order for [REDACTED]. -All nurses currently working will be in-serviced by assistant director of nurses (ADON) immediately on how to obtain a fingerstick glucose level and disinfect the blood glucose meter following facility's policy and procedure. -All oncoming nurses will be in-serviced by ADON starting 6/5/19, prior to coming onto the floor, about proper use of blood glucose meters according to manufacturer instructions. The nurse will demonstrate how to obtain a fingerstick glucose level and disinfect blood glucose meters following the facility's policy and procedure. -DON and ADON will continue to ensure compliance with obtaining a fingerstick glucose level and disinfecting blood glucose meters by performing two to three random audits on how to obtain a fingerstick glucose level and disinfect blood glucose meters following facility's policy and procedure daily, starting on 6/6/19, for two weeks, then weekly for two months, and monthly for three months. D. Removal of Immediate Jeopardy The facility's plan to remove Immediate Jeopardy was accepted and the Immediate Jeopardy was lifted on 6/5/19 at 6:01 p.m. Record review and observations revealed the facility had implemented their new policy and procedure for Obtaining a Fingerstick Glucose Level and Disinfecting blood glucose Meters. They purchased new blood glucose meters, labeled them with each resident's name, stored them in their own containers labeled with each resident's name, and educated the nursing staff on the proper cleaning and storage of the meters. However, deficient practice remained at an D level, isolated with the potential for more than minimal harm. II. Failure to ensure blood glucose meters were cleaned, stored, and sanitized in a manner consistent with standards of practice A. Blood glucose meters care and facility expectations 1. Professional standards According to the Centers for Disease Control and Prevention (CDC) Injection Safety, Infection Prevention during Blood Glucose Monitoring and Insulin Administration, retrieved from https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html (6/2019): The CDC has become increasingly concerned about the risks for transmitting [MEDICAL CONDITION] virus (HBV) and other infectious diseases during assisted blood glucose monitoring and insulin administration. CDC is alerting all persons who assist others with blood glucose monitoring and/or insulin administration of the following infection control requirements: Fingerstick devices should never be used for more than one person.Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. According to the CDC Infection Prevention during Blood Glucose Monitoring and Insulin Administration, obtained from https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html#anchor_ on 6/20/19, Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions to prevent carry-over of blood and infectious agents. 2. Facility policy and procedure The Policy and Procedure for Cleaning Blood Sugar Glucometers and the Correct Way to Obtain a Blood Sugar, undated, was provided by the staff development coordinator (SDC) on 6/5/19 at 12:08 p.m. It read in part, performing a blood sugar will be done in the safest, sanitary, and antiseptic way possible to avoid the risk of infection and to get the most accurate results. Each medication cart would have two glucometers to allow for required sanitization time. After obtaining a blood sugar, wipe the glucometer off with the bleach wipes, put the sanitized glucometer into the clean plastic container in each cart and allow sanitizing for at least two minutes, and rotate the two glucometers between residents. 3. Manufacturer's instructions for Assure Platinum blood glucose meters According to the Assure Platinum QAQC Manual Blood Glucose Testing, last updated 12/2014, retrieved from http://www.arkrayusa.com/diabetes-management/sites/arkrayusa.com.diabetes-management/files/AssurePlatinum_QAQCManual_6368-04.pdf on 6/18/19, To reduce the change of infection, before performing a blood glucose test, observe the following safety precautions: All components that come into contact with blood samples should be considered to be biohazards capable of transmitting [MEDICAL CONDITION] diseases between patients and healthcare professionals. Additionally, the instructions documented the meter should be cleaned and disinfected after use on each patient. Cleaning and disinfecting of blood glucose meters is a high priority because blood glucose meters are at high risk of becoming contaminated with bloodborne pathogens such as [MEDICAL CONDITION] Virus (HBV), [MEDICAL CONDITION] Virus (HCV) and Human Immunodeficiency