Every finding on record at Providence Place

Based on observation, interview and document review, the facility failed to ensure fingernails were trimmed and fingernail hygiene was maintained for 3 of 3 (R1,R3,R4) dependent residents reviewed for personal care. Findings include: During an observation on 7/14/26, at 11:45 a.m., R1's left index finger was shaped triangular with a point in the center measuring approximately 0.5 centimeters (cm) in length. The rest of her fingers and thumb were trimmed but appeared jagged and uneven. During an observation on 7/14/26, at 12:20 p.m., all ten of R3's fingernails had black matter under them from the finger to the end of the nail. Her nails were about 0.5 cm and shaped unevenly. During an observation on 7/14/26, at 12:42 p.m., LPN-A asked R3 if she could cut her nails. R3 stated nails could be cleaned but not cut. During an observation on 7/14/26, at 12:45 p.m., R4's thumb nails and index fingernails were observed to have a rust-colored substance under them. His left 5th digit was approximately 1 cm in length. His right and left thumbs were approximately 0.5 cm in length. R1's quarterly minimum data set (MDS), dated [DATE], indicated she had diagnoses of diabetes mellitus Type 2 with complications, bilateral above knee amputation, macular degeneration, and moderate cognitive impairment. She rejected care and was dependent on staff for personal hygiene. R1's treatment administration record (TAR) directed staff to complete finger and toenail care and indicated nail care was completed on 7/9/26. R1's care plan, dated 7/14/26, directed assistance from one staff to perform personal hygiene and indicated she refused care at times. She likes her nails long and polished. R1's progress notes, skin checks and TAR lacked documentation of R1 refusal of care. R3's quarterly MDS, dated [DATE], indicated she had diagnoses of diabetes mellitus and dementia, had moderate cognitive impairment, refused care and was dependent on staff for personal hygiene. R3's care plan, dated 6/19/26, directed moderate assistance of one staff person for personal hygiene and nurse to cut nails. Her care plan indicated she had a history of refusal of personal care. R3's TAR directed to complete finger and toenail care on bath day and indicated nail care was completed on 7/11/26. R3's progress notes, skin checks and TAR lacked documentation of refusals of care. R4's care plan, dated 8/30/24, indicated he required substantial assistance of one staff for personal hygiene needs and the nurse for nail care on bath day. It directed to keep R4s fingernails short and nurse or podiatry to cut long nails. It indicated he had a history of care refusals. R4's annual MDS, dated [DATE], indicated he had diagnoses of paranoid schizophrenia, dementia, bilateral myopia (blurry distance vision in both eyes) and severe cognitive impairment. R4 required maximal assistance of staff for personal hygiene and did not refuse care. R4's TAR directed to complete finger and toenail care on Saturdays. It indicated toenail and fingernail was completed on 7/11/26. R4's progress notes, skin checks and TAR lacked documentation of R1 refusal of care. During an interview on 7/14/26, at 11:45 a.m., nursing assistant (NA)-A stated nurses do all nail care for diabetic residents. During an interview on 7/14/26, at 12:20 p.m., R3 stated her nails were cleaned about two days prior. She asked if they were dirty and stated if they were dirty, she would want them cleaned. During an interview on 7/14/26, at 12:40 p.m., NA-B stated he was responsible for R3's personal hygiene but not her nail care as the nurses were required to perform her nail care. During an interview on 7/14/26, at 12:39 p.m., licensed practical nurse (LPN)-A stated R3 gets her nails cleaned on her bath day and they were cleaned last on 7/9/26. She said the staff have tried to perform nail care a couple times a week but R3 refused, and refusal of care should be documented. She was unsure when the dark matter was under her nails. During an interview with registered nurse (RN)-A on 7/14/26, at 12:48 p.m., she stated nurses were responsible for all nail care for diabetics. She stated R4 was not diabetic. NA's were responsible for providing R4's nail care and the nurses were responsible for ensuring nail care was done. She stated if nail care is not provided the nurse is responsible to assign it to another NA or complete it themself. She stated his long nails were concerning and she would attempt to cut them. During an interview on 7/14/26, at 1:00 pm, RN-B stated nurses conduct skin checks with residents' bath/shower and nail observation was expected to be included as a part of the assessment. She stated the nurses were responsible for nail care for residents with diabetes and the nail care was expected to be completed on the residents' bath/shower day. She stated the NA's were responsible for hand hygiene with morning and evening care. During an interview following observation of R1's nails on 7/14/26, at 1:05 p.m., RN-A stated R1's nails were just trimmed. She stated they should be filed to avoid injury. She stated R1 often refuses to allow them to cut her nails. RN asked R1 if she would allow her nails to be cut. R1 agreed to nail care. During an interview on 7/14/26, at 1:20 p.m., the assistant director of nursing (ADON) stated nurses should perform nail care for diabetic residents on their shower day. The ADON stated R4 frequently refuses cares and requested a NA to attempt to cut his nails. ADON stated refusal of nail care should be documented. The NA's were responsible for the residents' primary personal hygiene. During an interview on 7/14/26, at 1:43 p.m., the director of nursing (DON) stated nurses were responsible to perform nail care for diabetic residents' fingernails and toenails on their bath day, as it was part of the bath. If care is refused, it should be documented. She expected the nurses to reapproach if care was refused. She stated concerns of jagged or long nails were the residents getting skin tears or hurt themselves and concerns of dirty nails were infection control. During an interview on 7/14/26, at 2:24 p.m., family member (FM)-A stated she was concerned about the lack of personal hygiene provided by the facility to R1, and she provided personal care to R1 during her visits. During an interview on 7/14/26, at 2:39 p.m., FM-B stated she was not informed that R4 was refusing nail care but expected his nails would be clean and trimmed. During an interview on 7/14/26, at 3:30 p.m., the assistant executive director (AED) stated it was hard to convince R4 to allow nail care as he refuses care. He stated refusal of care should be documented. During an interview on 7/14/26, at 3:55 p.m., the administrator stated preferences should be listed on the resident care plan and refusal should be documented. He stated the facility did not have a policy specifically for nail care. The facility Activities of Daily Living policy, dated 4/1/26, directed a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene.

Based on interview and record review, the facility failed to develop, implement, monitor, and revise individualized interventions to address alcohol-related behaviors for 2 of 2 residents (R1 and R2) reviewed for behavioral health services. Findings include:R2R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 had moderate cognitive impairment and no behaviors or rejection of care. R2's diagnoses included non-Alzheimer's dementia, anxiety, and depression. R2 was independent with his wheelchair and most activities of daily living. R2's used antidepressant medication.R2's community life care plan focus revised 4/30/25, indicated R2 self-directed leisure pursuits. R2's substance abuse care plan focus revised 8/12/25, indicated R2 drank alcohol and occasionally used cocaine. R2 was agreeable to work with LADC (licensed alcohol and drug counselor). R2's antidepressant medication care plan focus revised 2/7/26, indicated R2 had history of suicidal ideations and feelings of sadness, low self-esteem, tearfulness, withdrawal from cares/activity, ineffective coping, and feeling lonely/isolated related to depression and substance abuse mood disorder. Interventions and dates included:-4/11/25; approach every three months to discuss treatment options.-4/16/25; therapy community assessment indicates resident can be independent when leaving the facility. SLUMS score indicated concern for cognitive impairment. BIMS score indicated moderate cognitive impairment.-4/30/25; R2's preferences included cards, smoking, cooking, music, going on walks, news channels, discovery and history channels, and encouraging R2 to participate in Well-Fit program's group exercises and/or individual cardio.-5/8/25; observe behavior and attempt to determine pattern, frequency, intensity, and triggers. Offer aromatherapy. Report to nurse ongoing signs/symptoms of depression. Staff to conduct room checks to ensure resident is not smoking in his room. Encourage out of room activities that promote physical activity.-5/14/25; remind R2 of group programs, provide word puzzles, word searches, and pens/pencils.-9/6/25; agreed to find housing. Remain in structured safe setting such as facility to support quality of life and best functioning. Validate, listen, help problem solve, and offer reassurance when R2 expressed distress. Support sobriety and smoking cessation. Encourage meaningful activities. R2 enjoyed socializing.-10/27/25; attempt non-pharmacological interventions.-11/5/25; maintain supervision of peer interactions on the unit. If substance abuse or boundary concerns were suspected, room searches to remove substances may be appropriate to reduce harm to self and others.R2's Associated Clinic of Psychology note dated 2/26/26, identified interventions to explore ambivalence, set harm-reduction goals, cognitive restructuring for urges/boredom, and problem-solving for high-risk situations. Treatment recommendations included continued need for behavioral/environmental structure due to cognitive deficits and ongoing alcohol abuse.R2's Psychiatric Progress Note dated 4/10/26, identified R2 continues to drink regularly from the best I can tell here.R2's provider note signed 5/16/26, identified R2 reported consumption of vodka and beer approximately once a week.R2's provider note signed 5/23/26, identified R2 had recently consumed one bottle of vodka, and R2 stated the occurrence was a one-time event.R2's progress notes on 5/28/26 at 8:43 p.m., 6/3/26 at 4:30 p.m., and 6/4/26 at 5:22 p.m., indicated R2 had slurred speech and a strong odor of alcohol. Staff encouraged R2 to remain on unit and return to room, held medications, notified providers, and implemented fall precautions.R1R1's quarterly Minimum Data Set, dated [DATE], indicated R1 was cognitively intact, had continuous inattention, and no behavior, mood, and rejection of cares. R1 was independent with ambulation and activities of daily living. R1 diagnoses included traumatic brain injury, malnutrition, depression, and psychotic disorder. R1 used antipsychotic and antidepressant medication.R1's care plan focus of antidepressant medication revised 11/26/25, identified R1 had diagnoses of adjustment disorder with mixed anxiety and depressed mood and unspecified mood disorder. R1's care plan focus of substance use disorder was revised 3/30/26 and identified R1 had a history of substance use disorder as evidenced by history of alcohol dependence, other stimulant dependence, and cocaine dependence. R1 was seen by in-house LADC and wavered whether he wanted to go to an inpatient treatment center. R1's care plan focus of antipsychotic medication revised 3/31/26, identified R1 yelled and swore at staff and played music loud while suspected to be under the influence. R1 told stories which were not consistent and changed based on whether he was under the influence. Interventions and dates included:-11/30/25; educate R1 on ways to utilize coping skills when feeling urge to use. Encourage frequent contact with family/friends that do not encourage substance use.-11/30/25; attempt non-pharmacological interventions, such as reassurance or validation of feelings and observe effectiveness.-12/17/25; approach every three months to discuss treatment options. Contact emergency personnel as needed. Therapy community assessment indicated no supervision was required in the community, and resident was safe to be in the community independently.-3/31/26; see behavior contract.-5/13/26; R1 agreed to work with chemical dependence counselor to determine if he should go into treatment and what might be the best options for him given his goals. When R1 expressed distress, validate his distress, listen to him, help him problem solve and offer reassurance. Work with ACP (Associated Clinic of Psychology)/psychiatry to help him work on issues bubbling up, such as historical abuse. R1's goal was to meet with LADC and attend alcoholics anonymous meetings. It was a good time to work with him on housing options. R1 was spiritual and would benefit from seeing the in-house chaplain.-5/13/26; resident continued to see both in-house ACP and psychiatry on a regular basis to manage mood and medications.-5/15/26; continue close monitoring of mood, alcohol related behavior, passive suicidal ideation statements, and ability to recall/report events accurately. Use calm, direct communication and reinforce safety plan, while avoiding power struggles around disputed details.R1's provider note dated 5/28/26, indicated R1 had not had any alcohol for at least a week, had a substance abuse counselor, and provider encouraged participation in support groups.R1's ACP note dated 5/28/26, indicated interventions to process grief response and improve understanding on the exacerbation of substance use disorder, explore when urges to use are stronger and less, identify coping strategies to reduce urges to use. The note indicated encouragement to continue recovery support participation, medication compliance, and monitoring sleep/energy/mood changes.R1's provider note dated 5/29/26, indicated R1 had a physical altercation while intoxicated in the smoking area around 6:00 p.m. Staff intervened before any physical contact occurred.R1's provider note dated 6/3/26, indicated R1 had altercation with another resident where the other resident pushed and kicked him. R1 was picked up by police and returned to the facility later. The note indicated R1 had an alcohol dependency counselor but rarely engaged with them, and R1 continued with AA groups.R1's progress note dated 6/10/26 at 4:23 a.m., indicated R1 and other residents were smoking in a resident's room. LPN-A smelled cigarette smoke from a resident room, told the residents to stop smoking in the room and management would be notified. LPN-A indicated he was told residents, which included R1, had an altercation at the front of the building which required police presence. LPN-A indicated he was not present and was helping another resident at the time of the altercation and did not meet with the police.The facility reported incident (FRI), submitted to the state agency on 6/10/26 at 4:41 p.m., identified RN-A notified the administrator of R1's progress note on 6/10/26 at 9:30 a.m. and no other staff had reported the incident to the administrator. The FRI description of incident indicated R2 stated the residents were just 'drinking stupid', and R1 got into a confrontation with R5. R2 reported there were no blows and no one hit anyone, and R2 went up to bed after the incident. R4 indicated R1 pushed R2, and a resident was hit by a cane. R4 called the police when things got heated. The FRI indicated there were no known injuries. The facility outlined immediate steps taken:-Residents involved will be assessed for injury.-R2 indicated he felt safe and was not afraid of R1.-R4 was given a trauma assessment and indicated she felt safe in the facility and R1 made her anxious.-R1 will have a 1:1 while intoxicated to ensure his and others safety.R1's progress note dated 6/10/26 at 1:53 p.m., indicated R1 had no behaviors and slept most of the shift.R1's progress note dated 6/10/26 at 3:30 p.m., indicated R1 signed out of the facility on a leave of absence.During observation and interview on 6/24/26 at 11:19 a.m., R1 sat up in bed and stated he had been asleep. R1 stated there had been drinking going on when asked about the incident on 6/10/26. R1 stated there were one or two residents who had alcohol daily, and R2 had alcohol on 6/10/26. R1 stated staff did not encourage drinking and did not have to communicate to staff when drinking. R1 stated he got in a verbal altercation with a female resident recently, and staff had to shadow him for 24 hours.During observation and interview on 6/24/26 at 11:09 a.m., R2 was laying in bed with the television on. R2's wheelchair and cane were next to his bed. R2 stated the incident on 6/10/26 was just an argument and it's nothing. R2 stated just some words were said and R1 pushed him and they say I hit [R1] with my cane. R2 stated R1 asked him for a cigarette but he didn't give R1 a cigarette. R2 stated the staff did not help and had asked what happened and went back into the building.During interview on 6/24/26 at 5:10 p.m., R5 stated R1 and R2 got in a fight and were yelling at each other. R5 was not sure what they fought about and stated R1 liked to fight. R5 stated nothing happened to me and did not remember if any staff helped on 6/10/26.During interview on 6/25/26 at 7:35 a.m., R4 stated she was present for the incident in the smoking area on 6/10/26. R4 stated R1 was begging for cigarettes most of the night and was drunk and belligerent. R4 stated R1 asked R5 for cigarettes multiple times and called R5 a c word. R4 and R2 tried to intervene, and R1 snatched a cigarette from R2's mouth and threw the lite cigarette at R2. R1 bumped into R2, R2 stood up, and R1 pushed R2 a few times. R4 stated staff watched from the lobby and did not help when R4 waved at them to help. R4 stated R1 was red in the face and seemed dangerous and did not feel physically threatened by R1. R4 stated staff did not let R1 into the building for a while, and R4 called the police. R4 stated she escorted the police into the building and did not see any staff and left the police when they saw R1. R4 stated residents, such as R1, drink and smoke weed and should not be allowed to get to the point of affecting other residents' quality of life.During interview on 6/25/26 at 12:38 p.m., NA-D stated she was smoking outside down the street when she heard arguing and metal tables and chairs. NA-D went into the building and looked out the window and saw residents arguing and a resident pointed to one of the male residents and waved at her. NA-D stated R1 came into the building and started to yell at her. NA-D stated she told R1 he needed to go back to his room, and R1 got mean. NA-D stated she knew R1's history of arguing and being mean when drunk, so NA-D went into a bathroom down the hallway and locked the door. NA-D stated two other nursing assistants were doing their rounds, and R1 had fallen down a couple times. NA-D stated she waited until R1 disappeared before going back to her assigned work unit. NA-D could not remember if she told her nurse or supervisor since she was wired about the situation. NA-D stated there wasn't much I could do about the situation with the other residents and herself. NA-D stated R1 had gotten into staff's faces before and put his chest on staff. NA-D stated there was a time months ago when R1 and another resident were drinking in a resident room and were loud and other residents indicated they were scared. Staff asked R1 if he could go back to his floor, and it took a bit to get R1 off the floor and R1 was loud as he left the unit.During interview on 6/25/26 at 12:16 p.m., NA-C stated she came out of a resident room and saw NA-D and asked if she was okay, and NA-D indicated she was smoking outside and heard residents outside arguing and saying get back. NA-C did not see any fighting when she looked outside and saw R1 and other residents. R1 entered the building and was on a unit on the first floor when R1 dropped to the floor, and NA-C thought something was wrong with R1. NA-C got RN-B, and R1 got off the floor and asked NA-C if he scared her and walked off the unit while playing his music loud. R1 was intoxicated and acting like he was on some kind of drugs or something. R1 was loud, had slurred speech, and walked and waddled like [a] drunk person. NA-C stated R1 came to her unit on other nights and smoked in other residents' rooms and swore and yelled into staff's faces. NA-C stated staff were not trained to work with intoxicated people and had no way to diffuse situations of intoxicated residents.During interview on 6/24/26 at 3:15 p.m., NA-A stated she worked overnight on 6/9/26 into 6/10/26. NA-A stated the police came to the unit she worked, and she could not find a nurse to speak to. The police told NA-A a resident called the police and a resident had hit another resident. NA-A stated R1 was on the unit with the police and told the police Don't touch me while being close to the police's face and walked away. NA-A stated another nurse told her R1 had thrown himself into the elevator that night. NA-A stated she reported to LPN-A about the police presence when LPN-A returned to R1's unit. NA-A stated R1 and R2 were drinking together and seemed pretty drunk. NA-A stated staff monitor drunk residents for safety and report to the nurse. NA-A stated nurses were supposed to intervene when residents are drunk and indicated nurses do not intervene. NA-A stated R1 required a staff one to one when intoxicated but was not consistently implemented. During follow-up interview on 6/25/26 at 4:36 p.m., NA-A stated R1 and R2 were in another resident room at the beginning of her shift on 6/9/26 and asked the evening shift nurse what was going on, and the evening shift nurse was dismissive. NA-A stated it was a rare sighting to see the three residents in the same room. NA-A stated an hour or two into her shift she smelled cigarettes from a room R1 and R2 were in together and reported to LPN-A, the overnight nurse, who told the residents to stop smoking in the room, and he was going to report the smoking to management. NA-A stated R1, R2, and the other resident dispersed after LPN-A spoke with them. NA-A stated R1 was aggressive and cursed when intoxicated, and R2 slept in bed most of the time she worked with him and was known to drink.During interview on 6/25/26 at 9:40 a.m., NA-B stated she worked overnight 6/9/26 into 6/10/26. NA-B stated the police came up to the unit she worked on, and the police indicated R1 hit another resident. NA-B stated the police indicated she was at the facility entrance for a while and saw no staff on the first floor to speak with. NA-B stated R1 went up to the police aggressively and R1 stated he tried to hit me too. NA-B stated she did a safety check on R1 at the start of her shift, and R1 was not in his room and did not see R1 until the police officer was present. After the police left, R1 went to his room and calmed down. NA-B stated they told LPN-A the police officer was present and indicated R1 and R2 were arguing and thought R1 hit R2. NA-B stated they completed a safety check on R1 at 3:00 a.m. and 5:00 a.m., and R1 was in his room both times. NA-B stated she could tell R2 was intoxicated by the way he talked and smelled and had eyes low. NA-B stated R2 did not talk about what happened on the smoking patio and stated he was tired and went to his room. NA-B was not aware of any new interventions for R1 or R2 since 6/10/26.During interview on 6/25/26 at 4:27 a.m., the police officer who responded to the situation on 6/10/26 stated staff indicated R1 and R2 were drinking together earlier in the day and there was an altercation between the two residents. The police advised staff to separate R1 and R2. The officer stated R1 was always intoxicated when she responded to calls involving him and was not close enough to R2 to determine if he was intoxicated.During interview on 6/24/26 at 2:17 p.m., LPN-A stated he was on another facility floor helping with a wound dressing when the incident occurred and the police came. LPN-A stated he heard about the incident when he returned to his assigned unit from two nursing assistants and a phone call from RN-B. LPN-A stated the police were already gone when he heard R1 was involved in an incident which caused police presence and did not know about the other residents who were involved. LPN-A stated he checked on R1 afterwards, and R1 was sleeping in bed and did not smell like alcohol. LPN-A stated R1 had a history of drinking and playing loud music in the hallways. LPN-A stated approximately two weeks ago R1 was placed on a one to one related to his behaviors. During a follow-up interview on 6/25/26 at 2:09 p.m., LPN-A stated he was not aware of any related information which would indicate the need to make an immediate report to the DON or administrator.During interview on 6/24/26 at 3:36 p.m., RN-B stated she managed the locked building door overnight by pressing a button to let people in and asked people what they were at the facility for when she did not recognize someone who was requesting facility entrance. RN-B stated she was not aware of a resident-to-resident altercation on 6/10/26, and the police and emergency services personnel had been at the facility a lot recently for altercations and other reasons. RN-B stated she calls the overnight supervisor to alert them of any police or emergency personnel presence, since she does not always know why they are in the facility, and the supervisor would know where to direct them. RN-B stated she did not speak with the police on 6/10/26. RN-B stated there were cameras on an electronic device which pointed out to the smoking area but was hard to see and grainy and no one monitored the smoking area overnight. RN-B stated R1 had walked onto her unit multiple times previously and into a resident's room where the resident was sleeping half the time, and R1 would be intoxicated, slurring his words, and smelling like alcohol. RN-B stated they held residents' medications when they were intoxicated and completed an assessment related to intoxication.During interview on 6/24/26 at 2:04 p.m., RN-A stated she reviewed clinical notes daily, and an investigation started when she was not sure what happened based on the note from 6/10/26 at 4:23 a.m. RN-A stated she expected staff to contact the DON or administrator immediately of any verbal or physical altercation but did not believe LPN-A knew what happened at the time of the incident.During interview on 6/24/26 at 1:50 p.m., the administrator stated he was in the morning interdisciplinary meeting around 9:30 a.m. on 6/10/26 when RN-A read the progress note and notified him. The administrator stated the progress note was vague, so he and the assistant executive director started to investigate what happened. The administrator stated they interviewed the involved residents and LPN-A and reviewed the facility's camera footage. The administrator stated R1 was close to R2's face because R1 wanted a cigarette, and R2 hit R1 one or two times with his cane. R1 went into the building after the altercation. The police showed up around 12:45 a.m. on 6/10/26 and did not see staff during the incident.The facility five-day Investigation Report Summary, submitted to the state agency on 6/16/26 at 4:40 p.m., identified the altercation occurred at the facility on the smoking patio through witness interview and security camera footage. The facility interviewed R1, R2, R4, and R5. The summary of interviews with witness(es) indicated R1 would not leave R2's personal space, and R2 hit R1 with a cane. R1 walked away from the smoking patio and entered the building where he met with staff who were on their way to diffuse the situation. R4 called the police when R2 hit R1 with a cane. The facility interviewed LPN-A, the nurse of R1 and R2 on the overnight shift of 6/9/26 into 6/10/26, and LPN-A indicated he was helping another nurse, and the police had already left the building when he heard about the situation. LPN-A indicated he observed R1 in R1's bed, and R1 did not smell like alcohol at the time. The facility educated the involved residents on the importance of respecting each other and to not get into arguments or will be separated. The residents were educated on the importance of not sharing cigarettes with other residents. The facility was assisting R1 to discharge to a less retractive community/ Low-income housing.R1's intervention under the antidepressant medication care plan focus revised 6/16/26, identified R1 had insight he was not functioning well neurologically, writing things down for R1 and encouraging him to write things down helped R1 to remember things, R1 agreed seeing friends was helpful and struggled to identify and initiate activities to improve mood, would benefit from being invited to attend things, encourage enrollment in a treatment program, use calm and direct communication while avoiding power struggle.R1's ACP note dated 6/18/26, indicated R1 was six days sober and recommended to reinforce prosocial behavior and routines to support sobriety.R2's SUD (substance use disorder) Facility Evaluation of Impairment - V2 dated 6/19/26, indicated R2 had odor of alcohol or marijuana present, slurred speech, and mood changes. R2 had a clear cup of unidentified liquid and confirmed he consumed alcohol. Staff notified the nurse practitioner, placed hold on medications, increased monitoring and/or observation of condition, encouraged resident to stay in room, made sure environment free of obstacles, adjusted bed to appropriate height, and observed for withdrawal symptoms.During interview on 6/24/26 at 2:43 p.m., the assistant executive director (ED)-A stated he interviewed the overnight nurse supervisor, who was also the direct overnight nurse of R1 and R2, and no other staff. ED-A stated LPN-A and facility staff received education about reporting incidents and timing of reporting since 6/10/26. ED-A stated the two residents were separated after the incident, and R1 went on a leave of absence the morning of 6/10/26 and had no other issues since 6/10/26. ED-A stated residents were monitored on the smoking area with camera footage, and residents were required to have an assessment to be independent in the smoking area or out in the community.During follow-up interview on 6/25/26 at 9:22 a.m., ED-A stated R1 had a history of picking fights when intoxicated and this was R1's first fight when not intoxicated. ED-A stated R1 was not intoxicated according to LPN-A. ED-A stated R1 required a staff one to one when intoxicated through the facility SUD assessment. ED-A expected staff to complete the SUD assessment when residents returned to the facility after being in the community or when staff noticed signs and/or symptoms of intoxication. ED-A stated R1 had supportive services. ED-A stated R1 wanted to discharge and worked with R1 to find housing. ED-A stated R2 had not had any previous interactions with other residents like on 6/10/26.During interview on 6/25/26 at 7:01 a.m., NA-E stated R1 fought when intoxicated and staff tried to calm him down when behaviors occurred. R1 was not easy to calm and ran after staff previously. NA-E stated R2 gets intoxicated but did not fight with others. NA-E guided residents to go to their room when they were loud or yelling at staff or appeared intoxicated and notified the nurse of concerns.During interview on 6/25/26 at 2:42 p.m., NA-F stated R2 slept a lot the evening of 6/9/26, and R1 was independent. NA-F stated they were not aware of resident-specific care plan interventions regarding intoxication management for R1 or R2.During interview on 6/24/26 at 12:53 p.m., LPN-B stated he performed a SUD assessment if a resident appeared intoxicated, notified the provider, held medications, monitored resident and maintained safety. LPN-B stated a couple weeks ago he received education of the African American Survival Services and could call the service when residents were intoxicated or disruptive to the community. LPN-B stated he would call the DON or administrator after calling the service.During interview on 6/25/26 at 7:14 a.m., RN-C stated R2 had slurred speech and incontinent when drinking. RN-C stated R2 made comments such as oh hunny and I like to see you walking away and was not physically or verbally aggressive or fought with others. RN-C stated staff document behaviors under progress notes. RN-C stated she received report of R2 drinking once or twice in a two-week period, and R2 smoked out his bedroom window even though he knew he was not supposed to. RN-C stated she would document resident 1 to 1s implementation in a progress note.During interview on 6/24/26 at 1:01 p.m., social worker (SW)-A stated she completed an assessment on R2 after the incident to make sure R2 was safe. R2 confirmed he felt safe and did not want any extra precautions taken, such as moving rooms or staying away from R1. SW-A stated ACP and LACD and peer recovery group followed up with all residents involved with the 6/10/26 incident, and the social workers updated care plans based on ACP or LADC notes. SW-A stated there were no care plan changes she was aware of after the incident.R1's intervention under the substance use disorder care plan focus dated 6/25/26, directed staff to continue reinforcing prosocial behavior and routines to support sobriety.During interview on 6/25/26 at 4:17 p.m., the long-term care assistant director of nursing (ADON) stated multiple staff managed the substance use disorder unit. The ADON reviewed R1's care plan and was unsure what prosocial behavior meant. ADON indicated a website browser search identified prosocial behavior meant encourage to interact and socialize with others.During joint interview on 6/29/26 at 10:02 am with the director of nursing (DON), ED-A, administrator, and SW-B, R1 care plan and behavioral services were reviewed. R1's behavioral contract was part of R1's care plan from the previous regional director of operation and was not sure what the behavioral contract with R1 was. Prosocial behavior and routines that support sobriety meant to encourage R1 if he was having a good day and boost him up and tell him he looks good. Staff were to encourage R1 to talk about how he was doing. R1 liked to socialize and not talk about his feelings. The facility representatives reviewed no R1 activity recommendations plan despite the interventions in which R1 struggled to identify and initiate activities to improve mood and would benefit from being invited to attend things. The facility representatives stated R1 spent time outside the facility and directed his own activities. R1's activities were reviewed at quarterly care conferences, and activities were tracked by the community of life team. Facility representatives stated African American Survivor Services and LASD were confidential services unless R1 was willing to share information. The staff were educated they could call African American Survivor Services 24/7 if a resident showed signs/symptoms of intoxication or having a hard time and could take residents on outings and car rides. The team reviewed the intervention to utilize coping skills and stated they could only specify trigger or coping skills if R1 shared with the facility staff. The team helped R1 focus on meetings for the week related to substance use and encouraged him to participate. During continued interview, R2's care plan and behavioral services were reviewed. The team verified there were no changes in R2's care plan after the 6/10/26 incident. The team stated R2 was offered LASD and ACP visits and other group meetings. R2 was not open to most services offered besides African American Survivor Services. The African American Survivor Services organizer met with residents at the facility twice a week, but the meeting notes were confidential and not viewable to the facility. The team verified the care plan did not specify R2's triggers for alcohol use and stated asking R2 about his drinking triggers could be a trigger itself. Staff were to monitor R2 for signs/symptoms of substance use, and R2 was not willing to share his triggers with the facility. The team verified R2's records did not indicate his target behaviors or non-pharmacological interventions for behaviors. The team stated they have a PIP (Personal improvement plan) to look at psychotropic medications, target behaviors, and nonpharmacological interventions. The management team expected staff to notify them immediately of events such as the one which occurred between R1 and R2 on 6/10/26, because immediate follow-up for residents was important to promote the best possible psychosocial wellbeing.R1's Mood and Behavior Review assessment dated [DATE], identified R1 used antipsychotic and antidepressant medication. R1 had verbal behavioral symptoms directed towards others and other behavioral symptoms not directed towards others. The assessment did not fill in the area to indicate review of current target behaviors and resident specific interventions. The assessment indicated redirection was generally effective for R1's mood and behaviors.R1's Care Conference Summary Resident Profile dated 5/21/26, identified a care conference occurred on 6/3/26 and Community Life section was not filled in. The Care Conference Summary's signature and date section was blank.The facility did not provide activity tracking for R1 from the community of life team.The facility did not provide a recent care conference summary for R2 or activity tracking for R2 from the community of life team.The facility Behavioral Health Services policy dated 4/1/26, indicated a resident care plan will have person-centered, evidence-based, trauma-informed interventions. The policy directed the facility to provide meaningful activities to promote engagement and positive, meaningful relationships. The policy directed the facility to review and revise the care plan as needed, such as when interventions were not effective or when the resident experienced a change of condition.

Based on observation, interview and document review, the facility failed to take appropriate steps to ensure raw meat items were stored and discarded in a timely manner to reduce the risk of cross contamination and potential food born illness in 1 of 1 walk- in refrigerators used in the main production kitchen. In addition, the facility failed to ensure frozen food items were stored in a clean area and in a manner to reduce the risk of cross contamination and potential foodborne illness in 1 of 1 walk-in freezers in the main production kitchen. This had the potential to affect all residents who consumed food from the kitchen. Furthermore, the facility failed to ensure the unit refrigerator on 1 of 6 units was kept clean to reduce the risk of cross contamination and potential food born illness. Findings include: On 5/11/26 at 10:26 a.m., an initial kitchen [NAME] was completed with dietary manager (MGR)-D. A single walk-in refrigerator was in use, opened and inspected. The unit contained metal shelving racks which had 4 shelves. On the second shelf from the bottom was a large metal tray that contained 6 undated and unlabeled packages of meat which appeared to be in the original packing. On the same tray was a package of raw meat wrapped in clear plastic dated 4/2/26 which had a brown colored liquid substance coming from the bottom of the clear plastic that was touching the undated/unlabeled sealed packages of meat. Upon inspection, MGD-D stated the raw meat in clear plastic dated 4/2/26 should be thrown away. MGR-D dated the 6 undated/unlabeled packages of meat, and indicated it was hamburger that had come in last week on delivery. The shelf above (second shelf down from the top) contained a chunk of turkey that was wrapped in a clear plastic sitting directly on the metal shelving rack. It had a sticker dated 4/16 and use by 4/21. MGR-D stated this was left over from when the turkey was cooked and was going to be sliced and served. MGR-D stated the date must be wrong and planned on using it. MGR-D stated that once a week, on Monday mornings, she went through the fridges to ensure there was no expired food in the fridges and stated she must have missed the items above. Continuing the initial kitchen tour, a single walk-in freezer was in use, opened and inspected. The unit contained metal shelving with a prepackaged wild brown rice and chicken soup. Upon inspection, the soup was noted to have visible ice on the top of the soup. MGR-D stated the facility would use the soup but since surveyor was asking about it, was going to throw it out. MGR-D stated air must have gotten into the prepackaged container. Another shelf contained an opened carboard box that had a plastic bag labeled personal belongings sitting on top. Inside the plastic bag was a gray plastic tub with 2 packages of brats. Neither the bag nor the packages of brats were labeled with a name. The cardboard box contained 4 bags of unopened egg noodles. The eggs noodles appeared to have ice buildup and frost inside the packaging. MGR-D stated the brats inside the personal belongings bag must be staff food that was put in the freezer. MGR-D stated staff was able to store food in the freezer as long as it was labeled and stated since the food wasn't labeled it shouldn't be in the freezer. MGR-D stated air must have gotten inside the egg noodle bags at some point and stated it appeared as though the egg noodles have frost on them. Under the shelves in the freezer appeared to have food build up. MGR-D stated the freezer should be cleaned daily which would include underneath the shelving units. During an observation and interview on 5/11/26 at 5:14 p.m., nursing assistant (NA)-I stated the unit fridge was for resident food. During inspection of the unit fridge, an open, labeled and uncovered can of monster (energy drink) was noted. NA-I stated the can should be covered. There were two undated pitchers of juices on the bottom shelf of the fridge which NA-A stated were just put in the fridge for supper. NA-I stated it was kitchen staff's responsibility to clean the unit fridges. NA-I verified the drawers at the bottom of the fridge and the bottom of the fridge itself had a red colored liquid substance in them. During an interview on 5/14/26 at 1:22 p.m., MGR-D stated it was dietary staff's responsibility to inspect and clean the unit refrigerators daily on the floors. A facility policy titled Food Safety Requirements, dated 4/1/26, was provided. The document included the following: Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety, and storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms. Additionally, Refrigerated storage - foods that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer, whichever is applicable. Practices to maintain safe refrigerated storage include:Monitoring food temperatures and functioning of the refrigeration equipment daily and at routine intervals during all hours of operation;Placing hot food in containers (e.g., shallow pans) that permit the food to cool rapidly;Separating raw foods (e.g., beef, fish, lamb, pork, and poultry) from each other and storing raw meats on shelves below fruits, vegetables or other ready-to-eat foods so that meat juices do not drip onto these foods; Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded; andKeeping foods covered or in tight containers.

Based on interview and document review, the facility failed to ensure resident mail was delivered to residents on Saturdays for 4 of 4 residents (R65, R82, R51, R128) who voiced concerns with mail delivery during Resident Council. This had the potential to affect all residents residing in the facility.Findings include:On 5/13/26 at 10:59 a.m., a Resident Council meeting was held with four residents from varied areas of the facility. R82, and R51 stated mail was not delivered to residents on Saturdays. This was confirmed by R128, and R65. R65 indicated mail delivered by the post office on Saturdays was not delivered by any staff until Monday.During interview on 5/13/26 at 2:01 p.m., director of nursing (DON) stated the mail was sorted when it came into the building and should be delivered on the same day by facility staff. DON stated it was the responsibility of all staff to ensure residents received their mail and stated it was a resident right to have their mail delivered in a timely manner. DON stated her expectation was for mail to be delivered to residents on the same day it arrived at the facility. DON could not identify a specific staff member to oversee mail delivery.During interview on 5/13/26 at 2:37 p.m., Administrator (Admin) stated it was the responsibility of all staff working in the building to deliver mail to residents, including mail delivery on the weekends. Admin stated the facility received a high volume of resident mail throughout the week and it was his expectation mail would be delivered to the residents the same day it was delivered to the facility.A policy was requested but not provided.

Based on interview, and document review, the facility failed to ensure non-pharmacological interventions were attempted and recorded prior to the administration of as-needed (PRN) narcotic/opioid and non-narcotic medication to help facilitate person-centered care planning and reduce the risk of complication (i.e., constipation, sedation) for 4 of 4 residents (R2, R15, R23, R155) reviewed for pain. In addition, the facility failed to ensure a scheduled antifungal medication was, as applicable, evaluated for the appropriateness of its continued use and stopped per the provider order for 1 of 5 residents (R118) reviewed for unnecessary medications. Findings include: R2 R2's admission Minimum Data Set (MDS) assessment dated [DATE], identified R2 had intact cognition without hallucinations or delusions present and no behaviors, or rejection of care. In addition, the MDS outlined R2 received both scheduled and PRN pain medications during the review and did receive any non-medication intervention for pain. Further, R2 indicated they had occasional pain which they rated at six (6) out of 10 (10 being the worst possible). R2's care plan, printed 5/13/26, identified R2 had chronic pain with need for medication management with a list goal of will voice/display level of comfort acceptable to the resident through the review date. The care plan listed interventions to help R2 meet this goal which included, opioid side effect monitoring: Monitor resident for any of the following: Tolerance level (is med still effective in managing pain?), is resident displaying signs of physical dependence that may cause symptoms of withdrawal when the med is stopped, held, or missed? Increased sensitivity to pain, constipation, nausea, vomiting, dry mouth, Sleepiness, dizziness, and/or confusion, depression, Itching and sweating. Document any positive indications or areas of concern and update MD, and Observe/document verbal and non-verbal s/sx of pain: Resident reports pain, Weight changes, protective behavior, guarding behavior, facial mask, irritability, self-focusing, restlessness, depression, Atrophy of involved muscle group, Changes in sleep pattern, Fatigue, Fear of re-injury, Reduced interaction with people, Altered ability to continue previous activities, Sympathetic mediated responses (e.g., temperature, cold, changes of body position, hypersensitivity), Anorexia. The care plan lacked evidence of identifying resident-specific non-pharmacological interventions that had been attempted, what interventions were effective, should be offered, or which interventions were ineffective for R2's pain management. On 5/11/26 at 2:42 p.m., R2 was observed seated in her wheelchair. R2 stated she had left shoulder pain for which she took Tylenol (acetaminophen). R2 stated staff did not offer any non-pharmacological interventions (i.e., ice, heat or massage) and stated it would be nice if they did as it would be helpful. R2's May Medication and Treatment Administration Record (MAR/TAR) for 5/1/26 to 5/13/26 was reviewed and identified the following relevant information: - acetaminophen 325 milligram (mg) tablet – give 3 tablets (975 mg) by mouth as needed 4 times a day for mild pain. Do Not Exceed 4,000 mg in 24 Hours with a start date of 2/17/26 which had been administered twice. Both administrations were marked with U which indicated 'unknown' effectiveness. All administrations were documented with a pain scale. There was no documentation with administration of a nonpharmacological intervention being offered prior to administration. The MAR/TAR lacked any orders or documentation for nonpharmacological interventions offered or attempted prior to administration of PRN medication administrated for pain. R2's progress notes, dated 5/1/26 to 5/13/26, were reviewed. Progress notes lacked evidence of nonpharmacological interventions being offered or attempted prior to administration of PRN pain medication. R2's medical record was reviewed and lacked evidence of what, if any, non-pharmacological interventions were offered or attempted prior to the administration of the PRN pain medication all the administered doses from 5/1/26 to 5/13/26. R15 R15's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R15's short term or long-term memory were both marked as memory ok after staff assessment of mental status was completed. In addition, the MDS outlined R15 received both scheduled and non-medication interventions for pain during the review; however, did not receive any PRN pain medication. Further, R15 indicated they had frequent pain which they rated at 4 out of 10. R15's care plan, printed 5/13/26, identified R15 had actual/potential for acute and chronic pain with need for medication management related to fibromyalgia, PCV, osteoarthritis, gout, plantar fascial, fibromatosis, RLS with a list goal of will not have an interruption in normal activities due to pain through the review date. The care plan listed interventions to help R15 meet this goal which included, notify medical practitioner if interventions are unsuccessful or if current compliant is a significant change from past experience of pain, and provide analgesia as ordered, observe/document for side effects and effectiveness. Additionally, the care plan identified R15 had a terminal prognosis requiring hospice involvement/palliative care for cancer/end stage disease process with a list goal of comfort will be maintained through the review date. Listed interventions included: Observe closely for non-verbal indicators of pain. Administer analgesics as ordered. Monitor for side effects of medication and breakthrough pain. Notify medical practitioner if side effects of pain management pain ineffective, and offer comfort alternatives such as music of choice, aroma therapy, soft lighting, other. On 5/11/26 at 12:47 p.m., R15 was observed lying in bed and stated she couldn't talk due to being in so much pain. On 5/12/26 at 10:21 a.m., R15 was observed lying in bed moaning. R15's May Medication and Treatment Administration Record (MAR/TAR) for 5/1/26 to 5/13/26 was reviewed and identified the following relevant information: -oxycodone (opioid pain medication) 10 mg- give 10 mg by mouth every 4 hours as needed for pain and shortness of breath with a start date of 4/28/26 which had been administered 14 times. Three administrations were marked with an I which indicated ineffective and 5 with an U which indicated unknown per follow-up code guide. 6 administrations were documented with an e indicated effective. All administrations were documented with pain scale. There was no documentation with administration of a nonpharmacological intervention being offered prior to administration. The MAR/TAR lacked any orders or documentation for nonpharmacological interventions offered or attempted prior to administration of PRN medication administrated for pain. R15's progress notes, dated 5/1/26 to 5/13/26, were reviewed. Progress notes lacked evidence of nonpharmacological interventions being offered or attempted prior to administration of PRN pain medication. R15's medical record was reviewed and lacked evidence of what, if any, non-pharmacological interventions were offered or attempted prior to the administration of the PRN pain medication all the administered doses from 5/1/26 to 5/13/26. On 5/11/26 at 12:52 p.m., trained medication aid (TMA)-A stated that R15 was in constant pain and was going to visit with R15. R23 R23's admission MDS assessment dated [DATE], identified R23 had intact cognition with no hallucinations, delusions, verbal or physical behaviors. In addition, the MDS outlined R23 received both scheduled and PRN pain medications during the review; however, did not receive any non-medication intervention for pain. Further, R23 indicated they had almost constant pain which they rated at 10 out of 10. R23's care plan, printed 5/13/26, identified R23 had actual chronic and acute pain with needs for medication management related to chronic lower extremity pain and acute pain due to wounds with a list goal of will voice/display a level of comfort acceptable to the resident through the review date. The care plan listed interventions to help R23 meet this goal which included: observe for potential side effects and report to medical practitioner; opioid side effect monitoring: tolerance level, physical dependence, increased sensitivity to pain, document any positive indications and update MD; Observe/document pain characteristics PRN: Quality (e.g., sharp, burning), Severity (1 to 10 scale), Anatomical location, Onset, Duration (e.g., continuous, intermittent), Aggravating factors, Relieving factors; observe/document verbal and non-verbal signs and symptoms of pain; notify medical practitioner if interventions are unsuccessful of if current complain is a significant change from past experience of pain; and provide analgesia as ordered. The care plan lacked evidence of identifying resident-specific non-pharmacological interventions that had been attempted, what interventions were effective, should be offered, or what interventions were ineffective for R23's pain management. On 5/11/26 at 3:17 p.m., R23 stated she has chronic pain which she felt had not been managed well by the facility as she stated they made changes to her pain medication without talking with her. R23 stated they had not offered any sort of non-pharmacological interventions to help manage her pain, which might be helpful at times. During an observation and interview on 5/11/26 at 5:25 p.m., R23 was in the dining room telling staff that she was in pain and stated staff weren't doing anything about it. R23's May Medication and Treatment Administration Record (MAR/TAR) for 5/1/26 to 5/12/26 was reviewed and identified the following relevant information: -acetaminophen 500 mg tablet – give 1000 mg by mouth every 6 hours as needed for mild-moderate pain with max dose of 4000g in 24 hours with a start date of 4/11/26 and end date of 5/11/26 and restarted 5/11/26 which had been administered one time. The administration was marked with e indicating effective and was documented with a pain scale. There was no documentation with administration of a nonpharmacological intervention being offered prior to administration. -hydromorphone (opioid pain medication) 2 mg tablet – give 2 mg by mouth as needed for severe chronic pain as needed three times a day with a start date of 4/29/26 ending 5/11/26 which had been administered 18 times. Two administrations were marked with an I which indicated ineffective and four with an U which indicated unknown per follow-up code guide. The remaining 12 administrations were documented with an e indicated effective. All administrations were documented with pain scale. There was no documentation with administration of a nonpharmacological intervention being offered prior to administration. -hydromorphone 2 mg table – give 2 mg by mouth as needed for severe breakthrough pain max 3 times a day, at least 4 hours between doses, consider giving a doze 30-40 minutes prior to dressing change. Hold for RR (respiration rate) less than 10, sedation, confusion with a start date of 5/11/26 which had been administered 4 times. All administrations had a pain scale. There was no documentation with administration of a nonpharmacological intervention being offered prior to administration. The MAR/TAR lacked orders or documentation for nonpharmacological interventions offered or attempted prior to administration of PRN medication administrated for pain. R23's progress notes, dated 5/1/26 to 5/12/26, were reviewed. Progress notes lacked evidence of nonpharmacological interventions being offered or attempted prior to administration of PRN pain medication. R23's medical record was reviewed and lacked evidence of what, if any, non-pharmacological interventions were offered or attempted prior to the administration of the PRN pain medication all the administered doses from 5/1/26 to 5/12/26. R155 R155's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R155 had moderately impaired cognition, no hallucinations, delusions, behaviors or rejection of care. In addition, the MDS outlined R155 received both scheduled pain medications during the review; however, did not receive any PRN pain medication or non-medication interventions for pain. R155's care plan, printed 5/13/26, identified R155 had actual chronic pain with need for medication management with a list goal of will voice/display a level of comfort acceptable to the resident through the review date. The care plan listed interventions to help R155 meet this goal which included, Offer non-pharmacological interventions for pain relief such as music, repositioning, massage, integrative therapies and observe for effectiveness, and provide analgesia as ordered. Observe/document for side effects and effectiveness. On 5/11/26 at 12:30 p.m., R155 was observed laying in bed. R155 stated it was not a good day but did not elaborate. R155 was observed attempting to feed himself lunch. R155's May Medication and Treatment Administration Record (MAR/TAR) for 5/1/26 to 5/14/26 was reviewed and identified the following relevant information: -hydromorphone 2 mg tablet – give 2 mg by mouth every 4 hours as needed for pain with a start date of 11/26/25 which had been administered 2 times. Both administrations were marked with an e indicating effective. Both administrations were documented with a pain scale. There was no documentation with administration of a nonpharmacological intervention being offered prior to administration. The MAR/TAR lacked any orders or documentation for nonpharmacological interventions offered or attempted prior to administration of PRN medication administrated for pain. R155's progress notes, dated 5/1/26 to 5/14/26, were reviewed. Progress notes lacked evidence of nonpharmacological interventions being offered or attempted prior to administration of PRN pain medication. R155's medical record was reviewed and lacked evidence of what, if any, non-pharmacological interventions were offered or attempted prior to the administration of the PRN narcotic medication all the administered doses from 5/1/26 to 5/14/26. On 5/13/26 at 9:57 a.m., nursing assistant (NA)-H stated if a resident complained of pain, they notified the nurse or TMA (trained medication aid) right away. NA-H stated they did not offer any interventions. On 5/13/26 at 12:03 p.m., trained medication aid (TMA)-A stated if a resident reported pain, they notified the nurse and administered a PRN medication. TMA-A stated if a resident asked for an ice pack or other nonpharmacological interventions then they would provide it but did not offer them unless requested. On 5/13/26 at 12:21 p.m., licensed practical nurse (LPN)-B stated they should be offering and documenting non-pharmacological interventions prior to administering PRN pain medications. LPN-B stated if any non-pharmacological interventions were offered, they would be in the progress notes. On 5/14/26 at 10:07 a.m., assistant director of nursing (ADON)-A stated the expectation was that non-pharmacological interventions would be offered prior to any PRN medication administration and documented in the progress notes as the medication notes are linked to the progress notes. ADON-A stated it was important to offer non-pharmacological interventions prior to PRN administration as want to reduce medications whenever able. On 5/14/26 at 11:37 a.m., ADON-A stated she had reviewed R2, R15, R23 and R155's electronic medication records and paper records. ADON-A verified the PRN administered above for R2, R15, R23 and R155 and verified there were no documented non-pharmacological interventions offered with PRN pain medication administrations. On 5/14/26 at 12:56 p.m., director of nursing (DON) stated it would be on a case-by-case basis whether a resident would be offered non-pharmacological interventions prior to PRN pain medications as it was a resident's choice. DON stated (R2), (R23) and (R155) don't like non-pharmacological interventions and (R15) was on hospice. DON stated she would follow up. No additional information was provided. A facility policy titled PRN medications, dated 4/1/26, was provided. The policy does not specifically address non-pharmacological interventions and PRN pain medications. R118 R118's quarterly Minimum Data Set (MDS) dated [DATE], indicated R118 had intact cognition and was diagnosed with respiratory failure and debility. The MDS indicated R118 was independent with most activities of daily living (ADLs). R118's Physician's order form dated 3/9/26, indicated R118 was to use Nystatin powder to the groin daily for a duration of 14 days. R118's order summary dated 3/10/26, included an order dated 3/10/26 for Nystatin Powder applied topically to the groin in the morning and did not include an end date. R118's medication administration record (MAR) dated 5/1/26 to 5/12/26, indicated the Nystatin powder to the groin was administered every day during the period. R8's progress note dated: -4/24/26 to 5/8/26 were reviewed and did not indicate R118 had skin alteration to her groin. -4/24/26 at 1:48 p.m., indicated no skin issues were identified. -5/1/26 at 2:05 p.m., indicated no skin issues were identified. -5/8/26 at 1:31 p.m., indicated no skin issues were identified. -5/8/26 at 3:59 p.m., indicated no skin issues were identified. R118's pharmacist review dated 3/30/26, indicated R118 had an order for nystatin powder to the groin in the morning for redness. The review indicated antifungals should be discontinued when healing was complete, as prolonged, unnecessary use can cause drug-resistant fungal infections. The review indicated Candida [yeast] rashes typically take one to two weeks to resolve with treatment, so the pharmacist recommended the nystatin powder be discontinued. During an interview on 5/13/26 at 10:18 a.m., R118 stated she used the nystatin powder in her groin every day. R118 stated she did not currently have any redness or open areas in her groin. During an interview on 5/13/26 at 10:20 a.m., registered nurse (RN)-H stated R118 did not have any skin alterations at this time. RN-H stated at one point, R118 did have redness in her groin but was unsure when this resolved. During an interview on 5/14/26 at 2:26 p.m. with the director of nursing (DON) and assistant director of nursing (ADON)-B, the DON stated it depended on how the order was written when the nystatin powder should be discontinued, but confirmed discontinuation should be completed per the provider order.