Virus ,[MEDICAL CONDITION]. Transmission of [MEDICAL CONDITION] from resident to resident has been documented due to contaminated blood glucose devices. According to the Centers for Disease Control and Prevention, cleaning and disinfecting of meters between resident use can prevent the transmission of [MEDICAL CONDITION] through indirect contact. The manufacturer's instruction book, dated 1/2017, was provided by the ADON on 6/5/19. It included the cleaning and disinfecting guidelines and provided the following recommendations: -Cleaning and disinfecting can be completed by using a commercially available environmental protection agency (EPA) registered disinfectant detergent or germicide wipe. -To use a wipe, remove from container and follow product label instructions to disinfect the meter. -If blood is visibly present on the meter, two wipes must be used; use one wipe to clean and a second wipe to disinfect. With all recommended meter cleaning and disinfecting methods, it is critical that the meter be completely dry before testing a resident's glucose level. Please follow the disinfectant product label instructions to ensure proper drying time. 4. Manufacturer's instructions for Clorox Healthcare Bleach Germicidal Wipes (EPA-registered) According to the Clorox Healthcare Bleach Germicidal Disinfectants Usage and Efficacy, dated 2019, retrieved from https://www.cloroxpro.com/products/clorox-healthcare/bleach-germicidal-disinfectants/ on 6/18/19, the wipes were used for medical equipment cleaning such as blood glucose monitors. The kill time efficacy for [MEDICAL CONDITION] virus (HAV), [MEDICAL CONDITION] virus (HBV), and [MEDICAL CONDITION] virus (HCV) was one minute. According to the manufacturer instructions for Clorox Healthcare Germicidal Wipes, obtained from https://www.cloroxpro.com/wp-content/uploads/2018/09/Clorox-HC-Bleach-Grm-Wipes-tech-info-NI- .pdf include special instructions to clean and decontaminate [MEDICAL CONDITION](human immunodeficiency virus), HBV, and HCV. Contact time instructions [MEDICAL CONDITION].HBV, HCV decontamination read, Allow surfaces to remain wet for one minute, let air dry. B. Resident #82 1. Resident status Resident #82, under the age of 65, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 5/17/18 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required limited assistance with bed mobility, transfers, and personal hygiene, and extensive assistance with dressing and toilet use. She had an active [DIAGNOSES REDACTED]. 2. Record review The care plan, initiated 1/7/19 and revised 9/17/19, identified diabetes mellitus with interventions to administer diabetes medications as ordered and to discuss meal times, portion sizes, dietary restrictions and compliance with nutritional regimen. The computerized physician orders [REDACTED]. Finger stick blood glucose monitoring four times per day. If blood sugar is less than 70, follow the policy and procedure for [DIAGNOSES REDACTED] and notify the physician. The order was started on 5/30/19. 3. Observations The DON was observed preparing and administering medications to Resident #82 on 6/5/19 at 9:59 a.m. The order was for [MEDICATION NAME] 30 units SQ with meals. Check fingerstick blood glucose four times per day and hold if blood sugar less than 70. The order was written on 5/30/19. The DON prepared to administer the [MEDICATION NAME]by first obtaining a blood glucose level. She entered the resident's room with the supplies, which included a storage bin containing the blood glucose meter, alcohol swabs, and a single finger stick lancet. After washing her hands, she placed the basket containing the supplies on top of the resident's made bed. She donned clean gloves and prepared the resident's right ring finger by wiping it with an alcohol pad. She then placed a strip into the glucose meter, pricked the finger using the lancet to obtain blood, used a gauze to wipe off the first drop of blood, then the remaining blood was then placed on a strip that was attached to the blood glucose meter. The blood glucose result was 349 (high). She then removed the strip from the glucose meter. While still gloved, she went into the hallway with the supplies in hand and headed to the medication cart. She placed the used glucose strip and lancet inside the sharps container, placed the used gauze in the trash, and set the glucose meter and storage bin on top of the medication cart. She removed her gloves and donned a clean pair, unlocked the medication cart and began looking inside the drawers. She asked licensed practical nurse (LPN) #2, who was working on a nearby medication cart, for Clorox wipes