Based interview and record review, the facility failed to ensure accurate and complete clinical records for 3 of 5 residents reviewed for immunizations (R7, R59, and R130) by incorrectly documenting COVID-19 vaccinations as influenza vaccinations in the electronic medical record (EMR). This had the potential to result in inaccurate medical records, confusion regarding residents' immunization status, inappropriate clinical decision-making, and the transmission of inaccurate health information during transfers, hospitalizations, or discharge to another provider. Findings include: R7R7's quarterly Minimum Data Set (MDS) assessment, dated 2/10/26, indicated R7 was admitted to the facility on [DATE].R7's immunization record revealed an influenza vaccination was documented as administered on 9/26/25. The immunization record further revealed a second influenza vaccination was documented as administered on 4/15/26, during the same influenza season.R59R59's quarterly MDS assessment, dated 4/17/26, indicated R59 was admitted to the facility on [DATE].R59's immunization record revealed an influenza vaccination was documented as administered on 9/26/25. The immunization record further revealed a second influenza vaccination was documented as administered on 4/15/26, during the same influenza season.R130R130's quarterly MDS assessment, dated 2/24/26, indicated R130 was admitted to the facility on [DATE].R130's immunization record revealed an influenza vaccination was documented as administered on 9/26/25. The immunization record further revealed a second influenza vaccination was documented as administered on 4/15/26, during the same influenza season.During an interview on 5/14/26 at approximately 11:15 a.m., the Director of Nursing (DON), who also served as the facility's Infection Preventionist (IP), stated the influenza vaccinations documented in the EMR were entered incorrectly. The DON stated the vaccination clinic conducted in April 2026 was a COVID-19 vaccination clinic and not an influenza vaccination clinic.During a follow-up interview on 5/14/26 at 2:56 p.m., the DON stated staff would use the Minnesota Immunization Information Connection (MIIC) to verify which vaccine a resident actually received. The DON acknowledged it was best practice for residents' medical records to be accurate. A facility policy regarding accurate medical records was requested, however the facility was unable to provide a policy that addressed the requirement for maintaining accurate and complete medical records.

Based on observation, interview, and document review, the facility failed to ensure the need for enhanced barrier precautions (EBP) was identified and implemented for 4 of 4 residents reviewed for transmission-based precautions, three of whom (R2, R10, R135) received dialysis via dialysis access sites located on the right upper chest (a central venous catheter (CVC)), and one (R60) who had an open wound. The facility further failed to implement infection prevention and control practices related to oxygen equipment storage, handling, and use for 1 of 1 resident (R51) reviewed for oxygen therapy by failing to ensure oxygen tubing and nasal cannula equipment remained off the floor and failed to prevent potentially contaminated oxygen equipment from being reapplied to the resident without cleaning or replacement. Findings include: R2 R2's admission Minimum Data Set (MDS) assessment dated [DATE], identified R2 had intact cognition without hallucinations or delusions present with no behaviors, or rejection of care present. In addition, the MDS outline R2 received dialysis while a resident at the facility. During an interview and observation on 5/11/26 at 2:51 p.m., R2 stated she received dialysis via a port on her right upper chest. R2 stated staff did not wear gowns when they assisted her. There was no EBP sign on R2 door, plastic bin outside the door containing proper personal professional equipment (PPE) or bin for disposal of PPE by R2's door During a follow up observation on 5/13/26 at 8:24 a.m., there continued to be no EBP signage on R2's door. R2's care plan, printed 5/13/26, identified R2 required dialysis with potential for CVC malfunction related to renal failure. The care plan lacked identification of need for enhanced barrier precautions. R2's Treatment Details Report, dated 5/1/26, identified R2 had a tunneled Central Venous Catheter (CVC) on her right chest for dialysis access site which was used. R10 R10's significant change in status MDS assessment dated [DATE], identified R10 had severe cognitive impairment with physical behavioral symptoms presenting 1 to 3 days during the look back period, verbal behaviors, and other behavioral symptoms not directed towards others occurring daily which significantly interfere with resident's care. In addition, the MDS outlined R10 received dialysis while a resident at the facility. During an observation on 5/11/26 at 5:38 p.m., there was no EBP signage on R10's door. Furthermore, there was no bin containing PPE outside R10's room or bin for disposal for PPE by R10's door. During a follow up observation on 5/13/26 at 8:25 a.m., there continued to be no EBP signage on R10's door. R10's care plan, printed 5/13/26, identified R10 required dialysis with potential for fistula/graft malfunction related to end stage renal failure. The care plan lacked evidence of the need for enhanced barrier precautions. R10's Treatment Details Report, dated 5/1/26, identified R10 had a tunneled Central Venous Catheter (CVC) on her right chest for dialysis access site which was used. R135 R135's admission MDS assessment dated [DATE], identified R135 had intact cognition without delusions and no behaviors, or rejection of care present. In addition, the MDS outline R135 received dialysis while a resident at the facility. R135's care plan, printed 5/13/26, identified R135 required dialysis with potential for CVC malfunction related to renal failure. The care plan lacked identification of need for enhanced barrier precautions. R135's Treatment Details Report, dated 5/1/26, identified R135 had a tunneled Central Venous Catheter (CVC) on his left chest for dialysis access site which was used. During an interview and observation on 5/11/26 at 12:22 p.m., R135 stated he received dialysis through a dialysis port on his right upper chest. R135 stated staff did not wear gowns when assisting him. There was no EBP sign on the R135's door, plastic bin outside the door containing PPE or garbage bin for disposal of PPE by R135's door. During a follow up observation on 5/13/26 at 8:24 a.m., there continued to be no EBP signage on R135's door. During an interview on 5/13/26 at 12:06 p.m., trained medication aid (TMA)-A stated if a resident was on any sort of precautions (EBP, contact, etc), there would be a sign on the resident door indicating what type of precautions they were on along with a PPE bin outside the door. During an interview on 5/13/26 at 9:54 a.m., nursing assistant (NA)-H stated they were familiar with R2, R10 and R135. NA-H stated R2 was on fall precautions but not on EBP precautions. NA-H stated R10 and R135 were not on EBP either. NA-H verified R2, R10 and R135 did not have EBP signage on their doors or PPE bins outside their rooms. During an interview on 5/13/26 at 12:30 p.m., licensed practical nurse (LPN)-B stated R2, R10 or R135 were not on EBP precautions. After reviewing R2, R10 and R135's medical records, LPN-B verified R2, R10 and R135 have tunneled CVC dialysis access sites. During an interview on 5/14/26 at 10:10 a.m., assistant director of nursing (ADON)-A stated it was not the facility practice for residents on dialysis with tunneled CVC access sites to be on EBP precautions. ADON-A stated a resident may be on EBP for another reason, but the facility did not put residents on EBP for a dialysis site alone. ADON-A reviewed R2, R10 and R135's medical records, verified R2, R10 and R135 had tunneled CVC dialysis access sites and verified R2, R10 and R135 were not on EBP precautions. ADON-A reviewed the precautions list kept in the nursing office and verified no residents listed were on EBP for dialysis. On 5/14/26 at 1:03 p.m., director of nursing (DON) stated she would have to look at the policy regarding wearing PPE and dialysis. DON added, if we touch the fistula, then we would have to wear PPE, but we don't touch the fistula, so we don't have to wear PPE. No additional information was provided. A facility policy titled Hemodialysis, dated 4/1/26, identified the following: 14. The nurse will ensure that the dialysis access site (e.g. AV shunt or graft) is checked before and after dialysis treatments and every shift for patency by auscultating for a bruit and palpating for a thrill. If absent, the nurse will immediately notify the attending physician, dialysis facility and/or nephrologist, 16. Residents with external dialysis catheters will be assessed every shift to ensure that the catheter dressing is intact and not soiled. Change dressing to site only per the dialysis facility's direction, and 17. The staff will ensure that appropriate PPE is worn and follow current infection control practices when assessing dialysis access sites. R60 R60's quarterly Minimum Data Set (MDS) dated [DATE], indicated R60 had severely impaired cognition, was dependent on staff for personal hygiene, and was at risk for developing pressure ulcers/injuries. R60's diagnoses included Alzheimer's disease, dementia, bipolar, and overactive bladder. R60's care plan dated 4/23/26, indicated R60 had actual skin impairment and required wound care of a gluteal fold (area between the buttocks and the upper thigh) wound, and instructed, Treatment as ordered and Daily wound monitoring in place. R60's care plan lacked evidence EPB was required. R60's provider orders dated 5/7/26, indicated, Right gluteus wound cleanse with wound cleanser, pat dry. Apply foam QD [every day] and PRN [as needed]. Until healed. Additionally, Left gluteus wound cleanse with wound cleanser, pat dry. Apply Medi honey [medical grade honey product used to promote wound healing, prevent infection, and support skin repair] and foam QD and PRN. R60's provider orders lacked evidence of EBP. R60's progress note (PN) dated 4/22/26, indicated Skin has open area on L gluteal fold. R60's PN dated 5/6/26 at 3:57 p.m., indicated, Left Gluteal Fold. Issue type: Pressure ulcer/injury.Stage 2 Pressure ulcer/injury – partial thickness skin loss with exposed dermis. In addition, New skin issue.Right Gluteal Fold.Stage 3 Pressure ulcer/injury – full thickness skin loss.mixture of serous and sanguineous fluid. During observation on 5/11/26 at 6:30 p.m., R60's doorway lacked signage for EBP and there was no isolation cart anywhere in R60's hallway. During observation on 5/12/26 at 12:47 p.m., nursing assistant (NA)-G wheeled R60 into her room to offer toilet, check and change, and lay down. NA-F also into room to assist. Both NA's donned gloves, and neither NA donned a gown. NA-G placed a transfer belt around R60 and both NAs assisted her to a standing position by the toilet. R60's brief was removed and she was transferred to toilet. R60 was able to pass some urine and small bowel movement. NA-G and NA-F assisted with peri care. Dressing dated 5/11/26 was covering the left gluteal fold and an undressed open wound was observed on the right gluteal fold. A new brief was placed, pants pulled up and R60 was assisted into bed. During interview on 5/12/26 at 12:59 p.m., NA-F stated was not sure how long R60 had the two wounds on her bottom, but it was the NA's responsibility to notify the nurse of new skin concerns. NA-F further stated would notify the nurse that the one dressing was missing, and needed to be replaced. During observation on 5/12/26 at 1:02 p.m., registered nurse (RN)-D and nursing assistant (NA)-G went into R60's room to complete wound care. RN-D and NA-G both donned gloves and neither donned a gown. RN-D prepared two new dressings by writing the date on each one. R60's pants and brief were pulled down and the old dressing removed. The left gluteal wound appeared closed and nearly healed, while the right gluteal wound was approximately 4 cm and open and reddened with some oozing of clear drainage. RN-D used wound cleanser on the right wound, patted dry, and placed a foam adhesive dressing over it. RN-D then cleansed the left wound, patted it dry and placed a foam adhesive dressing over it. During interview on 5/12/26 at 1:14 p.m., NA-G stated R60 had one wound for quite a while and another one just recently developed. NA-G stated could not remember R60 ever being on EBP and thought gloves were the only requirement when completing any cares for R60. During interview on 5/12/26 at 1:22 p.m., RN-D stated R60 had wounds for a couple months and could not recall that she was ever on EBP. RN-D stated EBP should be used when there was an open wound, and that he probably should have worn a gown during wound care earlier. During observation on 5/13/26 at 7:24 a.m., R60's door had EBP signage and an isolation cart in the hallway outside her room. During interview on 5/13/26 at 11:58 a.m., licensed practical nurse (LPN)-A stated she had been working at the facility for about three months and had been completing wound care on R60 since then. LPN-A stated EBP was initiated this morning and confirmed EBP had not been used previously during wound care on R60. During interview on 5/13/26 at 2:17 p.m., RN-E stated she completed wound rounds on R60 that morning and felt that the left gluteal wound appeared healed and the right wound was open and stable when compared to the previous week. RN-E stated EBP should have been initiated last week when the right gluteal wound was discovered as a new open wound. RN-E could not explain why EBP had not been initiated until today. During interview on 5/14/26 11:19 a.m., director of nursing (DON), who was also the infection preventionist (IP), stated EBP should be initiated as soon as an open wound was identified. DON could not explain why EBP were not initiated for R60 until today. Facility policy Enhanced Barrier Precautions dated 4/1/26, indicated, EBP was an infection control intervention utilizing gown and gloves during high contact resident care to reduce transmission of multidrug-resistant organisms (MDRO). The policy further indicated and order would be obtained and EBP initiated for residents with wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO. (Peripheral IVs, continuous glucose monitors, insulin pumps, or ostomies without an associated indwelling medical device are not an indication for EBP.) The policy indicated gowns and gloves would be readily available outside the resident room and would be used during all high contact resident care including wound care: any skin opening requiring a dressing. R51 R51's quarterly Minimum Data Set (MDS), dated [DATE], identified R51 received oxygen therapy and used a noninvasive mechanical ventilator. The MDS further identified R51 required substantial to maximal assistance with most activities of daily living and was cognitively intact. R51's physician orders identified prior orders for continuous oxygen at 4 liters per minute (LPM) via nasal cannula or mask to maintain oxygen saturations at or above 90%, oxygen at 2 LPM via nasal cannula while sleeping until CPAP supplies arrived, and CPAP/BIPAP settings of CPAP 16/EPAP 8 with 3 LPM oxygen. Those orders discontinued on 4/24/26 following hospitalization and return to the facility on 4/25/26. R51's care plan, dated 4/29/26, identified R51 had altered respiratory status and required oxygen therapy, including interventions to provide oxygen as ordered and observe pulse oximetry readings. During interview and observation on 5/13/26 at 7:33 a.m., R51 stated the night nurse applied oxygen at 2 LPM overnight and licensed practical nurse (LPN)-F removed it that morning. Observation revealed the oxygen tubing and nasal cannula lying on the floor while the oxygen tank remained turned on. During interview and observation on 5/13/26 at 9:07 a.m., LPN-E stated staff completed daily vital signs for R51 and R51's oxygen saturation levels should remain above 90%, with oxygen applied at 2 LPM as needed to maintain those levels. LPN-E picked up the oxygen tubing and nasal cannula from the floor, reconnected the tubing to the oxygen source, and immediately reapplied the nasal cannula to R51 without cleaning or replacing the equipment. LPN-E stated he was unsure when the oxygen tubing had last been changed. During interview on 5/14/26 at 10:00 a.m., the director of nursing (DON), who also served as the facility's infection preventionist (IP), was asked about concerns related to oxygen tubing and nasal cannulas being left on the floor and not routinely changed. The DON/IP stated, I would have to find out a little bit more about why and she (R51) gets angry a lot. The DON/IP further stated R51 was very particular, liked certain people only, and will fixate on people and if they do the slightest thing. When asked about the infection risk associated with oxygen tubing and a nasal cannula being picked up from the floor and placed directly back into a resident's nose without cleaning or replacement, the DON/IP refused to comment on the infection risk.

Based on observation, interview, and document review, the facility failed to ensure resident's dignity was maintained for 2 of 2 residents (R60,R51) observed during personal cares. In addition, the facility failed to ensure dignity was maintained for 2 of 2 residents (R47, R134) who experienced uncontrolled loss of bladder and bowel function waiting for staff to answer their call lights. Findings include: R60's quarterly Minimum Data Set (MDS) dated [DATE], indicated R60 had severely impaired cognition, was dependent on staff for personal hygiene, and was frequently incontinent of bowel and bladder. R60's diagnoses included Alzheimer's disease, dementia, bipolar, and overactive bladder. R60's care plan dated 4/23/26, indicated R60 had actual skin impairment and required wound care of a gluteal fold (area between the buttocks and the upper thigh) wound, was incontinent of bowel and bladder and required perineal care after each incontinent episode, had a communication problem and had difficulty expressing wants due to impaired cognition, and had an ADL (activities of daily living) self-care deficit and required substantial to maximal assistance with personal cares. During observation on 5/12/26 at 1:02 p.m., registered nurse (RN)-D and nursing assistant (NA)-G into R60's room to complete wound care and perform incontinent care. R60's door was left ajar approximately 18 inches on the right side of the doorway. R60 was lying in bed. There was no privacy curtain and R60's bed was to the left and in view from the doorway. R60's pants pulled down to her ankles and incontinent brief removed. R60 was positioned on her left side with her exposed bottom to the center of the room. At 1:10 PM housekeeper (H)-A knocked on R60's door and announced self as laundry. Neither RN-D nor NA-G said anything to stop H-A from entering. H-A entered R60's room and placed clean clothes in her closet and left the room. During interview on 5/12/26 at 1:14 p.m., NA-G stated the resident's room should be closed during incontinent cares to provide privacy and maintain dignity. NA-G stated someone should have spoken up and stopped H-A from entering R60's room while she was exposed. NA-G stated staff should knock and wait for a response prior to entering a resident's room. During interview on 5/12/26 at 1:22 p.m., RN-D stated R60's door should have been closed during incontinent and wound care, and that H-A should have waited for a response before entering her room. RN-D further stated he or NA-G should have said something when H-A knocked to stop him from entering. RN-D stated it was important to protect the resident's privacy and dignity during cares. During interview on 5/12/26 at 1:35 p.m., H-A stated he knocked and announced himself when he delivered clothing to R60's room and did not hear anyone tell him not to enter. H-A further stated the door was partially open which he thought indicated it would be okay to enter. H-A stated he could see that R60 was exposed, and he should not have been allowed to enter when personal cares were being completed. During interview on 5/13/26 at 2:17 p.m., RN-E stated they would expect staff to pull privacy curtains and close the resident's door during cares. They would also expect staff to knock prior to entering a resident room and for staff inside to respond whether they could enter or not, and for the staff at the door wait for that answer. RN-E stated it was usually not appropriate for non-nursing staff to enter a resident's room while personal cares were being performed. During interview on 5/14/26 at 11:19 a.m., director of nursing (DON) stated would expect the door to be closed during cares and staff would not enter without permission. DON further stated the staff performing personal cares should respond and inform the person knocking not to enter when it was not appropriate to do so. R51 R51's quarterly Minimum Data Set (MDS), dated [DATE], indicated R51 was admitted to the care facility on 2/5/2020 and was cognitively intake. The MDS further indicated R51 required substantial to maximum assistance with most activities of daily living (ADLs). R51's care plan, dated 2/5/2020, indicated R51 had an ADL self-care performance deficit related to chronic cellulitis, morbid obesity, osteoarthritis, cancer and chronic pain and required substantial assistance of one staff for personal hygiene and assistance of 2 staff for transfers via a mechanical lift. During observation and interview on 05/13/2026 at 9:18 a.m., Nursing Assistant (NA)-E provided incontinent care to R51 in bed. NA-E gathered supplies, removed the resident's oxygen and turned the oxygen concentrator off, removed the resident's blanket, and provided perineal and skin care while the resident remained exposed in bed. NA-E discussed the resident's skin condition and treatments with the resident while applying barrier cream to the groin and buttocks areas and assisting the resident with dressing and repositioning. During the care, multiple staff entered the resident's room without waiting for permission to enter. At 9:40 a.m., the Administrator knocked and immediately entered the room while the resident remained uncovered from the waist up and wearing only a brief. R51 stated, big ole negative on that one, that [administrator], shame on him, he just walked right in. The administrator stated he heard voices and thought someone said, come in. At 9:41 a.m., Licensed Practical Nurse (LPN)-D knocked and entered the room without waiting for a response while the resident continued receiving care in bed. At 10:02 a.m., Registered Nurse (RN)-G knocked once and immediately walked into the room with morning medications while care continued. Facility policy Promoting/Maintaining Resident Dignity dated 4/1/26, indicated, All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. The policy further instructed, Maintain resident privacy. R47 R47's admissions Minimum Data Set (MDS) dated [DATE] identified R47 with intact cognition, used a walker or wheelchair for mobility and required set up or cleanup for toileting hygiene. In addition, R47 had diagnoses of anxiety, chronic obstructive pulmonary disease, respiratory failure, fibromyalgia, opioid abuse, pulmonary fibrosis and dependence on supplemental oxygen. During interview with R47 on 5/11/26 at 11:55 a.m., R47 stated on 5/10/26 during the day shift she had the urge to have a bowel movement so she pressed her call light on and could not wait so she stood up and walked to the bathroom using her wheeled walker and wearing her oxygen tubing. During the walk, she had an accident on the floor before getting to the toilet. R47 said she had waited as long as she could for help, but staff did not arrive in time. I felt so bad. I kept saying I was sorry because I felt really bad, but I could not hold it. Review of call light logs for 5/10/26 identified a wait of 38 minutes and 53 minutes at 1:06 p.m. R134 R134's admissions MDS dated [DATE] identified R134 with intact cognition, did not reject cares, required substantial to maximal assist with dressing, hygiene and bed mobility. In addition, R134 had frequent incontinence of urine and stool, and an unhealed pressure ulcer. Also, R134 had diagnoses of Multiple Sclerosis (MS), heart failure, diabetes, obesity and a stroke leading to partial paralysis of lower limbs. During observation and interview with R134 on 5/11/26 at 11:36 a.m., R134 stated he had an experience in April [2026], I pooped in my brief and had to sit in it.before they came. R134 stated he had pressed his call light for assistance and the staff ignored him. R134 stated he was very upset and angry about experiencing the episode. Review of facility call light log for R134 on date of April 19, 2026, identified a call light wait of 58 minutes and 15 seconds. During interview with registered nurse (RN)-A on 5/13/26 at 8:21 a.m., RN-A stated, usually 10 minutes is max for waiting for someone to answer [the call light]. RN-A stated a delay in answering a call light could result, in a medical emergency including falling, having a urine or bowel accident and the effects of waiting, affects their mental health and dignity. During interview with nursing assistant (NA)-A on 5/13/26 at 8:31 a.m., NA-A stated expectation of answering a call light as 5 to 6 minutes. NA-A stated there was a risk of residents being impatient, at increased risk for falls and, feel upset if they have an accident before staff can help them. During interview with RN-B on 5/13/26 at 9:12 a.m., RN-B stated she was the nurse manager on the unit including R47 and R134. RN-B stated expectation of staff to answer call lights in under 10 minutes. RN-B stated risk of long call lights included residents attempting to transfer themselves without assistance, and emotional distress. RN-B stated, it is emotional if someone has an accident waiting for help. I would feel bad if it happened to me. And angry. RN-B reviewed call light logs for R47 and R134 and stated the wait times were too long and not acceptable. During interview with director of nursing on 5/13/26 at 1:05 p.m., DON stated expectation of staff to answer call lights within 15 minutes. DON reviewed call light logs for R47 and R134 and stated, that is not ok. Facility policy titled Notification of Changes, effective 04/2025 state, All staff members who see or hear an activated call light are responsible for responding.

Based on observation, interview, and document review, the facility failed to honor 1 of 1 residents (R61) request for larger than the regular/standard portion sizes, reviewed for food choices who had complained of hunger between meals when receiving the facility's standard portion size of protein. Findings include:R61's quarterly Minimum Data Set (MDS) dated [DATE], indicated R61 had intact cognition and was diagnosed with diabetes and depression, and malnutrition. The MDS indicated R61 had no weight gain or loss of five percent or greater in the last month or 10 percent or greater in the last six months.R61's diet order dated 11/20/25, indicated R61 was to receive a CSC regular texture diet. The diet order did not include a reference to large portions.R61's dietary progress note dated 2/25/26 at 12:01 p.m., indicated R61 had complained of increased hunger for meals, and the dietician had added for the resident to receive larger protein portions at all meals to his meal ticket.R61's care plan dated 5/14/26, indicated R61 had potential for a nutrition problem related to a diagnosis of diabetes, a history of a heart attack and a stroke, a therapeutic diet related to diabetes, reduced mobility with need for staff assistance, and recurrent depression. The care plan indicated that R61 was to receive double protein portions, and staff were to provide and serve the diet as ordered.During an observation on 5/12/26 at 11:36 a.m., R61 was observed sitting at a dining table with three other residents. R61's meal ticket indicated he was to get larger protein/main dish portions. R61 was given one piece of what appeared to be chicken (a light colored meat) that was about 75% of the size of a deck of cards, about 1/2 to 3/4 cups mixed vegetables, and three small potatoes. When R61's given portion of chicken was compared to multiple other residents' in the dining room whose tickets did not indicate larger portions, R61's portion was noticeably smaller.During an interview on 5/12/26 at 11:36 a.m., R61 stated he was supposed to get larger portions of his main meal because he gets hungry, but they never give it to him, and confirmed he did not feel that he had gotten large protein servings since he had asked for the increase.During an interview on 5/12/26 at 11:39 a.m., registered nurse (RN)-E was asked about the portion sizes of R61's meal and stated that, after looking at R61's meal, his protein serving did not look like a large serving or larger than other residents' servings.During an interview on 5/14/26 at 2:12 p.m., the dietary manager (D-MGR) stated that when a resident needs large portions, this was communicated to staff on the resident's meal ticket. The D-MGR stated that if a resident was supposed to get double portions, staff should give six ounces instead of three ounces of meat. The D-MGR stated that the chicken pieces came pre-proportioned, so she will have to look into their size. The D-MGR stated she would expect staff to find a resident a larger piece of chicken if they were supposed to have larger protein portions. At 2:48 p.m., the D-MGR brought a document indicating the facility bought bone-in 4.5-ounce pieces of chicken that included an assortment of wings, drumsticks, breasts, and thighs. The D-MGR stated that they were only required to give the residents three ounces of protein, so they had been giving everyone larger portions, including R61. When asked how long they had been serving this size of chicken pieces, D-MGR was not able to give a date, but stated this was the standard size of chicken portions they had been giving all residents on a regular portioned diet and a larger protein portioned diet. During an interview on 5/14/26 at 2:19 p.m., dietary aide (DA)-A confirmed that she helped to plate and serve food. DA-A stated that if a ticket said larger protein, they were supposed to give two pieces of meat instead of one.A policy regarding diet choices was requested but not received.

Based on interview and document review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to 1 of 2 residents (R6) reviewed, whose Medicare Part A coverage ended and remained in the facility. Findings include:R6's quarterly Minimum Data Set (MDS) dated [DATE], indicated R6's most recent Medicare-covered stay was from 1/1/26 to 1/12/26.R6's Notice of Medicare Non-Coverage (CMS-10123) dated 1/12/26, indicated R6's last covered day of Medicare A would be 1/12/26 and indicated the resident representative was notified on 1/9/26.R6's SNF Beneficiary Protection Notification Review form dated 1/12/26, indicated R6 had not been provided a SNFABN as R6 was dropped to a non-skilled level.R6's Census list dated 4/19/26, indicated R6 remained at the facility after 1/12/26 (Medicare Part A discharge date ).During an interview on 5/13/26 at 9:08 a.m., the assistant administrator confirmed he had reviewed R6's medical record and stated that R6 had remained in the facility after Medicare Part A discharge in January. The assistant administrator stated he would have expected a SNFABN to be completed, but it didn't look like it had been.The facility's Advanced Beneficiary Notices policy dated 4/1/26, indicated the facility shall inform Medicare beneficiaries of his or her potential liability for payment. The policy directed when Part A services are used, the facility shall use the [SNFABN].