and he handed the container to her. She removed two Clorox wipes from the container and wiped the bottom of the storage bin that contained the lancets, alcohol swabs, and gauze for less than one minute. After wiping the bottom outer portion of the bin, she placed it back on top of the medication cart. She wiped off the glucose meter with a Clorox wipe for less than one minute and placed the meter back inside the storage bin. She took the basket and placed it in the top drawer of the cart and then removed her gloves. The DON did not clean and sanitize the blood glucose meter according to the Clorox bleach wipes manufacturer's instructions. She did not ensure a contact time of one minute and allow the surface to remain wet to disinfect the device and ensure blood borne pathogens were killed. 4. Staff interviews On 6/5/19 at 10:06 a.m., the DON was interviewed. She was asked if there was a specific dwell time the Clorox bleach wipes should be used to clean the blood glucose meter. The DON stated, What is that? The DON was provided with an explanation that the blood glucose meter should remain wet with the bleach wipes for a specific period of time. The DON was unaware the meter needed to stay wet for one minute to be effective to [MEDICAL CONDITION] and opened up the drawer of the medication cart where the meter had been stored and pointed out that it is drying. This interaction was less than one minute from the time she cleaned it and the blood glucose meter did not remain wet for one full minute. The ADON was interviewed on 6/6/19 at 12:45 p.m. She said the process had been changed (after being informed of the deficient practice that met the level of Immediate Jeopardy) and now every resident had their own glucometer. She said the supplies would be placed inside a plastic bag for a one-time use for one resident at a time. She said the glucose meter would be cleaned with a Clorox wipe after use for three minutes and then wrapped in a single clean Clorox wipe, letting it sit and dry prior to placing it back in the original container. III. Respiratory equipment stored in an unsanitary manner The facility failed to ensure respiratory equipment was stored in a sanitary manner for one (#55) of one resident reviewed for oxygen out of 29 sample residents. A. Facility policy The Cleaning and Disinfection of Resident Care Items and Equipment policy, dated 2001 and revised 10/2018, reads in part, semi-critical items consist of items that may come in contact with mucous membrane such as respiratory equipment. Such devices should be free from all microorganisms. Single resident use items would be cleaned and disinfected between uses by a single resident and disposed of afterwards. Reusable items are cleaned and disinfected or sterilized. B. Observations -On 6/3/19 at 12:50 p.m., a portable oxygen tank was hanging from the handle of a front wheel walker in Resident #55's room. The nasal prongs were hanging from the handles of the front wheel walker and the nasal cannula was not bagged. -On 6/4/19 at 8:56 a.m., oxygen tubing was observed in Resident #55's room and was connected to the oxygen concentrator. The oxygen tubing was lying across the resident's bed with the nasal prongs touching the bed linens and was not bagged. -On 6/5/19 at 8:24 a.m., oxygen tubing was connected to the concentrator in resident #55's room and the tubing was lying on the bed with the prongs touching the bed linens. -On 6/5/19 at 9:24 a.m., a portable oxygen tank in Resident #55's room was attached to the wheelchair with oxygen tubing lying on the seat. The nasal prongs were not bagged and were directly touching the seat of the wheelchair. -On 6/6/19 at 9:28 a.m., oxygen tubing was observed connected to the oxygen concentrator in Resident #55's room. The nasal prongs were not bagged and were lying across the resident's bed with the prongs touching the bed linens. C. Staff interviews Certified nurse aide (CNA) #5 was interviewed on 6/6/19 at 1:11 p.m. She said she was taught to ensure the oxygen was placed in the resident's nose and when it was not in use, the tubing should be stored inside the bag. Registered nurse (RN) #3 was interviewed on 6/6/19 at 1:03 p.m. She said she would check the oxygen tubing for residents, and if not in use, she would place the tubing inside a bag to ensure it was stored in a sanitary manner. The ADON was interviewed on 6/6/19 at 12:48 p.m. She said when the oxygen tubing was not in use, it should be stored inside the oxygen storage bag. She said the bags were located in the utility room and the nurses were responsible for changing the tubing. IV. Non-critical care equipment and hand hygiene A. Professional reference According to the Centers for Disease Control and Prevention (2018) Disinfection of Healthcare Equipment, retrieved from https://www,cdc.gov/infectioncontrol/guidelines/disinfection/healthcare-equipment.html, on 6/11/19, medical equipment surfaces (e.g.blood pressure cuffs, stethoscopes, [MEDICAL TREATMENT] machines and X ray machines) can become contaminated with infectious agents and contribute to the spread of hospital-associated infections. For this reason, noncritical medical equipment surfaces should be disinfected with an EPA-registered low or intermediate level disinfectant. Use of a disinfectant will provide antimicrobial activity that was likely to be achieved with minimal additional cost or work. Hand Hygiene Basics http://www.cdc.gov/handhygiene/Basics.html(3/29/17), on 6/11/19, reads .Healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patients including: before patient contact; after contact with blood, bodily fluids, or contaminated inanimate objects. When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use towel to turn off the faucet. Avoid using hot water, to prevent drying of skin. Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds. Either time was acceptable. The focus should be on cleaning your hands at the right times . B. Facility policy and procedure The Cleaning and Disinfection of Resident-Care items and Equipment policy was received on 6/6/19 at 4:05 p.m. It read in pertinent part that resident-care equipment, including reusable items and durable medical equipment would be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. Non-critical items are those that come in contact with intact skin but not mucous membranes. Non-critical resident-care items include bedpans, blood pressure cuffs, crutches and computers. Most non-critical reusable items can be decontaminated where they are used (as opposed to being transported to a central processing location). The Handwashing/Hand Hygiene policy was received on 6/6/19 at 4:05 p.m. It read in pertinent part, The facility considers hand hygiene the primary means to prevent the spread of infection. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personal shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents and visitors. Use an alcohol-based rub containing at least 62% alcohol: or, alternatively , soap and water for the following situations: -Before and after coming on duty; -Before and after direct contact with residents; -Before preparing or handling medications; -Before donning sterile gloves; -Before handling clean or soiled dressings, gauze pads, etc; -Before moving from a contaminated body site to a clean body site during resident care; -After contact with a resident ' s intact skin; -After handling used dressings, contaminated equipment; -After contact with objects (e.g. medical equipment) in the immediate vicinity of the resident; -After removing gloves. C. Observations Certified nurse aide (CNA) #7 was observed on 6/4/19 at 2:28 p.m. She exited a resident's room with the vital sign (VS) basket, which held the blood pressure cuff and thermometer. She proceeded to the nurses' station and placed the basket on top of the counter. She documented information on a paper and then picked up the VS basket and walked in to room [ROOM NUMBER]. She took the blood pressure (B/P) of the resident in bed A and when she finished she walked over to the resident in bed B and took her B/P next. After finishing getting VS from both of the residents, she exited the room and entered into room [ROOM NUMBER]. She took the B/P of the resident in the first bed and then exited the room. She directly went out the back door, which led to a courtyard, and took the B/P of a resident sitting in his wheelchair. She came back into the facility and entered into room [ROOM NUMBER]. She approached the resident in bed D and asked him if she could check his VS. After taking his B/P she went to the resident in bed C and took his B/P. After taking his B/P she walked over to the resident in bed B and took his blood pressure as well. She exited the room and entered room [ROOM NUMBER] and checked the B/P on the resident in bed B. She exited the room and entered into room [ROOM NUMBER] and took the B/P on the resident in bed A. She exited the room and entered room [ROOM NUMBER] and asked the resident in bed A if she could check his B/P. After checking his B/P, she exited the room and walked to a sitting area across from the nurses station. She checked the B/P of a resident sitting in her wheelchair watching television. She then returned the VS basket to the nurses station. She did not