Based on observation, interview and record review, the facility failed to ensure the comprehensive care plan was accurate and updated to reflect the resident's current transfer, mobility, ambulation, and toileting needs. The care plan contained conflicting and inconsistent interventions and functional status information, which had the potential to result in staff confusion and inconsistent care delivery for 1 of 1 resident (R128) reviewed for care planning. In addition, the facility failed to ensure two care conferences were done to correspond with the Minimum Data Set (MDS) cycle for 1 of 1 resident (R11) reviewed for care conferences. Findings include: R128's quarterly Minimum Data Set (MDS), dated [DATE], indicated R128 was independent with toileting, always continent of bladder, however frequently incontinent of bladder. R128's Continence Evaluation, dated 4/29/26, indicated R128 had functional incontinence of bladder and occasional incontinence of bowel indicating a check and change toileting schedule per resident request. A check and change toileting program is a scheduled approach used for residents who experience urinary and/or bowel incontinence. Under this program, staff routinely check the resident at designated intervals for incontinence, provide incontinence care as needed, and change briefs or clothing to maintain cleanliness, comfort, and skin integrity. R128's care plan identified multiple conflicting entries related to R128's toileting, transfers, and mobility status. The care plan dated 9/3/25 identified R128 as independent with toileting, while a separate intervention dated 12/31/25 indicated toilet transfers were NA because the resident wore pull-up briefs and required barrier cream after incontinent episodes. Additional interventions directed staff to encourage toileting during rounds dated 5/13/24, listed toileting schedule as independent dated 2/3/26, and identified toilet hygiene required set-up/clean-up assistance of one staff person dated 2/3/26. The care plan also contained conflicting transfer information, including supervision assist of 1 with transfers dated 12/31/25 and chair to bed transfer - independent dated 4/29/26. Additional care plan documentation indicated R128 had bladder incontinence related to functional loss and diuretic use but remained continent of bowel at all times dated 5/13/24. R128's care plan further identified inconsistent mobility interventions. One care plan intervention dated 3/26/25 identified R128 as requiring a wheelchair with foot pedal for mobility, while another intervention dated 3/26/25 indicated the resident used a four-wheeled walker for ambulation with supervision of one staff person. During interview on 5/13/26 at 10:47 a.m., licensed practical nurse (LPN)-E stated R128 had returned from the hospital and was no longer ambulating upon return. LPN-E stated prior to hospitalization, R128 required standby assistance with transfers, but now required staff assistance. LPN-E stated R128 was mostly continent but was sometimes incontinent of bladder. LPN-E further stated R128's condition had changed significantly since hospitalization and had recently started to improve again. During interview on 5/13/26 at 12:50 p.m., the Director of Rehabilitation (DOR) stated therapy had initially treated R128 as a full body mechanical lift following return from the hospital. The DOR stated R128 had progressed to stand pivot transfers with staff assistance as of that morning and had begun ambulating with a walker during therapy sessions only. The DOR stated R128 knew when toileting was needed but could not independently get to the bathroom. The DOR stated therapy discussed additional toileting interventions with occupational therapy, including use of a bedside commode; however, R128 declined use of a bedside commode in the resident room. The DOR confirmed R128 was only to ambulate with therapy staff at this time. During interview on 5/14/26 at 9:07 a.m., nurse manager and LPN-F stated it was expected to update the care plan and Nurse Aide Reference (NAR) guide when a resident's condition changed. LPN-F stated R128's condition had fluctuated significantly following hospitalization, explaining that one day R128 believed she was paralyzed and the next day ambulated with therapy. LPN-F stated prior to hospitalization, R128 had been independent with many tasks. LPN-F stated R128 currently required assistance of one staff person with pivot transfers into the wheelchair. LPN-F further stated R128 had walked to the bathroom with staff the previous day and confirmed R128 was expected to ambulate with staff assistance. A facility policy on Comprehensive Care Plans was requested and not received. R11 R11's significant change (SCSA) Minimum Data Set (MDS) dated [DATE] identified R11 had intact cognition, required assistance with hygiene, did not reject care, and had diagnoses of paralysis on dominant side of body from a stroke, diabetes, and depression. During interview with R11 on 5/11/26 at 3:14 p.m., R11 stated she did not recall having a care conference since she was admitted in October of 2025. R11 stated she was interested in discussing a discharge or transfer and did not know how long she was to stay in the facility. On 5/12/26 at 3:02 p.m., the facility administrator emailed State Agency Surveyor (SA) and stated there was no documentation to support a care conference that was conducted for R11 for her quarterly and SCSA MDS cycle. During interview with social worker (SS)-A on 5/13/26 at 8:40 a.m., SS-A stated expectation of care conference timing to correspond with each MDS cycle and as needed, if there were changes. During interview with registered nurse (RN)-B on 5/13/26 at 9:11 a.m., RN-B stated expectation of care conference timing to correspond with each MDS cycle and as needed. RN-B viewed R11's electronic medical record (EMR) and verified one care conference was conducted at admission on [DATE]. RN-B verified R11's medical record failed to show a care conference to correspond with the quarterly MDS dated [DATE] and the SCSA MDS dated [DATE]. During interview with SS-B on 5/13/26 at 10:50 a.m., SS-B stated she was filling in for the transitional care unit social work position and had worked at facility for a month. SS-B stated expectation of care conferences to be done on admission, quarterly, SCSA and as requested to correspond with the MDS cycle. SS-B reviewed R11's medical record and stated, [R11's] care conferences were missed. Facility policy titled Care Planning- Resident Participation effective 4/1/26 indicated, The facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes. The facility will make an effort to schedule the conference at the best time of the day for the resident/resident's representative. The facility will obtain a signature from the resident and/or resident representative after discussion or viewing of the care plan.

Based on observation, interview and document review, the facility failed to ensure routine personal hygiene (i.e., nail care) was completed for 1 of 1 residents (R155) reviewed for activities of daily (ADLs) and who were dependent on staff for their care.Findings include:R155's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R155 had moderately impaired cognition, no hallucinations, delusions, behaviors or rejection of care. R155 was dependent on staff assistance for dressing, oral hygiene, toileting, mobility, and showering. Furthermore, R155 received hospice services.R155's diagnosis report, printed 5/14/26, included the following relevant diagnoses: vascular dementia without behavioral disturbances (cognitive decline from restrictive brain blood flow without exhibited behaviors such as aggrieve, anxious, psychoses or mood-altering symptoms), glaucoma-severe stage (advanced irreversible optic nerve damage where person experiences severe tunnel visions, compromised daily function and significant difficulty navigating spaces), need for assistance with personal care, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (weakness and paralysis of dominant side following a stroke).R155's care plan, printed 5/13/26, identified R155 had an ADL self-care performance deficient related to cognitive impairment, impaired balance, chronic pain which included the following interventions:- Check nails length and trim and clean on bath day and as necessary. Report any changes to the nurse.- Bathing: totally dependent on staff for bathing- Bathing: assist of 1 with shower/occasional bath and skin condition. Nurse nails.- personal hygiene: is dependent on assistance of 1 staff to completeThe care plan lacked evidence of R155 having a history or refusing staff assistance with ADLs (specifically nail care) or preference for longer fingernails.R155's care sheet, printed 5/14/26, identified R155 required assistance of 1 staff as needed with dressing, was independent with grooming and assistance of 1 staff with showers.R155's May 2026 Treatment Administration Record (TAR) was reviewed for 5/1/26 to 5/13/26 and included bath/shower documentation, and whether fingernails and toenails were intact or trimmed/filed. The TAR specified:Nail care answers if No or NA further information MUST BE documented in progress note to explain. Refused shower MUST BE documented in progress note details on reapproaches. every evening shift every Wed. Refused shower MUST BE documented in progress note details on reapproaches. With a start date of 4/22/26.-5/6/26: was blank-5/13/26: indicated R155 received a bed bath, and fingernails were intact and were not trimmed or filed. The TAR lacked evidence nail care had been provided in May. R155's progress notes, dated 4/1/26 to 5/13/26, were reviewed. Progress notes lacked evidence of R155 being offered nail care or refusing nail care.During an observation on 5/11/26 at 12:32 p.m., R155 was observed to have fingernails ranging in length from approximately 1/8 to 1/4 inch in length, jagged with dark colored debris underneath. R155 didn't answer when asked about his nails. R155 did nod his head yes when asked if staff assist him with trimming and cleaning his fingernails.On 5/12/26 at 10:19 a.m., R155 was observed sleeping in bed. R155's fingernails were observed to continue to be approximately 1/8 to 1/4 inches in length, some with jagged tips with dark colored debris underneath. At 1:52 p.m., R155 was observed awake in bed with a hospice volunteer by his bedside.On 5/13/26 at 7:55 a.m., R155 was observed sleeping in bed. R155's fingernails continued to have dark colored debris underneath, jagged edges on multiple nails and nail lengths ranging from 1/8 to 1/4 inch in length. At 8:26 a.m., it was observed staff was assisting R155 with breakfast.During an interview on 5/13/26 at 9:55 a.m., nursing assistant (NA)-H stated R155 required extensive assistance. NA-H stated R155 did not refuse staff assistance with any ADLs, but staff must give R155 enough time when assisting him. During an interview on 5/13/26 at 12:16 p.m., licensed practical nurse (LPN)-B stated R155 was used to a routine. LPN-B stated she thought if you missed a step in R155's routine, he might refuse but would be accepting upon reapproach. LPN-B stated if R155 or any resident refused assistance it would be documented in a progress note.During an observation and interview on 5/13/26 at 2:26 p.m., registered nurse (RN)-F stated they were familiar with R155. RN-F observed R155 fingernails and stated there were long with sharp edges, should be cut, and had stuff underneath them. RN-F stated it should be a collaboration between hospice and the facility to ensure R155's needs were being met which would include nail care. RN-F stated they hoped R155 was being provided hand hygiene prior to meals as he ate with his hands.During an interview on 5/14/26 at 9:58 a.m., assistant director of nursing (ADON)-A stated the expectation for nail care was that it be offered on shower days and as needed. ADON-A stated the importance of appropriate nail care was for hygiene purposes, helping stop the spread of bacteria, overall cleanliness, and to help decrease the risk of a resident scratching themselves causing a skin tear or wound. ADON-A stated hospice had been providing bed baths recently due to R155's decline and nail care may have not been getting done. ADON-A stated it should be a collaboration between hospice and the facility, and if R155 was refusing nail care with hospice they should be informing the facility and this would be documented in the progress notes. ADON-A stated she was going to review R155's medical record along with hospice charting. No additional information was provided for refusals of nail care.During an interview on 5/14/26 at 12:59 p.m., director of nursing (DON) stated the minimal standard would be offering nail care on shower days. DON stated the biggest part of nail care was resident choice. During a follow up interview on 5/14/26 at 3:54 p.m., DON stated nail care was offered on shower days and R155's nail care was done yesterday. DON stated she will follow up about any refusals of nail care prior to survey entrance. No additional information was provided.A facility titled policy Activities of Daily Living, dated 4/1/26, identified Care and services will be provided for the following activities of daily living:Bathing, dressing, grooming and oral care;Transfer and ambulation;Toileting;Eating to include meals and snacks; andUsing speech, language or other functional communication systems.

Based on observation, interview, and document review, the facility failed to ensure insulin was administered as ordered for 1 of 2 residents (R2) reviewed for insulin administration and wound care was provided as ordered for 1 of 1 resident (R60) reviewed for pressure ulcers.Findings include: R2 - not following provider orders R2's admission Minimum Data Set (MDS) assessment dated [DATE], identified R2 had intact cognition without hallucinations or delusions present with no behaviors, or rejection of care present. Diagnoses included diabetes. Furthermore, Section N: Medication identified R2 received insulin injections 4 days out of 7 days. During an interview on 5/11/26 at 2:34 p.m., R2 stated she received insulin injections for her diabetes. R2's care plan, printed 5/13/26, included the following: -has diabetes mellitus with a goal of will be free from any s/sx [signs/symptoms] of hypoglycemia through the review date with the following interventions: Dietary consult for nutritional regimen and ongoing monitoring. Observe for compliance with diet and document any problems. Observe/document/report to medical practitioner PRN s/sx of hypoglycemia: Sweating, Tremor, Increased heart rate (Tachycardia), Pallor, Nervousness, Confusion, slurred speech, lack of coordination, Staggering gait. Observe/document/report to medical practitioner PRN for s/sx of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing, acetone breath (smells fruity), stupor, coma. Observe/document/report to medical practitioner PRN for s/sx of infection to any open areas: Redness, Pain, Heat, swelling or pus formation. R2's May Medication Administration Record (MAR/TAR) from 5/1/26 – 5/13/26 included the following: -Aspart Insulin injection (fast acting insulin) - inject 6 units subcutaneously with meals related to type 2 diabetes mellitus with unspecified complications. Hold BG [blood glucose] less than 130 with a start date of 4/29/26 with administration times of 8 a.m., 12 p.m., and 5 p.m. The record indicated it was administered as ordered except for the following: -5/1/26 at 12 p.m., coded with a 2 -5/4/26 at 8 a.m., coded with a 13 and 12 p.m., coded with a 2 -5/5/26 at 8 a.m., coded with a 13 -5/6/26 at 8 a.m., coded with a 13 and 12 p.m., coded with a 2 -5/7/26 at 8 a.m., coded with a 13 -5/8/26 at 8 a.m., coded with a 13 and 12 p.m., coded with a 2 -5/11/26 at 8 a.m., coded with a 13 -5/13/26 at 12 p.m., coded with a 9 *Per chart code: 2 indicates out of facility without meds, 13 indicated no insulin required and 9 indicated a progress note. -Aspart Insulin Flex Pen 100 units/milliliter(mL) – inject as per sliding scale: If 130-150=0 units; 151-200=0 units; 201-250=1 units; 251 - 300 = 2 Units; 301 - 350 = 3 Units; 351 - 400 = 4 Units; 401 - 500 = 5 Units; 501 + = 6 Units, subcutaneously before meals and at bedtime for Type 2 Diabetes with a start date of 2/17/16. The record indicated this order was administered as ordered. The administration record included blood sugar readings. R2's Blood Sugar (BS) Summary, printed 5/14/26, identified the following relevant information (blood sugar readings are milligrams/deciliter (mg/dL)): -5/2/26 at 7:14 a.m., BS 101 -5/3/26 at 8:11 a.m., BS 111 -5/4/26 at 7:29 a.m., BS 86 -5/5/26 at 7:16 a.m., BS 101 -5/6/26 at 7:29 a.m., BS 91 -5/7/26 at 7:37 a.m., BS 90 -5/8/26 at 10:53 a.m., BS 91 -5/9/26 at 8:53 a.m., BS 106 -5/10/26 at 8:04 a.m., BS 120 -5/11/26 at 8:47 a.m., BS102 -5/12/26 at 7: 11 a.m., BS 93 -5/12/26 at 8:07 a.m., BS 93 -5/12/26 at 10:33 a.m., BS 127 -5/13/26 at 7:36 a.m., BS 94 -5/14/26 at 7:13 a.m., BS 97 R2's progress notes for 5/1/2 to 5/14/26 were reviewed and identified the following: -5/13/26 at 12:05 p.m.: noted resident out for dialysis Progress notes lacked evidence of holding insulin per order when blood glucose/sugar was below 130. On 5/14/26 at 8:17 a.m., licensed practical nurse (LPN)-C stated if a resident had a low blood sugar, the expectation would be the provider was notified. LPN-C stated if a resident had orders to hold insulin if a blood sugar was a certain level, it would be expected to follow that order and to notify the provider when it was held. During an interview on 5/14/26 at 9:40 a.m., assistant director of nursing (ADON)-A stated it was expected that physician orders were being followed. ADON-A stated it was important that if there were parameters to hold insulin if a blood sugar was low that the insulin was held as this had the potential to have negative effects all the way around. ADON-A stated the resident would likely become hypoglycemic. ADON-A reviewed R2's medical record. ADON-A verified R2 should not have received, and did receive, the scheduled morning dose of aspart insulin as R2's blood sugars were below 130 on 5/2/26, 5/3/26, 5/9/26, 5/10/26, 5/12/26, and 5/13/26. ADON-A stated the orders were clearly not being followed. ADON-A stated the 6 units of Aspart should not have been given those mornings per the orders. On 5/14/26 at 10:37 a.m., nurse practitioner (NP)-A stated they reviewed R2's blood sugars and were aware of R2's blood sugar trends. NP-A stated R2 was a brittle diabetic, and they had made changes to better manage her diabetes. NP-A stated the staff should be following the orders as giving insulin to someone with a low blood sugar could result in the person becoming hypoglycemic. NP-A stated he was going to review the orders as the order may be too stringent for R2 as her noon blood sugars tended to be higher. On 5/14/26 at 1:00 p.m., director of nursing (DON) stated the staff should follow a provider order and then added, a resident can choose to get the insulin even if low and go against provider orders as they have a choice. DON was going to follow up. No additional information was provided. A facility policy regarding following provider orders was requested but not received as facility indicated this was a procedural standard. R60 R60's quarterly Minimum Data Set (MDS) dated [DATE], indicated R60 had severely impaired cognition, was dependent on staff for personal hygiene, and was at risk for developing pressure ulcers/injuries. R60's diagnoses included Alzheimer's disease, dementia, bipolar, and overactive bladder. R60's care plan dated 4/23/26, indicated R60 had actual skin impairment and required wound care of a gluteal fold (area between the buttocks and the upper thigh) wound, and instructed, Treatment as ordered and Daily wound monitoring in place. R60's provider orders dated 5/7/26, indicated, Right gluteus wound cleanse with wound cleanser, pat dry. Apply foam QD [every day] and PRN [as needed]. Until healed. Additionally, Left gluteus wound cleanse with wound cleanser, pat dry. Apply Medi honey [medical grade honey product used to promote wound healing, prevent infection, and support skin repair] and foam QD and PRN. When reviewed on 5/12/26 at 12:43 p.m., R60's May 2026, treatment administration record (TAR) indicated left and right gluteus wound care to be completed daily with a start date of 5/8/2026. The right and left gluteus wound care was not documented as completed on 5/8/26, and 5/9/26. The wound care was documented as completed on 5/10/26, 5/11/26, by registered nurse (RN)-C. The wound care was documented as completed on 5/12/26, by RN-D. During observation on 5/12/26 at 12:47 p.m., nursing assistant (NA)-G wheeled R60 into her room to offer toilet, check and change, and lay down. NA-F also into room to assist. R60 was assisted to a standing position, brief removed and transferred to toilet. R60 was able to pass some urine and small bowel movement. NA-G and NA-F assisted with peri care. Dressing dated 5/11/26 was covering the left gluteal fold and an undressed open wound was observed on the right gluteal fold. A new brief was placed, pants pulled up and R60 was assisted into bed. During interview on 5/12/26 at 12:59 p.m., NA-F stated was not sure how long R60 had the two wounds on her bottom, but it was the NA's responsibility to notify the nurse of new skin concerns. NA-F further stated would notify the nurse that the one dressing was missing and needed to be replaced. During observation on 5/12/26 at 1:02 p.m., registered nurse (RN)-D and nursing assistant (NA)-G went into R60's room to complete wound care. RN-D prepared two new dressings by writing the date on each one. R60's pants and brief pulled down and the old dressing removed. RN-D confirmed the dressing had yesterday's date (5/11/26) indicating last time it was changed. RN-D used wound cleanser on the right wound, patted dry, and placed a foam adhesive dressing over it. RN-D then cleansed the left wound, patted it dry and placed a foam adhesive dressing over it. Medi honey was not used on either wound. During interview on 5/12/26 at1:22 p.m., RN-D stated he completed the wound care on R60 today only since the NA had reported the missing dressing and that R60's wound care was only scheduled three days a week on Monday, Wednesday, and Friday. RN-D stated he normally only worked on Tuesday's therefore, only treated R60's wounds as needed. When asked, RN-D stated he signed off R60's TAR as wound care being completed, even though he had not completed wound care at that time and had not planned on doing any wound care on R60 today. RN-D further stated was not aware the order had changed to complete wound care daily. RN-D confirmed did not use any Medi honey and could not say where the Medi honey was even stored. RN-D stated he should have read the order to realize it had been changed to daily wound care and for Medi honey to be used. During interview on 5/13/26 at 2:17 p.m., RN-E stated R60's wound care was changed from three days a week to daily on 5/7/26, and would expect wound care to be completed daily starting on 5/8/26. In addition, RN-E stated if the provider order was for Medi honey to be used, she would staff to be using Medi honey during wound care. RN-E stated would expect nurses to read and review resident orders, since they can change at any time. During interview on 5/14/26 at 11:19 a.m., director of nursing (DON) stated would expect provider orders to be completed as ordered. Facility policy for following provider orders was requested but not provided.

Based on interview and record review, the facility failed to ensure orders included resident-specific settings for the use and management of non-invasive ventilation machines for 2 of 2 residents (R15, R23) reviewed for the use of CPAP/BiPAP machines. In addition, the facility failed to ensure oxygen-related orders were reinstated after hospitalizations and readmission to the facility for 1 of 1 resident (R51) who used oxygen. Findings include: R15 R15's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R15's short term or long-term memory were both marked as memory ok after staff assessment of mental status was completed. In Section O- Special Treatment, Procedures and Programs, in section G1 Non-invasive mechanical ventilator was marked with a check mark to indicate R15 uses a non-invasive mechanical ventilator. During an observation on 5/11/26 at 12:47 p.m., a non-invasive ventilation machine (CPAP/BiPAP machine) on the bedside table. The mask for the machine was observed laying on the table next to the machine. No dates on the tubing or mask were observed. R15 declined to answer any questions. R15's care plan, printed 5/13/26, identified R15 had an altered respiratory status due related to OSA (obstructive sleep apnea) with an intervention to assist to elevate head of bed to no greater than 30 degrees. R15's care plan lacked evidence R15 required or used a CPAP or BiPAP machine. R15's May Medication and Treatment Administration Record (MAR/TAR), printed 5/13/26, included the following orders: -CPAP/BiPAP – on at bedtime, off in the morning. At bedtime at 9 p.m. with a start date of 3/17/26. Record indicated from 5/1/26 to 5/13/26, R26 wore the CPAP/BIPAP 4 times which was marked with a y indicating yes, 6 times did not wear have the CPABIPAP as it was marked with a n indicating no, and 2 times was marked with a 3 with the chart code indicating refused. -CPAP/BiPAP – on at bedtime, off in the morning. In the morning at 9 a.m. with a start date of 3/18/26. Record indicated from 5/1/26 to 5/13/26, all days were marked with off. The MAR lacked evidence of resident specific settings for the CPAP or BiPAP machine. Furthermore, lacked evidence of cleaning of mask, tubing or filters. R15's Task Log reviewed and lacked evidence of staff cleaning mask or tubing. R15's progress notes for 4/1/26 to 5/14/26 were reviewed. Progress notes lacked evidence of specific settings for R15's non-invasive ventilation machine which would determine whether R15 was using the machine as a CPAP (continuous positive airway pressure) or BiPAP (bilevel -two distinct pressures-positive airway pressure). During an interview on 5/13/26 at 9:57 a.m., nursing assistant (NA)-H stated they were familiar with R15. NA-H stated R15 wore a CPAP at night. NA-H stated they had not helped R15 put the mask on but had turned the CPAP machine on for R15. NA-H stated the nurses helped with putting masks on if a resident needed assistance and when tubing needed to be changed. During an interview on 5/13/26 at 12:25 p.m., licensed practical nurse (LPN)-B stated R15 had a CPAP machine that nursing assisted with by putting mask on and off and turning machine on and off. LPN-B stated R15 refused to wear her CPAP machine sometimes. LPN-B reviewed R15's orders and verified the orders to did have specific resident pressure settings. R23 R23's admission MDS assessment dated [DATE], identified R23 had intact cognition and used a non-invasive mechanical ventilator. During an observation and interview on 5/11/26 at 3:23 p.m., R23 stated she had been on the portable ventilator since admission. R23 stated she returned from the hospital a little while ago. R23's care plan, printed 5/13/26, identified R23 had an altered respiratory status with an inability to lie flat with the following interventions: -administer medications/inhalers/nebulizer treatments as orders. -elevate head of bed, observe and document any shortness of breath when lying flat and with activities due to shortness of breath. -Observe/document and report to nurse/medical practitioner any s/sx [signs/symptoms] of respiratory distress; increased respirations, decreased pulse oximetry, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, hemoptysis, cough, pleuritic pain, accessory muscle use, skin color changes to blue/gray -Head of bed to be elevated (semi-Fowlers to fowlers) or out of bed upright in a chair during episodes of difficulty breathing (Dyspnea). The care plan lacked evidence of any resident specific settings for R23's CPAP machine. R23's May MAR/TAR included the following orders: - CPAP/BIPAP - filter maintenance: Wash reusable filters monthly by hand in warm soapy water (antibacterial), rinse well and let air dry. If filters are disposable, change monthly every day shift every 30 day(s) with a start date of 5/12/26. The record indicated it was completed on 5/12/26. - CPAP/BIPAP - Fill reservoir with distilled water at bedtime at 9 p.m. with a start date of 4/17/26 and end of 5/11/26 with a new order starting 5/11/26. From 5/1/26 to 5/11/26, all were marked with a check mark to indicate as completed except for 3 days (5/8/26-5/10/26) which were coded with a 6 indicating hospitalized . -CPAP/BiPAP – ON at bedtime, Off in the morning at 9 p.m. with a start date of 4/18/26 and end date of 5/11/26 with a new order starting 5/11/26. Of 11 opportunities (from 5/1/26-5/11/26), the record indicated 6/11 times it was marked as self, 2/11 times as on and 3/11 with a 6 which indicated hospitalized . -CPAP/BiPAP – ON at bedtime, Off in the morning at 9 a.m. with a start date of 4/18/26 and end date of 5/11/26 with a new order starting 5/12/26. Of 12 opportunities (from 5/1/26-5/12/26), the record indicated it was completed all days except for 3 which were documented with a 6. -CPAP/BIPAP - Wash face mask/nasal pillow and water chamber/reservoir by hand with warm soapy water (cannot contain antibacterial soap), rinse well and let air dry every day shift with a start date of 4/18/26 and end date of 5/11/26 with a new order starting 5/12/26. The record indicated this was completed all days (5/1/26-5/12/26) except for 3 days which were marked with 6. R23's progress notes for 4/1/26 to 5/14/26 were reviewed. Progress notes lacked evidence of specific settings for R23's non-invasive ventilation machine. During an interview on 5/13/26 at 9:56 a.m., NA-H stated they had not assisted R23 with the CPAP machine. NA-H stated they had seen R23 wear the CPAP mask when sleeping. During an interview on 5/13/26 at 12:02 p.m., trained medication aid (TMA)-A stated nurses were responsible for CPAP machines, and anything related to CPAP machines. During an interview on 5/13/26 at 12:21 p.m., LPN-B stated it was the nurse's responsibility to ensure R23's CPAP was working correctly, and the nurses would assist R23 with turning the machine on and off. LPN-B stated she had assisted R23 with shutting the machine off previously. LPN-B went and looked at R23's CPAP machine and confirmed it was the CPAP machine that R23 had since admission. LPN-B reviewed R23's orders and verified the orders did not have any settings. During an interview on 5/14/26 at 10:02 a.m., assistant director of nursing (ADON)-A stated the expectation would be if a resident had CPAP/BiPAP machine, staff would be ensuring the machines were being cleaned appropriately (i.e., masks wiped down, tubing changed, etc), which would be documented on the MAR/TAR. ADON-A stated the orders should include settings. ADON-A stated if the settings didn't come with the admission orders, they could be difficult to obtain but the facility did need to get the correct orders. ADON-A reviewed R15 and R23's electronic medical records. ADON-A verified the facility did not have orders for the setting for either R15 or R23. ADON-A stated the orders should contain the settings and if something happened to the machine or the resident was transferred, the settings need to be known. During an interview on 5/14/26 at 12:55 p.m., director of nursing (DON) stated the orders for CPAP and BiPAP machines should be followed. DON stated she would have to look at the facility policy to answer whether or not the settings for a CPAP or BiPAP needed to be included in the orders. No follow up was provided. A facility policy titled Noninvasive Ventilation, dated 4/1/26, indicated The facility will obtain an order for the use of a CPAP, BiPAP, AVAPS or Trilogy™ device and settings from the practitioner. R51 R51's quarterly Minimum Data Set (MDS), dated [DATE], identified R51 received oxygen therapy and used a noninvasive mechanical ventilator. The MDS further identified R51 required substantial to maximal assistance with most activities of daily living and was cognitively intact. R51's physician orders identified prior orders for continuous oxygen at 4 liters per minute (LPM) via nasal cannula or mask to maintain oxygen saturations at or above 90%, oxygen at 2 LPM via nasal cannula while sleeping until CPAP supplies arrived, and CPAP/BIPAP settings of CPAP 16/EPAP 8 with 3 LPM oxygen. Those orders discontinued on 4/24/26 following hospitalization and return to the facility on 4/25/26. R51's May 2026 Medication/Treatment Administration Records (MAR/TAR) identified no active orders for oxygen therapy, CPAP/BIPAP use, oxygen saturation monitoring, or oxygen tubing changes. Review of the April 2026 MAR/TAR identified oxygen tubing and humidifier bottle changes last occurred on 4/19/26 and the treatment discontinued on 4/24/26. R51's care plan, dated 4/29/26, identified R51 had altered respiratory status and required oxygen therapy, including interventions to provide oxygen as ordered and observe pulse oximetry readings. During interview on 5/12/26 at 10:00 a.m., R51 stated when admitted to the facility she used a CPAP with a face mask, but experienced leaking issues and was awaiting a replacement mask and currently used oxygen at night while waiting for CPAP supplies. R51 further stated she did not like when the oxygen tubing fell on the floor and staff did not pick it up, stating they should be providing her with new tubing weekly but that was not happening. During interview and observation on 5/13/26 at 7:33 a.m., R51 stated the night nurse applied oxygen at 2 LPM overnight and licensed practical nurse (LPN)-F removed it that morning. The oxygen tubing, and nasal cannula, was observed lying on the floor while the oxygen tank remained turned on. During interview and observation on 5/13/26 at 9:07 a.m., LPN-E, stated staff completed vital signs daily for R51 and R51's oxygen saturation levels should remain above 90% and R51 should be placed on oxygen at 2 LPM to keep oxygen saturations above 90%. LPN-E picked up R51's oxygen tubing and nasal cannula from the floor, reconnected it to the machine, and placed it directly back on R51. LPN-E was not sure when R51's oxygen tubing was changed. During interview on 5/14/26 at 9:07 a.m., nurse manager and LPN-F, stated staff expectations for residents receiving oxygen included monitoring oxygen saturation levels, verifying oxygen settings, and changing tubing periodically, but could not specify specifically how often. LPN-F reviewed R51's electronic medical record and stated, It is not in here, when unable to locate orders for oxygen flow rate, changing oxygen tubing, or when and how often to use oxygen. LPN-F further stated R51 previously had oxygen orders from 3/10/26 through 4/24/26 because R51 was not wearing the CPAP at night, but she was unsure what happened to the orders after hospitalization and return to the facility. During interview on 5/14/26 at 10:00 a.m., the director of nursing (DON), who also served as the facility's infection preventionist (IP), stated the standard practice was to change nasal cannulas once weekly. A facility policy titled Oxygen Safety, dated 4/1/26, directed staff is how to safely use and store oxygen but did not address the necessity for oxygen orders or the facility policy on how often oxygen tubing should be changed.

Based on observation, interview and record review, the facility failed to provide necessary behavioral health services, trauma-informed care planning, and coordinated mental health support for 1 of 1 resident (R130) reviewed for behavioral health services. The facility failed to implement interventions to address ongoing sanitation and environmental concerns in the resident's room, failed to develop and implement interventions to address R130's identified trauma triggers and feelings related to loss of control over her surroundings, and failed to revise or implement new behavioral health interventions after 10/24/25 despite continued concerns which had the potential to result in unmet psychosocial needs and unsafe living conditions. Findings include:R130's quarterly Minimum Data Set (MDS), dated [DATE], identified R130 was admitted to the facility on [DATE], was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, and was independent with most activities of daily living.R130's diagnoses, dated 8/13/25, included bipolar II disorder, post-traumatic stress disorder (PTSD), depression, and anxiety.R130's trauma-informed care screening, dated 8/19/25, identified R130 disclosed she had experienced something traumatic in the past but did not disclose the specifics of the event. The section addressing, what are some things that you do now to help manage consequences of going through difficult/tough times was left blank R130's care plan, dated 8/20/25, identified R130 had post-traumatic stress disorder (PTSD) and trauma but would not discuss specifics and triggers could include a sense that things were outside of her control. The care plan included interventions for staff to assist with calming approaches, including encouraging reading books, validating R130's feelings, and using a professional approach due to R130's perceived ideas that men have often tried to hit on her. However, the care plan lacked specific trauma-informed interventions to guide staff on how to support R130's need to feel in control of her surroundings while simultaneously addressing ongoing sanitation, clutter, food tray, and environmental concerns within the room. Additional care plan interventions, dated 10/24/25, identified R130 was not organizing her room and may benefit from staff support to set up her room and initiate functioning more within a normal range, and questioned whether R130 would benefit from a behavioral contract to assist with cleaning her room if it became problematic. The care plan lacked evidence a behavioral contract or other structured behavioral interventions were implemented to assist with R130 keeping her room clean and organized. Review of R130's care plan lacked evidence the facility updated, revised, or implemented additional interventions related to R130's trauma history, behavioral health needs, refusal of assistance, sanitation concerns, or ongoing room conditions after 10/24/25, despite continued concerns observed throughout the survey.R130's Associated Clinic of Psychology (ACP) notes, dated 8/20/25, identified R130 had a history of sexual abuse by her father and emotional abuse by her husband. Additional ACP notes, dated 10/24/25, identified R130 had multiple outpatient mental health supports. The ACP notes lacked any documentation of a completed behavioral contract regarding R130 keeping her room clean and organized. R130's progress notes identified the last documented social work intervention related to assisting R130 with room organization prior to survey occurred on 10/16/25, when the licensed social worker (LSW) attempted to assist R130 in cleaning her room but R130 appeared asleep and did not wake when prompted. Additional progress notes, dated 10/3/25, identified R130 provided verbal consent for the LSW to enter her room while hospitalized to move items and reduce tripping hazards but did not want assistance organizing or cleaning her room. R130's electronic medical record (EMR) lacked evidence the facility coordinated care, communicated recommendations, or implemented ongoing collaborative interventions with R130's outside mental health providers related to her PTSD, trauma history, room conditions, behavioral concerns, or identified psychosocial needs.During observation on 5/11/26 at 5:05 p.m., R130's room was observed extremely cluttered with a strong urine odor. The floor was not visible due to the number of belongings and clutter throughout the room. Old food trays, cups containing red liquid, milk cartons, and food debris were observed throughout the room. The facility also had concerns related to mice in the building.During observation on 5/13/26 at 7:45 a.m., R130's room contained both lunch and dinner trays from 5/12/26. The lunch tray appeared untouched and contained chicken, vegetables, and a baked potato. The dinner tray contained leftover food.During observation on 5/13/26 at 9:07 a.m., two unnamed housekeeping staff were observed cleaning R130's room while R130 remained present in the room and did not object to the cleaning. The floor contained multiple rusty-red colored stains and the room continued to have a noticeable odor of urine and old food.During interview on 5/13/26 at 10:47 a.m., licensed practical nurse (LPN)-E stated staff attempted to work with R130 regarding the condition of her room and social work was also involved. LPN-E stated R130 wanted to keep her belongings in the room and staff encouraged her to remove food trays when finished eating. LPN-E stated if staff attempted to remove items while R130 was not present, R130 instructed staff not to touch her belongings. LPN-E stated staff often left trays in the room because R130 slept in the mornings and ate later when awake and would eat the food on her trays at her leisure. LPN-E further stated he had no knowledge of R130's trauma history or past abuse and had not received guidance regarding trauma-informed approaches for R130 or other residents. During interview on 5/13/26 at 12:58 p.m., social services designee (SSD)-C stated the facility coordinated with Associated Clinic of Psychology (ACP) providers through referrals, faxes, emails, and weekly meetings and reviewed recommendations to determine whether care plans required updates. SSD-C stated R130 had multiple outside providers and that ACP had been assisting with concerns related to R130's room. SSD-C stated she continued to offer assistance with room organization, including offering boxes and garbage bags, and documented those offers in progress notes, acknowledging the last attempted was documented in October of 2025. SSD-C stated R130 could be resistant to housekeeping and cleaning and staff used repeated approaches as the only intervention. SSD-C further stated she was unsure whether a behavioral contract or risk versus benefit approach had ever been implemented for R130 and stated, maybe ACP did. SSD-C stated R130 made many of her own appointments and often did not involve the facility so there was no coordination with her outside mental health providers. SSD-C further stated she would need to review the record to determine whether R130 had trauma or PTSD and stated she had no knowledge of R130's past trauma history despite those diagnoses and abuse history being documented in the record and ACP notes. During interview on 5/14/26 at 9:07 a.m., third floor nurse manager and licensed practical nurse (LPN)-F stated R130 had a lot of trauma but she did not know the specifics. LPN-F stated R130's prior apartment had also been cluttered and contained roaches and many of R130's belongings were damaged prior to admission. LPN-F stated she did not know whether a behavioral contract or structured intervention existed for R130 and stated the facility had been in between social workers. LPN-F stated nursing assistants reported that is how she likes it regarding the condition of the room. LPN-F further stated she instructed staff to remove food trays or place items in the refrigerator but acknowledged those interventions were not care planned and there was no behavior monitoring in place related to food trays remaining in the room, room cleanliness, odors, or refusal of housekeeping services. LPN-F stated R130 received services from outside mental health providers and medication changes were expected to be faxed to the facility and uploaded into the medical record.During a follow interview on 5/13/26 at 2:41 p.m., SSD-C stated R130 was seen by an outside provider for medication management.During interview on 5/14/26 at 10:00 a.m., the director of nursing (DON) stated concerns related to food trays remaining in R130's room, odors, clutter, and the condition of the floor needed to be balanced with resident rights. The DON stated staff could not just take things out of her room without her permission and stated R130 had the right to keep old food trays and clutter in her room. The DON further stated removing items from the room could trigger her and staff attempted to balance infection control concerns with R130's rights. The DON did not identify specific trauma-informed interventions, behavioral supports, or staff approaches to minimize triggering R130 while addressing the sanitation and environmental concerns in the room.A facility policy titled Behavioral Health Services, dated 4/1/26, indicated it was the policy of the facility to, ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning and well-being.

Based on observation, interview, and document review, the facility failed to ensure medically related social services were provided for 1 of 1 residents (R61) observed who wore mismatched shoes which caused discomfort, despite staff knowledge of the lack of matching shoes.Findings include:R61's quarterly Minimum Data Set (MDS) dated [DATE], indicated R61 had intact cognition and was diagnosed with diabetes, depression, and an amputation. The MDS indicated R61 had no hallucinations, delusions, behavioral symptoms directed towards others, or rejection of care behaviors.R61's care plan dated 5/26/26 indicated R61 had a self-care performance deficit related to a right below-the-knee amputation. The care plan indicated R61 preferred to choose his own clothing and what to wear. The care plan indicated he required moderate assistance with tub/shower transfers, showering/bathing, and lower body dressing.R61's medical record was reviewed, and did not indicate that prior to survey entrance, staff had attempted to assist R61 with finding matching shoes.During an interview and observation on 5/11/26 at 12:04 p.m., R61 was observed sitting in his wheelchair, a black shoe with a thick sole observed on his right leg prosthetic, and a grey shoe on his left foot with a noticeably shorter sole. R61 stated that he didn't have any money, so he was unable to buy matching shoes. R61 stated he had only had the left leg without the right prosthetic for a while, so he had only needed the left shoe. R61 stated he had gotten a prosthetic about a month ago and didn't have a shoe for it, so the prosthetic company had provided one for the prosthetic, but not for his other foot. R61 stated that he wished he had matching shoes to wear, but he didn't. On observation, without opening drawers or doors, no additional shoes of R61's were present. R61 stated that because his shoes were different heights, his legs were different heights, and this caused him hip pain. R61 stated he had talked with staff about not having matching shoes and was sure the social worker knew about it, but no one had done anything to help.During an interview on 5/12/26 at 2:00 p.m., nursing assistant (NA)-J stated he had worked with R61 frequently in the past. NA-J stated that R61 needed a variable amount of help with activities of daily living (ADLs), so sometimes needed help with things like dressing, and sometimes was independent. NA-J stated that when assisting him, he had noticed that R61 did not own matching shoes. NA-J stated that he had assumed the prosthetic needed a special shoe and didn't know if the shoes needed to match or not, so he was unsure if anyone had tried to help him get matching ones.During an interview on 5/13/26 at 12:27 p.m., medical coordinator (MC)-A, from the prosthetic company, stated that it was not their usual practice to provide patients with shoes, but when R61 came in, he didn't have a shoe for his prosthetic, so they provided one solely for the prosthetic. MC-A stated it was better if the patient wore matching shoes and had expected R61 or the facility to obtain them.During an interview on 5/13/26 at 2:23 p.m., registered nurse (RN)-H stated that she had noticed that R61 did not have matching shoes since he came back with his prosthetic about a month ago but did not know if anyone had offered to help him get new ones.During an interview on 5/14/26 at 1:48 p.m., social services designee (SSD)-C confirmed she was R61's social worker and stated she had helped him with things in the past, such as getting new clothing. SSD-C stated that she had noticed that R61 did not have matching shoes. SSD-C stated she was unsure if anyone had offered to help him obtain new shoes before the survey start and confirmed she had not.During an interview on 5/14/26 at 2:57 p.m., with the assistant administrator and the director of nursing (DON), the DON stated that if a resident with a prosthetic needed matching shoes, she would expect the prosthetic company to notify them. The DON stated she was unsure if anyone had reached out to the prosthetic company regarding shoe wear recommendations.A policy regarding social services was requested but not received.

Based on interview and document review, the facility failed to ensure consultant pharmacist (CP) recommendations were acted upon timely for 1 of 5 residents (R129) reviewed for unnecessary medications. In addition, the facility failed to develop and/or implement a procedure outlining follow-up time frame expectations in the drug regimen review process for 1 of 5 residents (R118) reviewed for unnecessary medications. Findings include: R129 R129's admission Minimum Data Set (MDS) dated [DATE], indicated R129 had intact cognition and received high risk medications to include antianxiety and anticoagulant. R129's diagnoses include panic disorder, generalized anxiety disorder, atrial fibrillation, and peptic ulcer. R129's diagnoses lack evidence of diabetes mellitus (DM). R129's provider orders indicated the following: -Dated 3/30/26, Meloxicam Oral Tablet.Give 7.5 mg by mouth two times a day for INFLAMMATORY. R129's provider order lacked evidence of additional instructions to give with food or milk. -Dated 3/30/26, Eliquis Oral Tablet.Give 5 mg by mouth two times a day for Heart. -Dated 3/31/26, Jardiance Oral Tablet.Give 10mg by mouth one time a day for dm2 [diabetes mellitus type 2]. -Dated 3/31/26, Buspirone HCl Oral Tablet.Give 10 mg by mouth three times a day for psych. R129's consultant pharmacy medication review (MRR) dated 3/31/26 included the following: - R129 was taking Meloxicam and NSAID which should not be given on an empty stomach to help prevent upset stomach, ulceration, or bleeding. Recommendation included, Add to the instructions: Give with food or milk. - R129 was taking Jardiance for DM2 which was not listed as one of R129's diagnoses. Recommendation included, Verify and add this diagnosis to the diagnoses list to justify use of the above order. - R129 was taking Buspirone for psych and Eliquis for heart which were not appropriate diagnoses for use of these medications. Recommendation included, Clarify with the provider the diagnosis associated with this medication and update the MAR [medication administration record]. R129's MRR dated 4/29/26 included the following: - R129 was taking Jardiance for DM2 which was not listed as one of R129's diagnoses. Recommendation included, Verify and add this diagnosis to the diagnoses list to justify use of the above order. - R129 was taking Buspirone for psych and Eliquis for heart which were not appropriate diagnoses for use of these medications. Recommendation included, Clarify with the provider the diagnosis associated with this medication and update the MAR [medication administration record]. R129's MAR dated April 2026, instructed give Eliquis heart, give Jardiance for dm2, give Buspirone for psych, and lacked evidence of administration instructions for Meloxicam. R129's MAR dated May 2026, instructed give Eliquis heart, give Jardiance for dm2, give Buspirone for psych, and lacked evidence of administration instructions for Meloxicam. During interview on 5/14/26 at 12:37 p.m., CP stated would expect medications to be given for appropriate indications or associated with appropriate diagnoses. CP further stated would expect facility to respond to recommendations timely and would not expect to have to re-issue the same recommendation with subsequent monthly reviews. CP stated would have expected R129's medication indications for use would have been updated appropriately by now. During interview on 5/14/26 at 1:22 p.m., director of nursing (DON) stated would expect MRRs with recommendations that could affect resident safety be addressed as soon as possible. DON would not provide a timeframe for expected response for non-urgent recommendations stating, If it is not going to harm the resident, it is not a safety issue and therefore, did not consider lack of appropriate indication or diagnosis a safety concern. DON stated was aware the MRR process had room for improvement. R118 R118's quarterly Minimum Data Set (MDS) dated [DATE], indicated R118 had intact cognition and was diagnosed with respiratory failure and debility. The MDS indicated R118 was independent with most activities of daily living (ADLs). R118's order summary dated 3/10/26, included an order dated 3/10/26 for Nystatin Powder applied topically to the groin in the morning and did not include an end date. R118's pharmacist review dated 3/30/26, indicated R118 had an order for nystatin powder to the groin in the morning for redness. The review indicated antifungals should be discontinued when healing was complete, as prolonged, unnecessary use can cause drug-resistant fungal infections. The review indicated Candida [yeast] rashes typically take one to two weeks to resolve with treatment, so the pharmacist recommended the nystatin powder be discontinued. The review did not include a date by which a response was required. The review indicated no response 4/30/26. During an interview on 5/14/26 at 12:26 p.m., the consultant pharmacist (CP) stated the facility did not have a laid out time frame for when nonurgent recommendations needed to be completed, as it was based on the resident and the specific recommendation, but she would typically expect a provider to respond to a nonurgent recommendation within 60 days. The CP confirmed she did not include a time frame on the recommendation for when she expected a response for nonurgent concerns. Facility policy dated 9/2023, indicated CP would review the medication regimen of each resident monthly and report in writing any irregularities. The policy further indicated follow up timeliness would depend on severity of irregularity and be determined through consultation between the CP and DON.

Based on observation, and interview, the facility failed to ensure food was served at palatable temperatures for 1 of 1 residents (R88) who were observed and served cold food.Findings include: During the lunch dining service at the transitional care unit on 5/12/26 at 12:03 p.m., nursing assistant (NA)-A rolled a meal tray to R88's room to deliver lunch of honey mustard chicken, potato fingerlings, and a mixture of cooked vegetables. Dietary aide (DA)-A temped the food prior to NA-A delivering the tray into R88's room. Results of the temperatures were as follows:Honey Mustard Chicken was 117 degrees Fahrenheit (F)Potato fingerlings were 118 degrees F, andMixed vegetables were 100 degrees F.DA-A stated the chicken was supposed to be 145 degrees and above when we are serving. DA-A stated, I would want the food to be warmer than this when I eat it.During interview with DA-A and cook (C)-A on 5/12/26 at 12:06 p.m., both stated the food sits on the trays too long [before residents are served].During interview with R88 on 5/12/26 at 12:46 p.m., R88 stated, the chicken was cooked but definitely not warm or hot enough for my liking.During interview with dietary manager (D)-MGR on 5/13/26 at 12:38 p.m., D-MGR stated facility struggled with serving food at desirable temperatures because the residents in the dining room were served first and then the staff started plating the food for residents who ate in their rooms. The food was plated and rested on the rolling cart for a lengthy time before it was rolled to each resident. D-MGR stated R88's food lost temperature and it was not desirable to serve food that is 117 degrees.Facility policy titled Food Safety Requirements effective 4/1/26 state, Foods and beverages shall be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature.