perform hand hygiene or clean the B/P cuff in between residents. CNA #6 was observed on 6/4/19 at 3:14 p.m. She retrieved the B/P cuff from the VS basket that was just placed at the nurses station. She took the B/P of a resident who was sitting in a chair in the common area watching television. After checking the residents B/P, she headed down the hall holding the blood pressure cuff. She did not wash her hands or the B/P cuff before checking the residents blood pressure. Further, she did not clean or sanitize the B/P cuff after it was used. C. Interviews CNA #2 was interviewed on 6/6/19 at 8:39 a.m. She said hands should be washed or hand sanitizer used before entering a resident's room and after leaving their room. She said staff should wash their hands in between resident contact and when going from room to room. She said the blood pressure cuff should be cleaned with alcohol wipes, which were in the VS basket, after each use on a resident. CNA #1 was interviewed on 6/6/19 at 8:45 a.m. She said hands should be washed after touching any object. She said hands should be washed between resident care and when gloves were removed. She explained the blood pressure cuff should be cleaned between residents with bleach wipes and the thermometer and pulse oximeter should be cleaned with alcohol wipes that were in the VS basket. She said she was not sure if the bleach had to stay on the cuff for any period of time. She said the VS basket should be cleaned at the beginning and end of each shift. Licensed practical nurse (LPN) #2 was interviewed on 6/6/19 at 8:50 a.m. He said hands should be washed when visibly dirty, before entering a residents room, when changing gloves, when leaving the residents room, in between resident care, and when doing vital signs. He said the CNA should have cleaned the blood pressure cuff with bleach wipes in between residents. He said the dwell time for the bleach wipes was three minutes. The assistant director of nursing (ADON) was interviewed on 6/6/19 at 10:10 a.m. She said staff should wash their hands before and after leaving a resident's room, in between resident care, after using the bathroom, after touching their face or hair, and in between collecting the residents vital signs. She said the blood pressure cuff should be wiped down with bleach wipes and allowed to dry before using it on another resident. She said staff should use bleach wipes on the thermometer and pulse oximeter as well. She said the VS basket should be cleaned with bleach wipes in between residents.

Based on record review and staff interview, the facility failed to ensure that appropriate treatment and services were provided for one of three sample residents (#1) to prevent urinary tract infections. Specifically, staff failed to change the resident's indwelling catheter contributing to an emergent hospitalization for urosepsis, a systemic infection originating in the urinary tract. Findings include: 1. Sample resident #1, a [AGE] year-old male, was admitted to the facility on [DATE], with diagnoses, according to his face sheet, that included [MEDICAL CONDITIONS], diabetes, depression and frontal lobe syndrome. The resident also had a history of [REDACTED]. 2. Resident status - indwelling urinary catheter According to his most recent Minimum Data Set (MDS), a quarterly completed on 7/20/10 (resident was hospitalized and readmitted and the new readmit MDS was not complete at the time), the resident was moderately impaired in his cognitive abilities; he resisted cares; he was independent in bed mobility, transfers, ambulation in his room and was able to toilet himself; he required the assistance of one staff member for dressing; he required total assistance with bathing and required staff oversight for meals and personal hygiene. Review of the resident's telephone orders, revealed that the resident's Foley catheter was discontinued 7/30/10. Review of Nurse's Notes, revealed the resident's Foley catheter was reinserted 8/30/10. The Note read: "Order for Foley Cath (place indwelling catheter) - 16 F 10 cc (size and amount of sterile water in balloon to keep catheter tubing in the bladder) inserted without problems, draining clear, yellow urine ..." There was a corresponding Physician's Telephone Order (T.O.), dated 8/30/10, that read: "F/C (foley catheter) 16 F 10 cc. Cath care Q (every) shift. Monitor output Q shift." The orders did not address how often the catheter and bag were to be changed. However, the Assistant Director of Nursing (ADON) and the DON were interviewed on 11/24/10, at approximately 9:40 a.m. When asked what their facility policy was in regard to changing indwelling catheters, the ADON replied they were to be changed monthly and as necessary. She then provided the facility "Standing Orders", which were dated as "Revised October 25, 2004," reviewed and approved by the Quality Assurance Committee and the Medical Director. The orders on catheter care read in pertinent part: -"Change foley cath. bag and tubing monthly and PRN (as needed). -Date bag when changed. -Monitor urine for patency, color, and sediment in the cath. bag. Notify Physician of any abnormalities." 