Based on interview and document review the facility failed to identify the indication for the administration of opioid medications and failed to ensure non-pharmacological interventions were attempted/offered and documented prior to the administration of as needed (PRN) opioid medications for 2 of 3 residents (R1, R2) reviewed for pain. Findings include:R1's admission minimum data set (MDS) dated [DATE] indicated intact cognition with diagnoses including end stage renal disease (ESRD) and pressure ulcer of heel. R1's pain assessment dated [DATE] indicated R1 had pain that frequently interfered with therapy and day-to-day activities. R1 received scheduled and as needed (PRN) medications for pain. R1 had not received non-medication interventions for pain.R1's care plan dated 12/23/25 had a focus of actual chronic neuropathic pain with need for medication management related to neuropathy. Interventions included but not limited to: offer non-pharmacological interventions for pain relief such as rest or repositioning and observe/document pain characteristics as needed including quality, severity, anatomical location, onset, duration, aggravating factors, relieving factors.R1's provider order dated 12/23/25 instructed acetaminophen (a non-opioid pain-relieving medication) Give 650 mg by mouth every 6 hours as needed for pain.R1's medication administration record for January 2026 indicated R1 received PRN acetaminophen the following 2 times:-1/2/26 at 11:23 p.m., R1 received PRN acetaminophen for pain rated 8/10 (severe pain) which was recorded as E. A corresponding progress note dated 1/2/26 identified the medication was administered but did not include location or any recorded symptoms R1 was experiencing or what, if any, non-pharmacological interventions had been attempted or offered prior to medication administration.-1/4/26 at 5:59 a.m., R1 received PRN acetaminophen for pain rated 5/10 (moderate pain) which was recorded as E. A corresponding progress note dated 1/4/26 identified the medication was administered for foot pain but did not include what, if any, non-pharmacological interventions had been attempted or offered prior to medication administration.R1's provider order dated 12/23/25 instructed hydromorphone oral tablet (an opioid pain-relieving medication) Give 2 milligrams (mg) by mouth every 6 hours as needed for pain.R1's medication administration record for January 2026 indicated R1 received PRN hydromorphone the following 9 times:- 1/2/26 at 11:23 p.m., R1 received PRN hydromorphone for pain rated 8/10 which was recorded as E [effective]. A corresponding progress note dated 1/2/26 identified the medication was administered but did not include location or any recorded symptoms R1 was experiencing or what, if any, non-pharmacological interventions had been attempted or offered prior to the opioid medication administration. A night shift note dated 1/3/26 at 7:12 a.m., indicated at the start of night shift, R1 had complained of knee pain that was relieved with prn pain medication.- 1/4/26 at 4:09 p.m., R1 received PRN hydromorphone for pain rated 0/10 (no pain) which was recorded as E. A corresponding progress note dated 1/4/26 identified the medication was administered but did not include location or any recorded symptoms R1 was experiencing or what, if any, non-pharmacological interventions had been attempted or offered prior to the opioid medication administration.- 1/6/26 at 10:40 a.m., R1 received PRN hydromorphone for pain rated 4/10 (mild pain) which was recorded as E. A corresponding progress note dated 1/6/26 identified the medication was administered but did not include location or any recorded symptoms R1 was experiencing or what, if any, non-pharmacological interventions had been attempted or offered prior to the opioid medication administration. Daily skilled note dated 1/6/26 at 1:56 p.m., indicated R1 complained of pain and received pain medication which was effective.- 1/7/26 at 4:44 a.m., R1 received PRN hydromorphone for pain rated 7/10 (severe pain) which was recorded as E. A corresponding progress note dated 1/7/26 identified the medication was administered but did not include location or any recorded symptoms R1 was experiencing or what, if any, non-pharmacological interventions had been attempted or offered prior to the opioid medication administration.- 1/8/26 at 6:14 p.m., R1 received PRN hydromorphone for pain rated 4/10 which was recorded as E. A corresponding progress note dated 1/8/26 identified the medication was administered but did not include location or any recorded symptoms R1 was experiencing or what, if any, non-pharmacological interventions had been attempted or offered prior to the opioid medication administration.- 1/9/26 at 4:37 p.m., R1 received PRN hydromorphone for pain rated 9/10 (severe pain) which was recorded as E. A corresponding progress note dated 1/9/26 identified the medication was administered but did not include location or any recorded symptoms R1 was experiencing or what, if any, non-pharmacological interventions had been attempted or offered prior to the opioid medication administration.- 1/10/26 at 4:05 a.m., R1 received PRN hydromorphone for pain rated 7/10 which was recorded as E. A corresponding progress note dated 1/10/26 identified the medication was administered but did not include location or any recorded symptoms R1 was experiencing or what, if any, non-pharmacological interventions had been attempted or offered prior to the opioid medication administration.- 1/11/26 at 5:36 p.m., R1 received PRN hydromorphone for pain rated 4/10 which was recorded as E. A corresponding progress note dated 1/11/26 identified the medication was administered but did not include location or any recorded symptoms R1 was experiencing or what, if any, non-pharmacological interventions had been attempted or offered prior to the opioid medication administration.- 1/12/26 at 3:22 a.m., R1 received PRN hydromorphone for pain rated 5/10 which was recorded as E. A corresponding progress note dated 1/12/26 identified the medication was administered but did not include location or any recorded symptoms R1 was experiencing or what, if any, non-pharmacological interventions had been attempted or offered prior to the opioid medication administration.During an interview on 1/12/2026 at 4:16 p.m., R1 stated he had chronic pain in his knees and all over his body. Repositioning, ice packs, and rest help relieve his pain in addition to PRN medications. R1 stated he usually received hydromorphone but had received other medications and topical cream for pain that had been effective He could not recall the other medication names. R2's admission MDS dated [DATE] indicated independent for daily decision making with diagnoses including amputation and ESRD.R2's pain assessment dated [DATE] indicated R2 had pain that frequently interfered with day-to-day activities. R2 received scheduled and PRN medications for pain. R2 had not received non-medication interventions for pain. R2's care plan dated 12/26/25 had a focus of pain with need for medication management. The interventions included but were not limited to: Offer non-pharmacological interventions for pain relief and notify medical practitioner if interventions are unsuccessful or if current complaint is a significant change from past experience of pain.R2's provider order dated 12/16/25 instructed acetaminophen give 1000 mg by mouth as needed for pain 2 times daily.R2's medication administration record for January 2026 indicated R2 received PRN acetaminophen the following 2 times:-1/1/26 at 3:28 a.m., R2 received PRN acetaminophen for pain rated 10/10 which was recorded as E. A corresponding progress note dated 1/1/26 identified the medication was administered but did not include location or any recorded symptoms R2 was experiencing or what, if any, non-pharmacological interventions had been attempted or offered prior to the medication administration. However, the follow up note indicated R2 stated he felt better and did not need anything else for pain. -1/2/26 at 6:05 a.m., R2 received PRN acetaminophen for pain rated 10/10 which was recorded as U (unknown) due to resident at dialysis. A corresponding progress note dated 1/2/26 identified the medication was administered but did not include location or any recorded symptoms R2 was experiencing or what, if any, non-pharmacological interventions had been attempted or offered prior to the medication administration.R2's provider order dated 12/16/25 instructed oxycodone oral tablet give 5mg by mouth every 4 hours for pain.R2's medication administration record for January 2026 indicated R2 received PRN oxycodone the following 5 times:-1/7/26 at 8:26 p.m., R2 received PRN oxycodone for pain rated 6/10 (moderate pain) which was recorded as E. A corresponding progress note dated 1/7/26 identified the medication was administered but did not include location or any recorded symptoms R2 was experiencing or what, if any, non-pharmacological interventions had been attempted or offered prior to the opioid medication administration.-1/9/26 at 9:42 p.m., R2 received PRN oxycodone for pain rated 7/10 which was recorded as E. A corresponding progress note dated 1/9/26 identified the medication was administered but did not include location or any recorded symptoms R2 was experiencing or what, if any, non-pharmacological interventions had been attempted or offered prior to the opioid medication administration.-1/10/26 at 10:46 p.m., R2 received PRN oxycodone for pain rated 6/10 which was recorded as E. A corresponding progress note dated 1/10/26 identified the medication was administered but did not include location or any recorded symptoms R2 was experiencing or what, if any, non-pharmacological interventions had been attempted or offered prior to the opioid medication administration.-1/11/26 at 6:36 p.m., R2 received PRN oxycodone for pain rated 5/10 which was recorded as E. A corresponding progress note dated 1/11/26 identified the medication was administered but did not include location or any recorded symptoms R2 was experiencing or what, if any, non-pharmacological interventions had been attempted or offered prior to the opioid medication administration.-1/12/26 at 5:29 a.m., R2 received PRN oxycodone for pain rated 7/10 which was recorded as E. A corresponding progress note dated 1/12/26 identified the medication was administered but did not include location or any recorded symptoms R2 was experiencing or what, if any, non-pharmacological interventions had been attempted or offered prior to the opioid medication administration.During an interview on 1/12/2026 at 1:19 p.m., R2 stated he sometimes had pain to his amputation site, both arms, and all over his body when he was tired. Repositioning, ice packs, and rest helped relieve his pain in addition to as needed pain medication. R2 could not recall the name of the pain medication that was effective for him.During an interview on 1/12/2026 1:20 p.m., licensed practical nurse (LPN)-A stated when a resident was having pain, the nurse should ask the resident where their pain was and their pain level on a scale of 1-10. If a resident has more than 1 prn pain medication, the nurse would give the resident the medication they requested. The nurse would document the time the medication was given and the resident's stated pain level. The nurse would go back later to see if the medication were effective by asking the resident to rate their pain again. The medication was effective if the number was lower.Durning an interview on 1/12/2026 at 3:10 p.m., registered nurse (RN)-A stated a nurse would ask the resident where their pain was located and their current pain level. RN-A would offer a non-opioid pain medication first for a pain rating less than 7/10 and an opioid pain medication for pain rating of 7-10/10. If a resident asked for the opioid medication first, RN-A would educate about the benefits of starting with the non-opioid medication but would bring the resident the medication they requested. RN-A would document the medication administration and the pain level. RN-A would follow-up with the resident later in the day to see if the pain medication were effective by asking the resident to rate their pain again.During an interview on 1/12/2026 at 4:41 p.m., the director of nursing (DON) stated when documenting a prn pain medication administration the nurse should include the location of the pain, the resident's pain scale rating and any non-pharmacological interventions attempted prior to the medication administration so pain follow up could be completed accurately and pain could be tracked and trended over time.During an interview on 12/13/2026 at 2:04 p.m., nurse practitioner (NP) stated when a resident had multiple pain medications, the nurse should offer the non-opioid medication first even if the resident is requesting the opioid medication. Use of non-opioid medication may reduce the number of times the residents need the opioid medication. Use of opioid medications increases a resident's risk of falls and constipation. A nurse should document interventions offered/attempted prior to medication administration, pain location, pain level and follow up if the medication was effective. Pain location is valuable information so the provider can be notified if a resident is having pain in a new location.During an interview on 1/13/2026 at 3:25 p.m., pharmacist (Ph) was interviewed and stated non-opioid medications like acetaminophen would be utilized for general pain. Opioid medications like hydromorphone were usually reserved for severe pain. The Pain Management Program policy dated 11/2022 instructed documentation of the pain evaluation, intervention and evaluation of activities shall be done in a clear and concise manner per the plan of care. Frequency of documentation should include consistent monitoring of pain levels prior to administration of pain medication and the resident's level of pain relief post administration as well as alternate (non-pharmacological) measures to relieve pain.

Based on interview and record review the facility failed to include in the care plan interventions for safe eating and swallowing for 1 of 2 residents (R1) reviewed for quality of care and treatment. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified diagnoses of unspecified tremor (involuntary movement), absence of other parts of the digestive tract (removal or absence of part of the digestive tract which could be stomach, intestines or other components), and dysphagia oropharyngeal phase (swallowing disorder occurs in the mouth and throat affecting the ability to swallow both liquids and solids). R1 had cognition impairment. R1 required set up assistance with meals. R1 did not have difficulty with coughing or choking during meals or when swallowing medications. R1's care plan dated 1/16/25, identified a self-care performance deficit with an intervention labeled eating: set up. R1's physician order dated 1/16/25, identified regular textured diet with thin liquids. R1's progress note dated 2/14/25, included R1 had difficulty swallowing medications whole this morning. Choking and coughing when taking medications but able to clear independently. R1 stated this had happened before but more often lately. Nurse practitioner notified and orders for speech therapy (ST) recommended. R1's physician order dated 2/14/25, identified orders for ST to evaluate and treat for diagnosis of choking/coughing with medication administration. R1's progress note dated 2/14/25 at 12:50 p.m., directed R1 was seen by ST with recommendations to crush medications and put in applesauce or pudding. Nurse practitioner notified and order received to crush medications. Family notified of medications being crushed now. R1's physician order dated 2/14/25, directed to crush medications. R1's ST evaluation and plan of treatment dated 2/14/25, identified R1 should be in an upright position for all meals, remain upright for at least 30 minutes after all meals, eat and drink slowly, small bites, small sips, chew foods thoroughly, alternating bites and sips. To facilitate safety and efficiency, it is recommended R1 use the following strategies during oral intake: chin tuck and effortful swallow. R1's progress note dated 3/1/25, included R1 was on a regular diet, regular textured food, regular liquids. R1 can feed self with no chewing/swallowing problems noted. R1's progress note dated 4/20/25, included R1 and son were educated on proper positioning and eating in the dining room with peers for safety and to monitor in case of choking episode. R1 did not say much to the education but son verbalized understanding. R1's record review of the care plan did not include the addition of ST recommendations, that medications should be crushed and placed in applesauce or pudding, nor that R1 was a choking risk. During a phone interview on 5/20/25 at 1:27 p.m., family member (FM)-A stated the facility knew that R1 was a choke risk and had difficulty swallowing. One of the nurses gave FM-A and R1 education that she was to be upright while eating. R1 was on a regular diet and regular liquids. During an interview on 5/23/25 at 8:37 a.m., licensed practical nurse (LPN)-A stated she was working with R1 on 2/14/25, and R1 just could not swallow her pills. LPN-A crushed the pills and put them in pudding and R1 did not have difficulty swallowing that. LPN-A received an order from the nurse practitioner for ST to evaluate and treat. On 4/20/25, FM-A was with R1 in her room and it was right before a meal. R1 had requested to lay down. LPN-A educated FM-A and R1 that it was best to eat in a completely upright position and with other residents. During an interview on 5/23/25 at 10:07 a.m., speech language pathologist (SLP)-A stated R1 did good with eating food but complained that she felt like the food was stuck in her throat. SLP-A encouraged consistent cueing which included chew food well, do a liquid wash. SLP-A gave recommendations to be upright for all meals and 30 minutes afterwards, eat and drink slowly, small sips and bites, alternate between sips and bites. During an interview on 5/23/25 at 2:30 p.m., assistant director of nursing (ADON) reviewed R1's care plan and verified that ST recommendations of remaining upright position for all meals, remain upright for at least 30 minutes after all meals, eat and drink slowly, small bites, small sips, chew foods thoroughly, alternating bites and sips. To facilitate safety and efficiency, it is recommended R1 use the following strategies during oral intake: chin tuck and effortful swallow were not in the care plan. The expectation is that all recommendations from therapies would be included immediately in the care plan and the nursing assistant care guide.

Based on observation, interview, and document review, the facility failed to comprehensively assess supervision needs and develop individualized person-centered interventions to identify and mitigate risks and hazards for residents when out in the community and upon subsequent return to the facility. This failure resulted in the risk of serious harm, injury, or impairment for 3 of 3 residents (R2, R3, R1) reviewed for safety. The immediate jeopardy began on 2/27/25 when the facility failed to ensure a systematic process of an individualized community safety assessment to identify potential risks or establish prevention strategies to ensure resident safety for R2 who had vascular dementia and required supervision, R3 who had significant current alcoholism with impaired insight, judment, and memory, and R1 who had substance abuse disorder (SUD) with cognitive impairment and mobility limitation. The IJ was identified on 4/10/25. The executive director (ED), director of nursing (DON), assistant executive director, and administrative intern were notified of the immediate jeopardy on 4/10/25 at 5:53 p.m. The immediate jeopardy was removed on 4/11/25, but noncompliance remained at the lower scope and severity level of D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R2's hospital discharge summary dated 11/5/24 to 11/8/24, indicated R2's past medical history included, abnormal urination (history of incarceration for public urination), aggressive behavior of child (history of physical fights), anxiety disorder, counseling on substance use and abuse (chemical dependency treatment 8 times), family history of suicide, history of psychiatric hospitalization s, intravenous (IV) drug user, self-mutilation, substance use disorder (SUD) - (history of IV heroin, cocaine and alcohol use), and suicidal behavior (R2 reported history of chronic suicidal ideations since 2005). Hospital course identified R2 had failure to thrive, indicating R2 was reportedly altered, covered in feces, urine and had wandered into a shelter confused, according to the shelter. R2 was discharged to skilled nursing facility. R2's Nurse Practitioner (NP) visit dated 1/6/25, identified R2 had a Saint [NAME] University Mental Status (SLUMS) score of 23/30 showing moderate dementia. R2 could live in supportive housing, waiting on assisted living facility (ALF) setting which continues to be appropriate based on scoring. Assessment/Plan identified diagnosis of primary moderate vascular dementia with mood disturbance (moderate degree of cognitive impairment due to vascular disease, accompanied by mood changes with symptoms that may include difficulties with problem-solving, slowed thinking, and loss of focus): mood disturbances longstanding depressive disorder, history of homelessness, recommendation for assisted living setting for future housing. R2's ACP visit dated 1/8/25, identified R2's mental status exam indicated short term memory and insight/judgement was impaired and thought content was blocked. R2's treatment recommendations/plan identified R2 would present as someone who would benefit from remaining in a secure structured setting to support best functioning and quality of life. Strategies to support him to maintain his sobriety area warranted including placement considerations given his history and level of cognition. R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 admitted to the facility on [DATE] and identified R2 had moderate cognitive impairment. R2's care plan focus dated 2/21/25, identified R2 had cognitive loss/dementia or alteration in thought processes. Interventions included to cue and supervise as needed and observe/document/report to medical practitioner any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status. The care plan lacked evidence of interventions related to safety in the community and did not identify if R2 was safe to be independent in the community or not. R2's progress notes were reviewed in conjunction with facility sign out/sign in forms between 2/27/25 through 4/8/25. Progress notes identified multiple occurrences of R2 leaving the facility without indication that he was supervised. Further identified R2 did not complete the sign-out sheet, notify staff he was leaving, or inform staff of his whereabouts, who he was with/if he had supervision, his expected time of return, and his actual return. R2's progress note dated 2/27/25 at 3:55 a.m., identified R2 was unable to be located, a thorough search of the entire facility including all common areas, rooms, bathrooms, outdoor areas was conducted. A missing person's report made to the police department and the facility DON/supervisor notified. At 4:38 a.m., police came to the facility and gathered more information for R2. At 8:00 a.m., R2 was at the ED with complaints of SOB. ER was assessing and send R2 back to the facility later this morning At 11:10 a.m., R2 returned to the facility via ambulance. The progress notes indicated staff did not know when he was last seen until 3:55 a.m.; R2 was out of the facility and missing for at least 4 hours before the facility identified R2 was at the hospital. R2's record did not include a comprehensive community safety assessment that would identify individualized interventions for R2's safety in the community and/or ability to be unsupervised while out of the facility. R2's progress note dated 3/3/25 at 2:55 p.m., per report R2 last seen at 12:25 p.m. R2 had left the facility. At 3:44 p.m., writer began petition for guardianship for R2. At 4:21 p.m., R2 had not returned to the facility, did not sign out when he departed at 12:25 p.m. At 8:53 p.m., R2 had not returned to the facility yet, last seen at 12:25 p.m., call placed to family with concerns of whereabouts. According to family they have no idea of R2's location. Calls placed to hospitals with no admission record for R2. At 10:50 p.m., R2 had not yet returned to the facility, oncoming night shift nurse updated to call police if not returned to facility by midnight. On 3/4/25 at 12:15 p.m., R2 had not returned yet to the facility .a call placed to 911 about 12:15 a.m., to report R2 as missing. Police arrived at the facility around 12:55 a.m., gathered all necessary information about R2 missing. On 3/4/25 at 5:45 a.m., R2 was found lying in bed (at the facility) at this time. R2's progress notes identified R2 was gone for 17 hours and 15 minutes and R2's whereabouts were unknown. R2's occupational therapy (OT) encounter note dated 3/14/25, identified R2 had a SLUMS assessment completed that he scored a 19/30 (score under 20 identified cognitive impairment or potential dementia). Most of R2's points were lost on recall of objects. R2 engaged in community outing involving indoor and outdoor ambulation, wheelchair management (pushes w/c in front of him like a walker), uneven surfaces, dressing, toileting (both independent), money management, social interaction, managing both his device and hot coffee (he did without spilling or burning himself) and general community safety. R2 was educated about therapy trying to get him out of memory care and into a more appropriate setting. Plan: continue functional cognitive assessments and functional mobility. R2's progress note dated 3/14/25 at 11:16 a.m., met with R2 discussed sign out policy when leaving facility and calling if not making it back timely, R2 agreed, writer will assist with ordering a free cellphone. At 9:22 p.m., day shift nurse reported that R2 went outside to smoke. He signed out at approximately 5:30 p.m. However, R2 had not returned, writer called R2's family left message informed shift supervisor. Supervisor stated to wait until midnight if R2 does not return by then will report as a missing person. At 1:12 a.m., R2 did not return to facility, missing person report filed .At 6:26 a.m., two police officers came to the facility, all necessary information given. On 3/15/25 at 9:33 a.m., hospital emergency room called and stated R2 was being admitted for respiratory difficulty .At 8:35 p.m., R2 returned to the facility via ambulance. R2's progress notes indicated he was missing and whereabouts unknown for approximately 15 hours. R2's progress note dated 3/17/25 at 12:45 p.m. staff seen R2 at bus stop, R2 stated he was going to the store via a bus and intended to be back by dinner time. At 5:57 p.m., received phone call from metro transit police said R2 was lost and unable to go back. R2 will be sent back. At 6:31 p.m., R2 was sent back by metro transit police, was found on [NAME] Avenue/[NAME] Avenue southbound bus stop shelter waiting for a bus. R2 was alert and oriented x 2, denied alcoholic drink, R2 stated he checked out before he left, writer unable to find where R2 signed. Progress note dated 3/18/25 at 12:45 p.m., writer applied for an assurance wireless phone for R2 should arrive within 7-10 business days. R2's progrss notes identified R2 was gone for approximately 5.5 hours whereabouts unknown, and identified R2 was lost and unable to make his way back to the facility and the police brought him back. R2's progress notes dated 3/28/25 at 1:39 a.m., R2 was not in room for scheduled inhaler for COPD. At 2:02 a.m., writer got report from previous shift that R2 had not been seen in the facility since this morning. Writer checked around facility and not available. Writer called 911 and filed a missing person report with police. They will send police out as soon as possible. Writer called family and left message. At 2:50 a.m., police stopped at the facility requesting information regarding R2. Police stated to call and let them know when R2 returns so they can take him off the missing person report. At 10:33 a.m., identified R2 was on LOA. At 2:15 p.m., identified R2 returned to the unit between 1:00 p.m., and 1:30 p.m., R2 went to bed and was sleeping, message left with family that R2 was back. At 2:27 p.m., writer educated R2 on the importance of signing out, R2 stated, okay . R2's progress note identified on 3/28/25, R2 was missing for approximately 12 hours and his whereabouts unknown. -On 4/4/25 at 7:09 p.m., identified R2 was not in the facility until dinner time and med pass time. Tried to contact him through cell phone but did not answer, will continue to follow up. At 11:47 p.m., R2 was not in the facility, called and left voice message incoming nurse updated. On 4/5/25 at 1:12 a.m., writer called R2's phone again and phone went to voicemail left message for call back. Called and filed a missing person report with police. Stated they would send officers to come to the facility, called family, left voicemail. At 1:30 a.m., police called to inform they will be sending an officer to the facility. At 6:00 a.m., police stopped by to see if R2 was back. At 3:02 p.m., R2 has not returned to the facility, family notified. On 4/6/25 at 12:08 a.m., R2 has not returned to the facility. At 6:42 a.m., R2 did not return to the facility will update incoming nurse. At 12:42 p.m., nurse received a call form the hospital regarding R2's admission due to COPD exacerbation and pneumonia will be arriving back to the facility with medications after 1:00 p.m. At 1:45 p.m., R2 returned from the hospital to the facility at 1:40 p.m., Temperature was 99.1, pulse 105, oxygen saturations 94% on room air and blood pressure was 112/67, no complaints of pain or discomfort. R2's After Visit Summary (AVS) dated 4/5/25 to 4/6/25 identified R2 was in the hospital for treatment of COPD exacerbation. Summary included The patient presented to the ED due to new onset shortness of breath and mild cough over the past two days. R2 reported he was out of his as needed inhaler and R2 is most likely experiencing exacerbation of COPD due to lack of medication with a possible component of community acquired pneumonia. R2 was discharged with medications to treat this and will have an upcoming appointment with pulmonology on 6/3/25. R2's medical record identified R2 was gone from facility from 4/4/25 at approximately 7:00 p.m., and returned to facility on 4/6/25 at 1:45 p.m., gone for approximately 42 hours and 45 minutes. R2 was hospitalized from 4/5/25 at 3:11 p.m., and discharged from the hospital on 4/6/25 at 12:58 p.m., accounting for approximately 22 hours of hospitalization , with 22 hours of R2 missing and whereabouts unaccounted for. R2's progress notes dated 4/8/25 at 12:25 a.m., per PM nurse R2 was last seen around noon (on 4/7/25) on the floor .R2 not on the floor/room. R2's personal cell phone was left in his room. At midnight a call was placed to police and hospital, was not found, filed missing person report. Night supervisor was updated. At 4:27 a.m., two police officers followed up on missing person report .At 9:03 a.m., R2 returned to the facility, writer had conversation with R2 regarding the importance of signing out and ensuring he has his cell phone with them to keep the facility updated. R2 was in agreement. R2s progress notes identified R2 was gone from facility from 4/7/25 at approximately 12:00 p.m., and returned to facility on 4/8/25 at 9:03 a.m., gone for approximately 21 hours with whereabouts unknown. During an interview on 4/9/25 at 12:38 p.m., registered nurse (RN)-A stated all residents can leave the building anytime they want unless they reside on the secured unit. RN-A further stated all they must do is sign in/out on the sign out book. RN-A indicated they would not notice a resident was gone unless they went to go give their medications and could not find them. RN-A stated if a resident was not back by midnight, and we could not get a hold of them we would file a missing person's report with the police and document in the nurse's progress notes. During an interview on 4/9/25 at 4:28 p.m., OT-A stated a resident's cognition will be assessed on admission, the social worker would first screen a resident to get a snapshot of their cognition by performing a Brief Interview for Mental Status (BIMS) assessment. OT-A stated this was used to assess for delirium and was not a true show of cognition. OT-A stated the SLUMS exam is a brief screening test for detecting mild cognitive impairment and dementia and assess for orientation, short term memory, calculation and language-verbal fluency. OT-A indicated if the SLUMS score is less than 20 it can indicate dementia and require further cognitive testing. OT-A stated she assessed R2's SLUMS on 3/13/25 and he scored a 19 out of 30 indicating dementia. OT-A stated the Cognitive Performance Test (CPT) assesses a person's cognitive abilities, like memory, attention, and reasoning, through various tasks and questions without being able to the cue the individual. OT-A stated the CPT assessment can be used to diagnose cognitive impairments like dementia and guides interventions and support for persons with cognitive challenges. OT-A indicated the CPT assessment takes about an hour to complete so rarely was utilized in the long-term care setting as it was unrealistic. OT-A was unable to articulate what staff at the facility would be responsible to assess a resident's safety in the community. OT-A identified R2 did not have a CPT assessment, stated she did assess R2 while he was in the community on 3/14/25, and completed a SLUMS assessment with a score of 19/30 that indicated cognitive impairment but was unable to articulate if R2 was able to be safe in the community independently while residing at the facility. OT-A stated R2's short-term memory was not intact and if she was doing a discharge to home assessment on R2, he would require supervision. During a phone interview on 4/10/25 at 8:29 a.m., when asking nurse practitioner (NP)-A if the facility was responsible for identifying and assessing a resident's risk for leaving the facility without notification to staff and developing interventions to address the risk. NP-A stated he was not involved in the process in the identifying and assessing the resident's risk for leaving the facility and the development of associated safety interventions. NP-A stated that all residents that do not reside on the locked unit are able to come and go into the community from the facility and would require the resident to put the date and time they are signing out, where they are going and what time the expected return is. NP-A further stated they cannot stop residents from coming and going as it is their right, stated, this is not a prison. During an interview on 4/10/25 at 9:20 a.m., the medical director stated the process for a resident to leave the facility was all the residents that did not reside on the locked unit use a sign in and sign out process. Medical director stated, we are not a prison, we cannot stop someone from coming and going unless they are in a locked unit. Medical director further stated if a resident was their own decision maker we are assuming they have capacity to go safely in the community unsupervised. Medical director further stated the BIMS assessment was not comprehensive in determining a resident's cognition and to determine true cognition it would be a combination of cognitive tests that include a CPT, SLUMS and the [NAME] Cognitive Level Screen (ACLS) assessment. Staff did not routinely assess cognition upon admission unless warranted. Medical Director was unable to articulate a facility process of how a resident was comprehensively assessed to be safe independently in the community. During a phone interview on 4/10/25 at 10:51 a.m., licensed psychologist (LP)-A stated she performed a SLUMS assessment indicating R2 had cognitive impairment with short term memory impairment. LP-A stated residents with cognition concerns should be comprehensively assessed to be independent in the community several factors would need to be assessed to include cognition, diagnoses, capacity to create a contract and follow through, etc .then IDT should discuss this to put a safety plan in place for each resident. During an interview on 4/10/25 at 11:16 a.m., when asking director of nursing (DON), if the facility was responsible for identifying and assessing a resident's risk for leaving the facility without notification to staff and developing interventions to address the risk. DON explained the OT would be the professional to assess a resident to see if they would be safe to be in the community independently unsupervised. DON verified the OT that assessed R2 on 3/14/25, did not clearly state if R2 was safe to be independent in the community unsupervised. DON indicated their current process for a resident to leave the facility was if the resident did not reside on the locked unit the resident would utilize the sign in and sign out sheet located at each wing. The resident should write the time they leave and an expected return time along with where they are going. DON verified that residents do not always use the sign and sign out sheets and was unable to articulate what interventions the facility has in place to keep residents requiring supervision in the community safe. If a resident was missing, the staff call family and the resident to try and identify the resident's whereabouts and are to wait until midnight and call the police to file a missing person's report and notify myself, the family and the supervisor. DON stated she received a report this morning that R2 went missing yesterday sometime and had not yet returned to the facility, a missing person's report was filed with the police at midnight, and she did not have any more information on R2. During an observation and interview on 4/14/25, at 9:48 a.m., R2 was observed dressed and lying in bed in his room. R2 stated he currently didn't feel good and has the sniffles, further stated he was put on the locked unit because he was smoking in his room, rules are rules, don't bother me none. R2 stated he didn't come here to make friends and tried to stay to himself. R2 stated he was waiting to get out of here and get his own place. R2 stated he had been to the ED and hospital a few times recently due to his mental health. R2 did not wish to speak with surveyor any further and asked surveyor to leave. R3 R3's quarterly MDS dated [DATE], indicated R3 admitted to the facility on ,d+[DATE]. R3 was cognitively intact with a BIMS score of 15, was independent with activities of daily living and mobility, and utilized a wheelchair. R3's diagnosis report indicated R3 had diagnoses including alcohol [ETOH] abuse with withdrawal, alcohol dependence, alcoholic hepatitis (liver inflammation due to excessive ETOH consumption), alcoholic polyneuropathy (nerve damage from excess ETOH consumption), liver cirrhosis (scarring of the liver), opioid abuse, unspecified psychosis, major depressive disorder, anxiety disorder, adjustment disorder with mixed anxiety and depressed mood, adjustment disorder with disturbance of conduct, muscle weakness, unsteadiness on feet, history of falling, repeated falls. R3's psychiatry note dated 12/20/24, indicated she had diagnoses including generalized anxiety disorder, alcohol use disorder, major depressive disorder, and opioid use disorder. Her mental status examination included her insight, judgment, memory, and concentration are quite impaired. R3's physician orders included naltrexone hydrochloride (HCl) 50 mg daily for substance use disorder (dated 2/14/25). R3's care plan focus revised 3/25/25, identified she had limited physical mobility with fall risk related to ETOH abuse and noted she was independent with ambulation and utilized a wheelchair as needed. Interventions included: independent with bed mobility (dated 11/29/23), utilizes wheelchair as needed independently (dated 3/25/25), independent with toileting (dated 4/5/24), and independent with transfers (dated 4/5/24). R3's care plan focus revised 3/25/25, identified she had suspected/actual illicit drug/ETOH use and previously declined treatment services but had started to talk with the LADC. Interventions dated 4/5/24 included: Doctor updated regarding actual/suspected abuse, hold all mood altering or all sedative medication when ETOH or marijuana use suspected; Ensure safety and observe for withdrawal symptoms; and a list of symptoms of a drug overdose including alcohol poisoning. R3's care plan did not identify the symptoms of alcohol withdrawal or identify her supervision needs in the community or related interventions for her safety in the community and upon subsequent return to the facility. R3's physician note dated 1/8/25, indicated she had alcohol use disorder with recurrent episodes of alcohol use. She was most recently hospitalized [DATE] after being found intoxicated and her blood alcohol level was 0.33. R3's progress notes dated 1/9/25, 1/12/25, 1/13/25, 1/14/25, 2/8/25, and 2/9/25 indicated R3 was intoxicated and medications were refused and/or held. The notes did not indicate the provider was notified or identify what ongoing monitoring and interventions were implemented. R3's progress notes dated 2/10/25, indicated R3 was intoxicated, medications were held, vital signs taken, and provider was notified. R3 later request transport to the hospital because she wasn't feeling well and reported vomiting all day. R3's hospital notes between 2/11/25 through 2/13/25 identified R3 had a history of alcohol abuse and admitted to the hospital on 2/10/25 with nausea and vomiting. R3's principal diagnosis was alcoholic ketosis (buildup of acid in the blood caused by heavy alcohol use often in conjunction with poor nutrition) and she initially presented with tachycardia (elevated heart rate) to the 120's, hypertensive (elevated blood pressure) to 180's/100's, with numerous abnormal lab values. A hospital Social Work Initial Assessment indicated R3 reports she uses the w/c when at the facility, does not use an assistive device when she leaves the facility. She leaves the facility independently, usually via a cab ride she independently arranges. Patient reports her typical outing includes stops at Target and a liquor store. A progress note by hospitalist included R3 reported the nursing home don't really monitor where she goes so she regularly walks down to the bar on the corner of the street and drinks. R3's progress note dated 2/13/25, indicated R3 returned from the hospital. R3's record did not identify the concerns in hospital documentation, including lack of assistive device when leaving the facility and purchase/consumption of alcohol while in the community, were addressed. Further, did not indicate that her need for supervision in the community was assessed. R3's progress notes dated 2/25/25, indicated R3 was extremely intoxicated and found sleeping on the floor next to her bed with partially consumed bottles of alcohol at 3:00 a.m. Assessment and vital signs completed, assisted back to bed, and staff kept monitoring her situation with intervention of lowering her bed to the floor to prevent injuries in case she decided to get out of bed. The provider notification section of the note was blank and did not indicate the provider was notified. Further, progress notes indicated R3 remained intoxicated throughout the day, did not eat breakfast or lunch, refused all morning and afternoon medications, and refused assessment and vital signs. R3's progress note dated 2/25/25 at 8:55 p.m., indicated nurse went to get R3 from front desk, R3 was intoxicated, R3 stated she fell while downtown and hit her head while trying to get on a bus. R3 refused vitals, neurological checks performed, provider notified. Additional progress note at 10:58 p.m., indicated R3 sustained a bruise and head hematoma from the fall, identified contributing factor of R3 was not using her wheelchair, and noted care plan and care sheets were reviewed with no changes indicated. It was not evident in R3's record that her supervision needs were assessed or interventions were developed to ensure her safety in the community after she fell and sustained a head injury while intoxicated in the community. R3's record reviewed between 2/26/25 through 4/10/25 identified although R3 continued to be intoxicated almost daily, R3's record did not include a comprehensive assessments and/or monitoring of withdrawal symptoms nor assessments and/or monitoring of R3's medical condition while she intoxicated, nor safety interventions including the level of supervision while R3 was intoxicated inside the facility. Further there was no indication a monitoring system was developed to prevent and/or identify if/when R3 brought or had alcohol in room and not evident interventions were developed to keep R3 safe and other residents safe that may inadvertently have access to R3's alcohol. Additionally, R3's records did not include a comprehensive community safety assessment, despite R3's patterned history of leaving the facility, consuming alcohol while away, then returning intoxicated. R3's record did not include interventions that would prevent and/or mitigate R3's risks of serious injury or even death while in the community. Examples from the record include but are not limited to: R3's progress notes dated 2/26/25, 2/27/25, 3/1/25, 3/4/25, 3/5/25, and 3/11/25, indicated R3 was intoxicated and medications were refused and/or held. On 3/4/25, alcohol was also found in R3's room and she was verbally abusive towards staff and refused cares. R3's progress notes dated 3/12/25, indicated R3 was intoxicated, verbally aggressive to staff, and medications were refused and/or held. Note at 1:27 p.m., indicated she was sent to the hospital per provider order. Note at 8:06 p.m., indicated she was sent to the hospital for evaluation of a suspected gastrointestinal bleed after being found in her room intoxicated with black stool smeared in the bathroom. She returned to the facility at 6:30 p.m. and was still intoxicated, medications were held. R3's emergency department (ED) After Visit Summary dated 3/12/25, indicated R3 was seen for an alcohol problem and blood in stool with diagnosis of alcoholic intoxication with complication. R3's nurse practitioner note dated 3/14/25, indicated she was seen for evaluation following intoxication and concern for a gastrointestinal bleed two days ago. R3 continues to drink, had a blood alcohol level of 0.36, and she states that her last drink was several weeks ago but this is not accurate. R3's progress note dated 3/18/25, indicated R3's functional status abilities varied related to alcohol use. When intoxicated, she required supervision/touching assistance of one staff member for bed mobility, transfers, and ambulation for safety. When intoxicated, she required limited assistance of one staff member with toileting tasks and colostomy management. She was able to make her needs known but staff were to anticipate her needs as appropriate when intoxicated. R3's care plan did not identify individualized interventions that reflected the increased need for assistance when intoxicated. R3's Comprehensive Nursing Data Collection assessment dated [DATE], identified R3 was vulnerable to self-abuse described as alcohol abuse, susceptible to abuse from others described as vulnerable adult, susceptible to abuse others, and had verbal behavioral symptoms directed at others described as a history of verbal aggression when intoxicated. The assessment identified R3 had alcohol use daily and history of substance/cannabis abuse was marked as never. The assessment failed to identify R3's diagnosed history of opioid abuse. The Data Collection included an elopement assessment with each 'yes' answer assigned one point and a score of 4 or greater indicating potential for elopement. R3 had an elopement risk score of 3 indicating no elopement risk. The questions exhibits pacing or agitated behavior and has a diagnosis or OBS, dementia, psychosis, Alzheimer's, or other psychiatric diagnosis, were marked no. The assessment failed to identify R3's agitated behaviors where documented in provider and progress noted between 1/8/25 through 3/18/25, and further failed to identify R3's psychiatric diagnoses of unspecified psychosis, major depressive disorder, anxiety disorder, adjustment disorder with mixed anxiety and depressed mood, and adjustment disorder with disturbance of conduct. If the assessment identified these areas accurately, R3's score would have been 4 or greater, identifying her as an elopement risk. R3's progress notes dated 3/22/25 and 3/23/25, indicated R3 was intoxicated and medications were refused and/or held. Progress note dated 3/28/25, indicated R3 left the facility to go to the mall, walked out, and refused to sign out. Later returned in good condition. R3's progress notes did not identify how long R3 was out of the facility and/or when R3 returned. R3's progress notes dated 3/29/25, indicated she was missing from the unit at 8:00 a.m. and remained missing at 2:00 p.m. with supervisor to follow up. Note at 6:14 p.m., identified person in the community called the facility and stated resident was drunk and needed to be picked up, provided address, staff notified police. At 9:15 p.m. police dropped R3 off at the facility. She was intoxicated, non-compliant with cares, refused vital signs and assessment, and provider was notified. R3's record did not identify assessment of R3's supervision needs after she was found intoxicated in the community and returned to the facility by police. Further, did not identify what interventions were put in place to mitigate related risk while in the community and upon her return. Progress note dated 3/30/25, indicated R3 was intoxicated the whole overnight shift and called emergency services at 6:00 a.m. and was taken to the hospital while still intoxicated. There was no assessment or indication why R2 was sent to the hospital. R3's ED After Visit Summary dated 3/30/25, indicated R3 was seen for an alcohol problem with diagnosis of alcohol intoxication delirium with moderate or severe use disorder. Progress notes dated 3/30/25, indicated R3 returned from the hospital around 12:00 p.m. R3 then requested a cab be called for a shopping trip, refused to sign

Based on interview and document review, the facility failed to ensure a resident's advance directives was accurately and consistently documented in the resident's electronic health record (EHR) banner, Provider Order for Life-Sustaining Treatment (POLST), and physician orders to ensure the residents wishes would be followed in the event of a cardiac arrest. This resulted in immediate jeopardy for 1 of 33 residents (R84) whose code status was not accurately documented and was reviewed for advanced directives. The immediate jeopardy began on [DATE], when the POLST was signed indicating do not resuscitate (DNR) and a physician's order for R84 to have a full code status remained. The immediate jeopardy was identified on [DATE]. The assistant director of nursing (ADON) and director of nursing (DON) were notified of the immediate jeopardy on [DATE], at 7:40 p.m. The immediate jeopardy was removed on [DATE], however, non-compliance remained at an isolated scope with potential for more than minimal harm that is not immediate jeopardy (level D). Findings include: R84's admission Minimum Data Set (MDS) dated [DATE], indicated R84 had intact cognition and had been admitted to the facility on [DATE]. R84's Transfer/Admission orders dated [DATE], indicated R84's code status was a full code with the page signed by the provider on [DATE]. The report then indicated a copy of a signed POLST was still needed and this would need to be done by a provider, with the page signed on [DATE]. R84's POLST dated [DATE], indicated DNR/allow natural death and was signed by R84 and nurse practitioner (NP)-A on [DATE]. This POLST was found in both the EHR and paper chart with no further POLSTs found. R84's progress note dated: -[DATE] at 3:20 p.m., indicated data was collected for R84's admission by nursing staff and R84's code status was DNR. -[DATE] at 3:17 p.m., indicated R84's advanced directive could be found on her POLST and had the code status was DNR. -[DATE] through [DATE] were reviewed and lacked documentation to support the resident wished to receive CPR if she was found with no pulse and was not breathing. R84's provider note dated [DATE], indicated R84 had recently moved to the facility from her home in the community due to an increased level of care need. The note indicated R84 was a Jehovah's Witness and was excited to talk with another Witness who lived in the building. The note listed R84's code status as DNR. The note indicated R84 was diagnosed with diabetes, a heart arrhythmia (the heart beats with an abnormal rhythm), and obstructive sleep apnea (OSA, repeatedly stopping and starting breathing while sleeping). R84's care plan dated [DATE], indicated R84's code status could be found on her POLST and the goal of the care plan was to have her code status wishes honored. The care plan indicated that code status would be reviewed quarterly and as needed with the resident/resident representative. The care plan indicated R84 followed Jehovah's Witness practices, and the facility would help to coordinate visits with spiritual leaders from the same faith. R84's Care Conference Summary dated [DATE], indicated a care conference was held with R84 attending. The note indicated R84's advance directives were reviewed with her, and no changes were needed to the DNR status. R84's order summary dated [DATE], included an order, code status: full code, that was dated [DATE]. R84's EHR banner, printed on [DATE], indicated R84's code status was full code. R84's clinical profile in the EHR, printed on [DATE], indicated R84 was her own representative. During an interview on [DATE] at 4:01 p.m., R84 confirmed she would not want to be resuscitated if she was found with no pulse and was not breathing. R84 stated she was one of Jehovah's Witnesses as part of her religious belief she would want to enter the future world if it was her time and would not want to suffer by being resuscitated. During an interview on [DATE] at 4:09 p.m., licensed practical nurse (LPN)-B stated he was not R84's nurse but if a resident was found pulseless and not breathing, he would look at the POLST in the hard chart to determine if CPR should be initiated. During an interview on [DATE] at 4:37 p.m., LPN-A stated she was R84's nurse this shift and although both the POLST or the EHR banner could be referenced to determine code status, she would reference the EHR banner to see if R84 needed to be resuscitated because it was easier to access. LPN-A stated that R84 was a full code per the EHR banner and the provider order so she would initiate CPR if R84 was found pulseless and not breathing. When asked to review R84's POLST, LPN-A exclaimed ooooh and stated the POLST indicated R84's code status was DNR and believed this was the accurate code status. LPN-A stated she would be worried staff would perform CPR on R84 against her wishes because of the mismatch. During an interview on [DATE] at 5:09 p.m., health unit coordinator (HUC)-A stated when a resident was admitted , she would reference the hospital paperwork or admit orders to determine the code status to enter into the EHR until a POLST was reviewed with the resident and signed by the provider. HUC-A stated she was in charge of uploading POLSTs to the EHR and updating the physician order/EHR banner after reviewing the POLST. HUC-A confirmed R84's EHR banner/provider order did not match R84's most recent POLST. HUC-A stated she thought R84's accurate code status was DNR. HUC-A stated she was unsure how updating the EHR banner/provider order was missed after R84's POLST was completed. HUC-A stated she was supposed to be completing audits every two weeks to ensure resident code status in the EHR matched the POLST. HUC-A stated these audits had not been completed since R84 had been admitted in January as she felt they were pretty short-staffed and did not feel she had time. During an interview on [DATE] at 5:09 p.m., LPN-C stated if a resident was found pulseless and not breathing, she would check their code status on the EHR banner, and if the banner said Full code, she would start CPR. During an interview on [DATE] at 6:19 p.m. with the director of nursing (DON) and the administrator, the DON stated if a resident was found pulseless and not breathing, staff could look at either the POLST or the EHR banner/provider order as they should all match, to determine if CPR should be initiated. The administrator stated that R84's profile or face sheet could be referenced to determine if the resident was her own representative and confirmed that she was. The DON stated that the HUCs were in charge of completing audits to ensure the POLST and the EHR banner/provider order indicating code status, matched. The DON stated as this was an informal process, the frequency of these audits did change based on results and the DON thought audits were being completed monthly. The DON stated the health information system supervisor (HISS) oversaw ensuring these audits were being completed. On [DATE] at 7:27 p.m., the DON stated she had reviewed her emails and confirmed that code status audits were to be completed every two weeks, not monthly, and these were not completed for the floor R84 resided so far this month. During an interview on [DATE] at 6:42 p.m., the HISS stated the HUCs were supposed to complete audits or resident code status every two weeks. HISS stated he and the DON had decided on the audit frequency when the HUC checklist was updated in January and confirmed that audits were to be completed every two weeks to ensure EHR code status accuracy. During an interview on [DATE] at 7:29 p.m., the social services director (SSD) stated social workers reviewed code status wishes with residents at their care conferences and would review the POLST to see if it needed to be updated to honor the resident wishes. The SSD confirmed that R84 had wished to be DNR on her care conference on [DATE] and was her own decision-maker. During an interview on [DATE] at 1:30 p.m., registered nurse (RN)-C, the staff development coordinator stated she had assisted in educating staff members on the advance directive process. RN-C stated either the HUC, if working, or the nurse on duty would be in charge of ensuring when a new POLST was obtained, that the EHR banner/provider order matched the updated POLST. During an interview on [DATE] at 9:42 p.m., NP-A stated that on [DATE], she had a conversation with R84, as she was her own decision-maker, about her wishes in the circumstance that her heart stopped beating and she stopped breathing. NP-A stated R84 indicated she would not want to be resuscitated related to her religious beliefs. NP-A stated that it was important that R84's wishes to allow a natural death were honored as CPR would be a violent death for R84 and R84 had made it clear she did not want a violent death. NP-A stated once she completed a POLST with a resident she would attach it to the resident's hard chart for the HUC to upload but did not go in herself and verify that the provider order matched the updated POLST as she expected the HUC to do this. NP-A stated after the communication error involving R84's code status order being a full code instead of being updated to a DNR, she would now ensure the EHR provider order matched the POLST after she completed a POLST with a resident. The undated HUC Job Description, indicated the HUC would complete daily, weekly, and monthly audits as directed. The HUC Duties Checklist revised on [DATE], indicated POLSTs were to be audited every two weeks, on the first and third Friday of every month. The facility's Advanced Care Planning and POLST policy dated ,d+[DATE], indicated when the need for resuscitation occurred, the physician order, CPR/DNR section of the health care directive, and/or the POLST would be followed. The policy indicated if a resident was admitted with a signed POLST, it would be honored during the initial assessment period and a designated staff member must review the POLST with the resident as soon as possible to ensure its accuracy. The policy indicated the physician would review the POLST with the resident within the 14-day assessment period as part of the comprehensive assessment. The facility's Cardiopulmonary Resuscitation policy dated ,d+[DATE], indicated that if a resident experienced cardiac arrest, facility staff would provide basic life support, including CPR in accordance with the resident's advanced directives. The immediate jeopardy that began on [DATE], was removed on [DATE] when the facility developed and implemented a systematic removal plan. The removal plan was verified through interview and documented review as the facility had corrected R84's code status on the EHR banner/provider order to DNR, completed a facility-wide audit to ensure there were no other code status discrepancies, reviewed related policies and procedures, and provided education for all staff involved in ensuring advance directives were honored on the CPR and POLST policies/procedures and their respective roles in the process.