3. Change in condition - facility failures a. Change of condition Review of the Nurse's Notes and Physician Telephone orders, revealed the following, in pertinent parts: -10/28/10 - A telephone order was written on 10/28/10, read "[MEDICATION NAME] (a non [MEDICATION NAME] used specifically for urinary tract pain) p.o. (by mouth) 200 mg tid (three times a day) X 3 days - bladder discomfort." -There were no corresponding Nurse's Notes that documented the resident was having any bladder pain, or that the physician had been called due to pain and that the [MEDICATION NAME] had been ordered. However, the October Medication Administration Record (MAR) revealed, a new order 10/28/10, for [MEDICATION NAME] twice a day (noon and 8 p.m.). The MAR showed the noon dose was given, but the 8:00 p.m. dose was circled with an R - which indicated refusal. -10/29/10 - The nurse documented that she had administered the 4:00 p.m. medications and that the resident was alert at that time. -10/29/10 - No time indicated: "T.O. (telephone order) ______ (name of physician) [MEDICATION NAME](antibiotic) 500 mg BID (twice a day) X 5 days STAT (immediately). Dx. (diagnosis) UTI (Urinary Tract Infection)." The MAR indicated the 8:00 p.m. dose (when [MEDICATION NAME] scheduled to start) was refused, along with all 8:00 p.m. doses. The resident was then hospitalized . A urinalysis had confirmed the [DIAGNOSES REDACTED]. -10/29/10 - 8:30 p.m. - "This nurse went to give rt (resident) 2000 (8:00 p.m.) medication. Upon entry to room nurse noted rt with eyes closed in bed. When nurse tried to admin (administer) medication rt was hard to arrouse (SIC). When nurse admin the 1600 (4:00 p.m.) rt was arrousable (SIC) and talked to this nurse. Rt did not attend dinner or out for smokes (indicated he did not go outside to smoke cigarettes as per usual). Remaind (SIC) in bed all shift. This nurse took VS (vital signs) 101.6 (temperature), 24 (respirations) short & shallow, ox (pulse oximetry reading - oxygen saturation level) 83, B/P (blood pressure) 75/50. Wheezing bilat (bilaterally-both lungs) upper lobes. Rt had distinded (SIC) bladder, upon palpation (feeling with the palm of hand) urine was coming out around the catheter and was bloody. This nurse couldn't find a new cath (foley). This nurse called Dr. ____ (name). _____ (Dr. name) T.O. send rt to hosp ..." Review of Hospital Records, revealed resident #1 was admitted to intensive care (ICU) in critical condition and required intubation (the insertion of a breathing tube) secondary to urosepsis. The records revealed, in pertinent part: -Emergency Department Report - 10/29/10, read in pertinent part: "Male [MEDICAL CONDITION]: The Foley catheter is in place. The catheter appears to be quite old. There is urine leaking around the catheter ..." -History & Physical Report - 10/29/10, read in pertinent part: "Assessment: This is a [AGE] year-old male who is residing in a nursing home secondary to [MEDICAL CONDITION] with septic shock likely from a urinary tract infection and possible pneumonia ..." -Nephrology Consultation - 10/30/10, read in pertinent part: "(Resident #1) also had a significantly elevated white count and was noted to have a urinalysis consistent with a urinary tract infection. He was admitted to the ICU [MEDICAL CONDITION] possibly secondary to either his urinary tract infection or his leg wounds in conjunction with [MEDICAL CONDITION] secondary to bilateral pneumonias and acute [MEDICAL CONDITION]." -Interim Summary Report - 11/4/10 (date transferred from ICU to general unit) read in pertinent part: "...The patient is a [AGE] year-old gentleman who comes from an inpatient psychiatric nursing facility where he was noted to have fevers and decreased responsiveness. He was intubated for airway protection. He was started on broad-spectrum antibiotics for septic shock ..." -Pulmonary Consultation - 10/30/10, read in pertinent part: " ...Impression and Plan: 1. Shock, likely septic in nature, currently on pressors 2. [MEDICAL CONDITION], currently on a ventilator. The patient was originally intubated for airway protection. There are improving infiltrates. I doubt there is an active pneumonia. 3. Leg ulcers for which the patient shall receive wound care. 4. Infectious disease issues. Urosepsis along with leg wounds with pus on broad spectrum antibiotics at this time." b. Facility failures 1) Failure to change Foley catheter and bag, as expected per facility Standing Orders. Review of the Medication Administration Records (MARs) for August 2010, did not show the catheter was documented as being placed. MARs for September and October 2010, showed the orders to provide catheter care each shift and to monitor the urinary output each shift were documented. However, there was no order to change the catheter monthly. (Two random MARs of residents with catheters were reviewed. They both had the orders for catheter care each shift, to monitor urinary output each shift and to change the catheter each month.) During the interview on 11/24/10, at approximately 9:40 a.m., the DON and the ADON were asked to review the record of resident #1. -The ADON confirmed that she had changed the catheter on 8/30/10, had neglected to write it on the MAR and, therefore, the order to change the catheter did not get transcribed on to either the September or October 2010 MARs. -The ADON acknowledged that the catheter did not get changed from 8/30/10, until the resident was hosptalized on [DATE], with urosepsis. 2) Failure to have catheter supplies available The DON and ADON were interviewed on 11/24/10, at approximately 9:40 a.m. The DON and ADON were asked about the nurse's inability to find a catheter for resident #1 on 10/29/10 (see note above). They stated there should always be replacement catheters in the building. They took the surveyor on a tour of their medication rooms, where extra supplies were stored. There were no Foley catheter kits available. 4. Resident status upon return to facility - facility failures a. Review of Nurses' Notes revealed: The resident returned to the facility on [DATE]. There was an order to change the Foley catheter every two weeks. The MAR revealed the catheter was changed on 11/18/10. The following was documented in the Nurse's Notes, in pertinent part: -11/18/10, 6:00 p.m. - "This nurse notified that rt had blood in his catheter. This nurse went right away. This nurse noted dark red filled the catheter tubing. This nurse changed the rt bag and gave rt cranberry juice. This rt notified (Dr.). Return call from (Dr.) to continue to monitor ...(temperature) 95.1 ..." -11/19/10, 3:36 a.m. (Temperature) 98.1 ...Catheter still draining red blood. Catheter was changed with a 16 FR, 5 cc. Resident up several times to use bathroom during the night. .. -11/19/10, 6:47 a.m. "Dr. notified of red blood still draining from cath, Dr. ordered for irrigation." The corresponding Telephone Order was written at 5:45 a.m. and read, "Irrigate cath with distilled water until clear." -11/19/10, 8:45 a.m. "Reported that red blood in cath tube/bag, clotted blood in urethra and shaft of penis. Rt c/o (complained of) pain mid shaft. Tried to irrigate with 60 cc of distilled water. Able to instill 5 cc of distilled H2O (water). Rt. c/o pain at mid shaft of penis. Removed irrigation piston and tried to manipulate tubing. Noted red blood coming from tubing. Deflated balloon in catheter and removed tubing. Urethra draining red blood clots. Approx 250 cc's of blood. 911 initiated. 911 arrived and took resident to (name of emergency room ). Rt remained alert, oriented and cooperative with staff and emergency crew. (Dr. and mother notified of transfer)." -11/19/10, (Friday) 2:30 p.m. "Res (resident) returned from hospital at 1430 hours. 3 pronged (referred to catheter tubing with three prongs) catheter attached to through and through (referred to running fluid through and out of the tubing) 1000 ml at 3rd port, attach one liter more of NS (normal saline) when empty. After 2nd bag empties, attach one more. Keep at slow drop rate. When 3rd bag empties then d/c (discontinue) then irrigate with 0.25% aciatic (SIC) acid. Irrigation 100 ml at HS (hours of sleep) in bladder until further notice. Hold ASA (Aspirin) 81 mg X 7 days. Clean meatus (skin at opening in penis) q shift X 7 days with wound cleanser and apply [MEDICATION NAME] (antibiotic ointment)." Corresponding Telephone Order read, at 6:15 p.m.: "2 bags NS 1000 ml - when present bag finishes, attach 1000 ml to 3rd prong cath at slow drip until finished. Then attach last bag at slow drip. D/C when finished. *STAT*" -11/20/10, (Saturday) 2:50 p.m. "Clarification T.O. Run through and through at 40-50 gtts (drops) q hr until 8 a.m. Monday per NP (Nurse Practitioner for primary physician)." -11/20/10, 4:00 p.m. "Res. received 3 bags of saline, urine still dark red. Penis cleansed and [MEDICATION NAME] applied ..." -11/20/10, 8:55 p.m. ..."Foley through and through clamped this shift awaiting additional fluid from pharmacy to arrive this evening. MD aware of clamping (where the catheter is clamped off using a plastic device). Continue to monitor per NP ... Res had output in drainage bag, red in color, output of 1400 (cc's). Rt c/o pain 7/10. Admin PRN (as needed) pain medication with positive effect. Will continue to monitor." -11/21/10, 12:30 a.m. " ...drainage bag in place, draining red color of urine at this time ...Received report from evening nurse that she got order to run more fluids via foley at 40-50 gtts/hr. and pharmacy was contacted to deliver more fluids. Still awaiting for more fluids." -11/21/10, Delivery man came from pharmacy at around 0100 a.m. (1:00 a.m.), but without normal saline bags for irrigation. The only thing they sent us is two bottles of acetic acid bottles. This nurse contacted the pharmacy via urgent line, left message to send the normal saline bags, and also the MD (name) was contacted regarding of the delay from the pharmacy. He is aware and ordered to start irrigation with NS (normal saline) as soon as it arrives from the pharmacy. 11/21/10, 2:50 a.m. "Pharmacy was contacted again regarding of send N/S for irrigation. Message was left at the urgent line." 11/21/10, 3:54 a.m. "Pharmacist called and said N/S will be within the hour." 11/21/10 1:30 p.m. " ...Normal saline come in from pharmacy. Hanging at 50 gtts/hour. Called NP to clarify 50 gtts per hour and ordered new bag to get through the night. Urine still red in color, strong odor ..." 11/21/10 8:00 p.m. " ...Resident disconnected saline bag himself to go outside, refused to stay hooked up. Resident ate dinner and went outside to smoke ...Penis cleaned and cream applied with minimal pain. Resident in bed without pants hooked up to saline at 50 gtts per minute, urine still dark in color. Continue to monitor." See above; the order was for 50 gtts per hour. On 11/22/10 it was documented that the drainage system had malfunctioned. The nurse started a new bag and it ran for a while. At 12 noon, it was clogged again and an order was received from the NP to D/C the whole system and the current 3 prong catheter. It was replaced with an 18 Fr 5 cc cath. b. Facility Failures 1) Fluid administration The DON and ADON were interviewed on 11/24/10, at approximately 9:40 a.m. When asked about the documentation in the 11/21/10 note, about the saline running at 50 gtts/min, instead of 50 gtts/hour, on 11/21/10, they stated that they thought this was a documentation error. 2) Pharmacy delays - Cross-reference F425. During the interview on 11/24/10, at approximately 9:40 a.m., the ADON and DON were asked about the documented delays in receiving supplies from the pharmacy. The ADON stated they had some problems getting supplies from the pharmacy, but offered no explanation for the delay or plans on how to address this to prevent recurrence. A brief interview with the facility pharmacy consultant was conducted on 11/24/10. When asked about the reason for the difficulty in obtaining the irrigation fluids for resident #1, she stated they were investigating the problem; however, there was no information provided on the investigation or a plan to address the delays. 5. Actions taken during survey. The facility provided the following in-services to their nurses on 11/24/10: 1. Out of Stock House Supplies - nurses were to call the on-call nurse who will either come in or get the needed supplies, or the Central Supply staff member will come in. 2. Out of Stock Prescription Medications - nurses were to document in NNs why the medication was not in stock, the pharmacy's response and resolution. Notify physician and a medication order was to be written, unless the physician wrote an order to hold the medication. 3. Catheter changes - reminded that foley and suprapubic catheters were to be changed at least monthly and to document the change in the Nurse's Notes. 4. Sending a resident out of Facility - nurses reminded to complete a transfer form and to clearly document any compliance issues with bathing, especially if the resident has poor hygiene status as a result. They are also to document the last shower the resident had if due to resident refusal. In addition, the facility provided documentation that the overnight nurses were notified in writing on 11/29/10, that each medication room was to be audited nightly to be sure adequate supplies were on hand and to notify Central Supply the next day.