Based on interviews, and records review, the facility failed to ensure provision of oxygen therapy according to orders for 1 of 1 resident (R1) reviewed for respiratory care. This resulted in harm for R1 whose saturation levels were 65% after not receiving continuous oxygen as ordered by physician and had to call Emergency Services herself because the facility failed to respond to her call light ( 2 hours and 15 minutes) when she became short of breath. Findings include: R1's order summary report (OSR) as of 9/29/23, listed R1's diagnoses including history of sudden cardiac arrest, dependence on supplemental oxygen, chronic respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, and chronic obstructive pulmonary disease. The OSR directed staff to provide oxygen continuously at four liters per minute via nasal cannula, ensure tubing patency and proper flow rate, and ensure that portable tank is filled prior to use. The OSR also directed staff to obtain oxygen saturation and record results every shift. R1's quarterly Minimum Data Set (MDS) dated [DATE], showed that R1's cognition was not assessed, and R1 did not have any behavioral symptoms. The MDS identified R1's diagnoses including chronic obstructive pulmonary disease (COPD) and respiratory failure. MDS also indicated R1 was on oxygen therapy and independent with activities of daily living (ADLs) such as transfer, locomotion on unit, dressing, personal hygiene, and eating, but required limited physical assistance of one staff during toilet use. The corresponding care plan for the-above MDS, completed on 8/1/23, identified R1 with altered respiratory status/difficulty of breathing related to COPD and chronic respiratory failure. The care plan directed staff to provide oxygen as ordered. The care plan indicated R1's specific behavior was related to refusal of showers/bathing and refusal for assistance with bathing. The care plan did not indicate behavior related to non-compliance with oxygen therapy, such as ability to get up from recliner and turn on/off oxygen tank/concentrator. The care plan also showed updates or revisions after the care plan completion date (8/1/23), as follows: -On 8/16/23, the care plan related to R1's respiratory problem directed staff to observe/document and report to nurse/medical practitioner any sign or symptom of respiratory distress including decreased pulse oximetry. The care plan pertaining to R1's limited physical mobility with fall risk, also indicated R1 required staff assistance for ambulation, transfer, and to propel wheelchair to and from all destinations. The care plan did not indicate that R1 had behavioral issues related to oxygen therapy as of this date. R1's discharge MDS dated [DATE] (most recent assessment data prior to the hospitalization on [DATE]), indicated change in R1's ADL performance where R1 required staff supervision for bed mobility, transfer, locomotion on unit, dressing, and personal hygiene. This MDS noted R1 had rejection of care occurring one to three days in a seven-day period but did not identify any other behavioral symptoms that could impact a significant risk for illness or physical injury, or that could interfere with R1's care. The corresponding care plan to the assessment data identified on and after 8/19/23, showed the following updates/revisions: -On 8/21/23, the care plan related to ADL performance indicated further change, where R1 required set up with eating. The care plan revision did not indicate R1 had any behavior regarding oxygen therapy. -On 9/6/23, the care plan related to R1's limited physical mobility with fall risk, indicated that the intervention for fall was placement of commode at bedside and to encourage [R1] to wear briefs for incontinence management. This care plan update did not show R1 had behaviors regarding oxygen therapy. -On 9/29/23 (survey entrance date), the interventions in the care plan related to R1's incontinence, indicated R1 prefers to wear own underwear and uses commode independently. The care plan directed staff to keep commode at bedside and for staff to empty after each use. This recent care plan update showed conflict with R1's ADL performance that required limited assist of one-person physical help during toilet use that did not change since the MDS dated [DATE] and staff supervision required during transfers as identified since the care plan update on 8/16/23 and MDS dated [DATE]. -On 9/29/23 (survey entrance date and while R1 was on discharged status and still at the hospital), the care plan related to R1's behavior was updated to include the following: refuses to allow staff to turn off call light; removes oxygen nasal cannula or will turn off tank; refuses to allow staff to replace or turn on oxygen tank; de-saturates and refuses assessments; calls 911 independently of staff and removes oxygen before their arrival. The care plan did not indicate interventions or action plans specific to address these behaviors related to oxygen therapy. R1's medication administration record (MAR) for the month of 9/23, indicated an order to obtain R1's oxygen saturation every shift and record result. The MAR also indicated that on 9/25/23, the evening medications, including R1's oxygen saturations results for the evening and night shifts were already entered as 93 and 92 respectively, even though R1 was discharged to the hospital at 1:20 p.m. in the afternoon. The document titled, Nursing Home Visit-Progress Note dated 8/16/23, indicated provider evaluation following R1's hospitalization for hypercapnia (condition that occurs when a person has too much carbon dioxide (CO 2) in their bloodstream). The document indicated R1's COPD as severe disease with oxygen dependency. The document also indicated R1 was alert, talkative, pleasant, and reiterated to be on a full code status. The document dated 8/23/23, showed another provider evaluation of respiratory status following hospitalization [DATE] through 21 with altered mental status on chronic hypoxemic respiratory failure. The document noted provider discussion about hospice care related to R1's severe respiratory difficulty and likelihood of death due to the difficulty, however, R1 maintained to be on full code status. The document also noted the plan for R1 to remain on multiple breathing treatments and oxygen. A review of the progress notes dated 9/1/23 through 9/26/23 showed no indications related to R1 having behaviors related to noncompliance with oxygen therapy. The progress notes showed that on 9/5/23, R1 fell on urine on the floor. Although, R1 was oxygen-dependent, the progress notes documented R1 was not on supplemental oxygen and is not normally on oxygen. The progress notes dated 9/25/23, indicated R1 called 911 due to shortness of breath, and was taken to hospital at around 2:00 p.m. The facility's call light log for four days (9/21/23 through 9/25/23) showed multiple times of prolonged call light response times (15 times of longer that 15 minutes, five times of longer than one hour, and two times of longer than two hours) as follows: -On 9/21/23 at 8:41 a.m. (22 minutes) -On 9/21/23 at 9:25 a.m. (21 minutes) -On 9/21/23 at 6:30 p.m. (20 minutes) -On 9/21/23 at 7:29 p.m. (21 minutes) -On 9/21/23 at 8:12 p.m. (27 minutes) -On 9/21/23 at 9:50 p.m. (1 hour and 9 minutes) -On 9/22/23 at 9:31 a.m. (24 minutes) -On 9/22/23 at 12:06 p.m. (1 hour and 22 minutes) -On 9/22/23 at 6:59 p.m. (22 minutes) -On 9/23/23 at 6:47 a.m. (53 minutes) -On 9/23/23 at 11:26 a.m. (20 minutes) -On 9/23/23 at 11:52 a.m. (21 minutes) -On 9/23/23 at 12:39 p.m. (38 minutes) -On 9/23/23 at 2:22 p.m. (2 hours and 38 minutes) -On 9/24/23 at 1:05 p.m. (37 minutes) -On 9/24/23 at 1:48 p.m. (28 minutes) - On 9/24/23 at 3:30 p.m. (39 minutes) - On 9/24/23 at 4:24 p.m. (27 minutes) - On 9/24/23 at 7:41 p.m. (26 minutes) -On 9/25/23 at 1:11 p.m. (2 hours and 15 minutes). This entry showed that R1 had call light on for more than 2 hours prior to EMS arrival at the facility and finding her in room with an oxygen saturation of 65%. During interview on 9/29/23 at 12:30 p.m., police officer (PO)-A indicated responding to R1's call at the facility on 9/25/23 at around 1:00 p.m. PO-A stated they found R1 sitting in recliner, alert, short of breath, and with oxygen nasal cannula in place, however, it was connected to an oxygen concentrator that was turned off. PO-A stated the oxygen concentrator was behind R1 at about three to four feet away from the recliner, which was not within R1's reach. PO-A also stated R1 reported to the emergency medical services (EMS) crew she started being short of breath and called for help via call light for half an hour but nobody was responding. PO-A indicated they checked R1's oxygen saturation and it was 65%, so they immediately connected R1 to their portable oxygen tank, after which R1 reported feeling better. PO-A stated he noticed an un-touched meal tray on R1's table but did not know what meal it was or what day or time it may have been brought in. PO-A also stated he observed that R1's call light was on and remained on while they worked with R1, but no staff came to the room. PO-A stated they only saw staff as they were leaving to take R1 to the hospital. PO-A further stated they stayed at the facility for about seven to 10 minutes. During interview on 9/29/23 at 12:02 p.m., family member (FM)-A indicated R1 had three recent hospitalization s, and with this last one, R1 was not able to breath. FM-A stated the facility told her that R1 was turning off oxygen and it was because of that her saturation went down to 60%. FM-A stated that during a care conference on 8/28/23, the facility indicated R1 was declining with cares and had limited mobility. FM-A indicated behaviors related to R1 turning off oxygen tank/concentrator was not identified during the care conference. FM-A said, I have never seen her touch her oxygen concentrator or tank at all, never. FM-A also stated during one of her visited she had witnessed R1 wait an hour for a light to be answered. FM-A further stated that oxygen management and the long un-answered call lights are among the reasons why she requested that R1 not return to the facility when she gets discharged from the hospital. During interview on 9/29/23 at 12:53 p.m., the hospital staff (HS)-A identified HS-B as the one who encountered R1, who presented for shortness of breath at the emergency department. On 10/02/23 at 4:30 p.m., HS-B verified having seen R1 at the emergency department on 9/25/23. HS-B stated that R1 remains a patient at the hospital with an admitting diagnosis of acute on chronic hypercapnic hypoxic respiratory failure. During interviews with multiple staff members who provided direct care with R1, indicated consistent staff knowledge and observations about R1's lack of ability to transfer independently and that R1 did not exhibit behaviors pertaining to turning her oxygen concentrator off and not letting staff members turn off call light when answered, as follows: -On 9/29/23 at 4:31 p.m., nursing assistant (NA)-A R1 used to go to the bathroom herself but within the last month, she could no longer do that because of difficulty breathing and shortness of breath. NA-A stated R1 cannot transfer herself without staff. NA-A also stated R1 was compliant with oxygen use and had not observed R1 take her oxygen off. NA-A further stated that R1 will let you turn the call light off when you are there but once you turn back, she would put her light on again. -On 9/29/23 at 4:45 p.m., licensed practical nurse (LPN)-A stated R1 cannot turn oxygen on or off and staff members had to do that for her. LPN-A stated that although R1 can put or remove the nasal cannula from nostrils, she is alert and was compliant with oxygen use. LPN-A also stated she never saw R1 remove her oxygen cannula or turn off oxygen tank. LPN-A further stated R1 will let staff turn off the call light when answered. -On 9/29/23 at 4:50 p.m., NA-B stated R1 could not get up from recliner and walk by herself, R1 needed staff assistance for transfers. NA-B also stated R1 could not turn on or off the oxygen concentrator or tank. NA-B also stated once [R1] puts the light on, it's automatic, you have to be there. NA-B further stated he always turned the call light off when responding to R1's call, and R1 did not say anything. -On 9/29/23 at 4:53 p.m., NA-C stated that she worked with R1 almost every day. NA-C described R1 as someone who cannot get up from recliner without staff supervision and could not go to the bathroom by herself. NA-C stated R1 was alert and cooperative with oxygen therapy. NA-C further stated she never saw R1 take off her oxygen or turn off the oxygen concentrator or tank. -On 10 to 23 at 12:39 p.m., NA-F stated R1 was always in recliner chair and would not get up without staff helping. NA-F stated R1 always had her oxygen on. NA-F also stated to have never seen R1 without oxygen. -On 10/2/23 at 6:00 a.m., NA-G stated she had worked with R1, who needed one assist to get her up from recliner NA-G stated she never saw R1 remove or take oxygen off. NA-G also stated R1 would let staff turn call light off when she answered. -On 10/2/23 at 3:42 p.m., NA-H stated R1 always had her oxygen on, and he never saw R1 remove oxygen cannula or turn off oxygen tank. NA-H also stated R1 had always let him turn off call light when answered. -On 10/2/23 at 4:11 p.m., LPN-B described R1 as a complicated case because she gets very anxious when not connected to her oxygen. LPN-B stated, If she's in her recliner, then she could not turn off or on her oxygen. LPN-B further stated R1 is declining and needed staff assistance to stand up. During interview on 10/02/23 at 12:23 p.m., LPN-A indicated she was the nurse for R1 on 9/25/23. LPN-A stated R1 was difficult during medication pass at about 9:00 a.m. LPN-A stated one of the aides helped R1 to the bathroom while a podiatry staff was waiting to take her to another floor for podiatry services. LPN-A stated she left R1 in her room with an aide at about 9:45 a.m. and had no idea when R1 returned from podiatry services. LPN-A also stated she did not know that R1 was short of breath and had low oxygen saturation. LPN-A stated she did not know that R1 called 911. LPN-A indicated the next time she saw R1 was when she was leaving with the EMS crew, where R1 identified her to them as the nurse. Regarding pre-signing medications and pre-entering data R1's oxygen saturation for the evening of 9/25/23, despite R2 being in the hospital, LPN-A could not explain how it happened but acknowledged that was an error. During interview on 10/02/23 at 10:15 a.m., NA-D identified herself taking care of R1 on 9/25/23. NA-D stated she remembered R1 was rocking in her chair and described R1 as one who did not have the capability to get up from the recliner without a staff member to help. NA-D stated, In my opinion, she's a sit to stand indicating R1's need for an assistive device to help with transfers. NA-D stated that she assisted R1 into her recliner when she returned to the room from podiatry service, and that she switched R1's oxygen tubing from the portable tank to the longer tubing going to the concentrator. NA-D stated she did not touch the oxygen concentrator to turn it on, but NA-D said she knew the concentrator was already on because of the noise coming from the machine, and that she asked R1 if it was on, which R1 replied it was working. NA-D denied manually checking the oxygen concentrator to ensure it was on. NA-D further stated the last time she was in R1's room that day was about 12:30 p.m. and then she went to the 1st floor to relieve another staff member. NA-D indicated not knowing R1 called 911 related to shortness of breath. NA-D stated she did not see the EMS people arrive at or leave the facility. During interview on 10/02/23 at 3:46 p.m., the nurse practitioner (NP) stated that R1 recently had a decline overall, and NP indicated talking to R1 about going into hospice care but R1 declined. The NP stated R1 had severe COPD and it is very important to have the oxygen on all the time, and R1 understood that need. The NP stated that an oxygen saturation of 65% is not compatible with life. The NP added oxygen deprivation produces confusion to the person, and if not getting enough oxygen, a person may say something or does something because of the confusion, and could change a person, or make a difficult personality. The NP further stated, I'm grateful she called herself in. During interview on 10/2/23 at 4:55 p.m., the director of nursing (DON) stated that she won't argue that R1 de-saturated on 9/25/23 but added R1, did this to herself. The DON stated R1 got up from recliner and walked towards oxygen concentrator to turned it off. The DON stated she knew this because R1, did it before and she fell because she was trying to get up to go turn off her oxygen. The DON contradicted the information derived from pre-existing records dated prior to the incident (such as the behavior care plan dated 8/1/23 without the revisions made on 9/29/23 and the MDS data dated 8/19/23), and from all the other interviews, including staff members, regarding R1's decline in condition, and R1 having no behaviors related to oxygen use. The DON also did not consider the most recent revisions in R1's care plan related to ADLs (care plan revisions dated 8/16/23 and MDS dated [DATE]), instead, the DON marked the old interventions in the care plan and said R1 can walk short distances in her room independently. The DON also stated that R1's behaviors also included not allowing staff to turn the call light off after being answered, which was not corroborated by any of the direct care staff members interviewed. The DON stated surveyor should ask the management staff because they know this as R1's behavior. Regarding staff giving/signing off evening medications, including pre-entering assessment data for the evening and night shifts related to R1's oxygen saturation despite R1 having left the building at 1:20 p.m. on 9/25/23, the DON stated having no expectations pertaining to that practice as long as it gets done and on record. The facility's assessment and care plan policy were requested but the DON stated the facility follows the RAI (Resident Assessment Instrument) manual. The facility's respiratory care policy/procedure was also requested, and the facility provided a document titled, Documentation Guide: Community Life, undated, which did not specify guidelines for staff to follow to ensure provision of respiratory care, specifically, oxygen therapy according to the orders.

Based on interview, and document review, the facility failed to coordinate care with psychiatric providers, care plan and identify symptoms of psychosis, and obtain a monthly complete blood count (CBC) to identify the neutrophil level required before the pharmacy would dispense antipsychotic medication for 1 of 3 residents (R1) who had schizophrenia. This failure resulted in harm, when R1 abruptly missed nine doses of an antipsychotic medication, leading to worsening psychotic symptoms, resulting in hospitalization . Findings Include: R1's hospital discharge note dated 1/4/23, indicated he had paranoid schizophrenia. He was taking Clozaril (an antipsychotic medication for the management of severely ill schizophrenic patients who fail to respond adequately to standard drug treatment for schizophrenia) 100 mg once a day. His schizophrenia base line included his mood and signs and symptoms of psychosis (paranoia, disorganized thoughts, decline in self-care and hygiene, poor sleep, confused speech, and unable to determine reality and fantasy.) R1's admission record indicated R1 had two care providers: a primary care physician and a nurse practitioner. The admission record did not include R1's psychiatrists (P)-A or P-B as care providers. R1's medical order dated 4/28/23 at 3:00 p.m., indicated he was taking an antipsychotic medication Clozaril 200 mg at bedtime for schizoaffective disorder and bipolar (when the resident had either hypermania or depression) and a description for medication monitoring for side effects associated with Clozaril. R1's care plan dated 5/1/23, indicated he used the antipsychotic medication Clozaril. The care plan directed the nursing staff to give the medication according to the medical provider's instructions and to monitor for potential side effects. In addition, the nursing staff would instruct R1 about the risks and benefits associated with long-term use of Clozaril. The care plan described specific side effects associated with Clozaril use but did not include care planned interventions for R1's signs and symptoms of a worsening psychosis. R1's facility's nurse practitioner (FNP)-A specialized in the care for nursing home residents order dated 5/3/23, indicated R1 needed a blood test to monitor his neutrophil levels every month. One side effect associated with long-term Clozaril use is a significant loss of neutrophil levels leaving him unable to fight off infections. R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition, mild depression and delusions caused by his schizoaffective (schizophrenia symptoms to include depression or manic behavior) disorder. He did not have any hallucinations or delusions at the time of the evaluation. In addition, he had extensive heart and lung disease. R1 was able to move in bed, walk, and transfer himself independently. He did require supervision from one staff member to get dressed, use the toilet, and for all hygiene tasks. Facility's laboratory calendar book dated 5/4/23, indicated R1 needed a blood test to check his neutrophil level. R1's facility medical doctor (FDR)-A who specialized in the care for nursing home residents visit note dated 5/9/23, indicated R1's diagnosis was schizoaffectived disorder with cognitive deficits. R1 had an extensive mental illness with hospitalization s, and was currently taking Clozaril. FDR indicated R1 had repetitive disjointed responses to questioning and was unable to provide any coherent history. FDR-A documented the need for psychiatry involvement and continued clozaril with pharmacy monitoring of CBC's. R1's consultant pharmacist (PH)-A's medication review dated 5/9/23, indicated R1 was on Clozaril and suggested the nursing staff should add target behavior monitoring (target behavior monitoring is done for early identification when a residents previously controlled psychosis symptoms are re-emerging, and would require a psychiatrist to reevaluate his schizophrenia condition. The target behaviors are specific and individualized to the resident's psychosis history when he first went on Clozaril or the last time the dose was decreased.) R1's medical order dated 5/15/23 at 3:00 p.m., indicated his target behavior was for verbal/physical aggression. Nursing staff were directed to implement non-medication interventions such as re-directing him to an activity he enjoyed such as watching T.V. and offering aroma therapy to calm down. Target behaviors did not include R1's schizophrenia base line to include his mood, and signs and symptoms of psychosis (paranoia, disorganized thoughts, decline in self-care and hygiene, poor sleep, confused speech, and unable to determine reality and fantasy.) R1's June MAR dated 6/1/23 through 6/30/23, indicated the facility followed medication orders. There was no indication the facility was monitoring for signs and symptoms of worsening psychosis. R1's social service note dated 6/9/23 at 6:28 p.m., indicated the facility's social worker (SW) received a phone call from R1's mental health case manager (MHCM)-A. MHCM-A wanted to alert the facility R1's psychiatric history included paranoid behaviors and will accuse staff or others of stealing money that he never had, delusions that someone beat him up or punched him and delusions that he is often attack by people or objects. R1's progress note dated 6/13/23 at 5:47 p.m., indicated his cognition was intact, he did not have any acute changes to his mental status or signs of disorganized thoughts. R1's laboratory requisition form dated 6/28/23, indicated the only test he need was a thyroid test. Facility laboratory calendar book dated 6/29/23, indicated R1 needed a blood test to check his neutrophil. A note was added to the calendar indicating R1 refused to lab draw on 6/29/23, and it was rescheduled for another day. R1's July medication administration record dated 7/1/23 through 7/31/23, indicated a neutrophil test was required on 7/27/23, but the box for staff to document if it was done was left blank. Staff documented R1 received Clozaril every night until the nine days between 7/17/23 through 7/25/23, because the facility did not have the medication to give. R1's monthly orthostatic blood pressure was completed on 7/2/23. Lastly, the nursing staff on all shifts from 7/1/23 through 7/26/23, document no target behaviors of verbal or physical aggression. There was no indication the facility was monitoring for signs and symptoms of a worsening psychosis. R1's provider note dated 7/17/23, indicated the facility's nurse practitioner (FNP)-B who specialized in the care for nursing home residents visited him at the nursing home. Psychiatrist (P)-A was identified as his long-time psychiatrist. Facility laboratory calendar book dated 7/19/23, indicated R1 need his Valproic acid level and a liver panel (test of all the different liver components) and to add a neutrophil test. R1's laboratory request form dated 7/19/23, indicated R1 need his Valproic acid level and a liver panel. The box for a neutrophil level was blank. R1's progress note dated 7/19/23 at 8:00 a.m., indicated he refused the laboratory staff to draw his ordered blood tests. He stated, No I am not having my labs drawn it's not necessary. Staff told him the doctor wanted him to have the test results, but he still refused. Staff updated the facility's nurse practitioner. R1's SW note dated 7/20/23 at 4:57 p.m., indicated MHCM-A was called and updated regarding R1 refused the laboratory to draw his blood work. MHCM-A stated she noticed an increase in behaviors and paranoia and frequent urination during her visit on 7/19/23. The SW documented she notified R1's nurse about the new behaviors and symptoms. R1's progress note dated 7/24/23 at 11:42 a.m., indicated licensed practical nurse (LPN)-A contacted the facility's medical providers regarding the laboratory order for a Valproic and Hepatic blood test. R1's progress note on 7/24/23 at 2:14 p.m., indicated he refused his weekly bath. R1's SW note dated 7/25/23 at 3:43 p.m., indicated she called MHCM-A regarding his increased paranoia, obsessive behaviors and verbal aggression when redirected. MHCM-A instructed the facility to send him to the hospital for an evaluation. R1's FNP-A's order dated 7/25/23, indicated it was okay for the facility to transfer R1 to the hospital emergency room for a psychological evaluation. R1's medical record did not identify coordination of care with R1's psychiatrist pertaining to R1's behavioral health care needs related to antipsychotic medications and labs, and schizophrenia/schizo-affective behavior needs for level of functioning to identify appropriate goals and interventions. R1's psychiatry emergency room note on 7/25/23 at 5.23 p.m., identified MHCM-A told the receiving nurse over the past few weeks he started to decompensate. R1 developed increased paranoia regarding the staff trying to poison him. He was neglecting his hygiene needs, using racial slurs, and swearing. MHCM-A stated at baseline he has some degree of delusions, but the racial slurs and swearing were not. She also informed the receiving nurse he had been taking his Clozaril. R1 told the hospital staff the facility was not giving him his Clozaril. During the visit, the facility was contacted for information. The facility nurse stated he had increased paranoia, refused the lab to draw his blood work, refused food for the past three to four days and refused his medication. R1's progress note dated 7/25/23 at 6:19 p.m., indicated R1 was able to eat and was given Tylenol for pain. The hospital planned to send R1 back to the facility for continuation of care. R1's progress note dated 7/25/23 at 11:23 p.m., indicated he returned from the hospital and was observed almost falling out of his chair. He was assisted to his room and into bed where he slept without further concerns from the staff. R1's psychiatric registered nurse (RN)-A's progress note dated 7/25/23 at 8:42 a.m., indicated she received a phone call from MHCM-A regarding R1's emergency department visit on 7/25/23. MHCM-A was upset about the care R1 received at psychiatry emergency room regarding his paranoia and delusions. MHCM-A stated she was getting calls every day from the from the nursing home. MHDM-A told RN-A she was worried the facility would kick him out. In addition, R1 was swearing and using the N word. She was worried about R1 wetting his pants and did not know if the emergency room checked for a urinary tract infection. RN-A told her psychiatrist (P)-A was out of the office until 7/31/23. R1's progress note dated 7/26/23 at 8:22 a.m., indicated licensed practical nurse (LPN)-A called the pharmacy to request a Clozaril refill but lab work was required before they would send a refill. She updated the facility's primary care provider. R1's note from RN-A dated 7/26/23 at 9:04 a.m., indicated she spoke with psychiatry emergency room , and they told her they dropped the ball when they did not collect a urine sample during his 7/25/23 visit. While he was there his pants were wet with urine and he refused to change his pants. He called the staff the N word and would not eat. MHCM-A stated she would take him back today for a reevaluation. R1's psychiatry's office telephone message note from LPN-A dated 7/26/23, at 9:45 a.m., indicated she wanted to speak to P-A's nurse to discuss his medication. R1's progress note dated 7/26/23 at 10:00 a.m. indicated LPN-A notified MHCM-A, the facility NP, and the psychiatry emergency room regarding his Clozaril. R1's psychiatric nurse RN-B note dated 7/26/23 at 10:04 a.m., indicated LPN-A reported R1 did not receive his Clozaril medication since 7/17/23, as they forgot to order the labs. During the hospital admission on 7/25/23, R1 allowed the laboratory department to draw a neutrophil level and the results were sent to the facility. Since R1 was off Clozaril for longer than 48 hours he would need a new Clozaril order for a lower dose to be increased over time until he reached the previous 200 milligram (mg) dosage. R1's progress note dated 7/26/23 at 10:30 a.m., indicated he needed a hospital evaluation. R1's telephone order from psychiatrist (P)-B dated 7/26/23, at 10:38 a.m., indicated a new order for Clozaril. He would receive 50 mg on 7/26/23, and then 100 mg for two nights and 150 mg for two nights before resuming his 200 mg dosage. R1's progress note dated 7/26/23 at 10:45 a.m., indicated he developed a babbling nonsensical speech, and he was unable to hold himself up in bed. The facility NP evaluated him and directed the staff to send him to the emergency room for an evaluation. R1's emergency room documentation dated 7/26/23, indicated he was refusing his medication for a week and currently had an oxygen (O2) level of 85 percent (a normal level would be between 95 to 100 percent). MHCM-A told them she was worried about his recent change in mental status. He did not receive his Clozaril for one week and had refused his labs. R1's mental status at baseline was slightly delusional and normally pleasant. His physical exam indicated he was no longer oriented to his identity, the events leading up to his hospitalization , or where he was. His confusion indicated his previous stable schizophrenia and psychosis symptoms had deteriorated related to not taking his medication. The delirium (a mental state decline causing confusion, disorientation, and unable to think or remember clearly) was caused by the pneumonia and a deteriorated mental illness. R1's medical order dated 7/26/23, indicated the director of nursing (DON) wrote an order to stop the current neutrophil level every month. The new order directed the nursing staff to get a neutrophil level on 8/22/23 and continue collection every four weeks. In addition, nursing staff would fax the neutrophil test results to the pharmacy when available on 8/22/23 or 8/23/23, and then every four weeks. R1's email from PH-B dated 7/26/23 at 1:12 p.m., to the DON indicated R1 did not receive his Clozaril because his neutrophil level was not done in time. PH-B indicated Risk for Evaluation and Mitigation Strategy (REMS) safety program required by the Food and Drug Administration (FDA) required a current neutrophil level every month prior to dispensing a Clozaril refill. Facility's laboratory calendar book dated 7/27/23, indicated R1 needed a blood test to check his neutrophil level. R1's laboratory requisition form dated 7/27/23, for a neutrophil level. The requisition form was later faxed again to the laboratory to indicate it no longer need to be drawn. R1's nursing assistant (NA) task worksheet revised on 8/1/23, instructed the staff if he showed any aggressive behaviors to find a different caregiver to reapproach. During an interview on 8/1/23 at 3:41 p.m., MHCM-A stated she had worked with R1 for [AGE] years managing his care. He originally came to the facility related to falls and unable to care for himself. She said anytime the facility called her about R1's behavior or refusals she would go to the facility and address the issues with R1. After talking with him he was easy to redirect. R1 was on Clozaril since he was [AGE] years old around 1976. During the past two years he consistently took his medication. The Clozaril had stabilize his psychosis symptoms. She stated schizophrenia and symptoms of psychosis are more than verbal or behavioral aggression. The weeks prior to his hospitalization on [DATE], she noticed increased agitation, unable to redirect and he was very irritable. The facility told her on 7/25/23, R1 refused to eat because the staff were poisoning him. She instructed the facility to send him to the hospital for an evaluation on 7/25/23. She was upset with the hospital staff because they did not collect a urine sample to see if his frequent urination was the result of an infection. The next day when she visited R1 at the facility she found him speaking gibberish and unable to hold himself up in bed. She instructed the facility to send him back to the hospital for an evaluation. He was diagnosed with pneumonia leading to a heart attack and psychotic deterioration. R1 knows when he gets his Clozaril and today when she visited him in the hospital he kept saying where is my Clozaril. When R1 takes is Clozaril he is so nice and kind. During an interview on 8/1/23 at 12:00 p.m., the director of nursing (DON) stated she reviewed the events associated when R1 did not receive his Clozaril for nine days. She stated the facility held his Clozaril because he refused to complete the required neutrophil test to obtain more doses. On 7/25/23, when R1 was sent to the hospital she asked the staff to draw a neutrophil level because he had been refusing to get it at the facility. R1's blood work was completed, and she received an order to resume the Clozaril with a titrated (slowly increase the dosage in lesser amounts over days until the original dose is reached) dose. During an interview on 8/1/23 at 12:32 p.m., registered nurse (RN)-C stated R1 was admitted to the cardiology floor because he had altered mental status related to not taking his Clozaril. Currently, his cardiac condition had resolved, but he remained on the unit until an inpatient psychiatric bed was available. At this time, his psychosis behaviors had resolved. During an interview on 8/1/23 at 2:50 p.m., the DON stated the reason for target behaviors was for early detection when his psychotic symptoms were no longer being managed by his antipsychotic medication. The target behaviors would include any symptom he had when he first started taking Clozaril. She did a thorough record review and found he was put on Clozaril for verbal and physical aggression. Once she identified the target behaviors, she added personalized interventions for the staff to use on the NA task sheet. She provided the Psychoactive Medication Guide she used when managing resident's antipsychotic medication. She reviewed the key elements required when developing a target behavior. She stated she did not know examples of psychosis symptoms but was sure verbal and behavioral aggression was acceptable. She explained the staff did not document any target behaviors between 7/17/23 through 7/25/23 because he was not aggressive even though the facility staff documented he stopped eating because the food was poisoned, and he had worsening behaviors, delusions, and paranoia. The lack of documented physical or behavioral aggression led her to believe R1's worsening symptoms were the result of a medical condition such as a urinary tract infection (UTI). She spoke with MHCM-A who was also concerned during the same time frame R1 might have a UTI because he had increased incidents of urinating on his clothes. During her investigation regarding the missing Clozaril doses, she completed audits for the other five residents receiving the same medication. She found their care plans were lacking documentation regarding specific target behaviors. During an interview on 8/2/23 at 9:15 a.m., the DON stated R1 refused to get his blood work drawn on 7/19/23. She stated they kept trying to get the neutrophil level drawn. She updated MHCM-A on 7/19/23, about the missing lab work, and they both thought his symptoms were related to a medical condition that needed further evaluation. Once he was transferred to the hospital on 7/25/23, she requested the staff to draw his neutrophil level so he could get his Clozaril medication refilled. In addition, she said R1 had an order for a neutrophil level on 7/2/23, but he refused. She agreed the nurse working on 7/2/23 should have documented the refusal on a progress note. Even though he refused his blood draw on 7/2/23, he still had Clozaril to take so they were not concerned. The nursing staff were unaware if the neutrophil level was not done, he would run out of the medication until it was done. On 7/17/23 NP-B visited R1 and ordered additional laboratory tests. The staff attempted to get the missing neutrophil level at the same time with the additional tests. When he refused to have his blood drawn on 7/19/23, refusal was not documented in R1's medical record and the laboratory staff did not tell anyone he refused to get his blood drawn. She felt the mistake occurred because the monthly neutrophil level was ordered 17 days before the next Clozaril refill, and the lack of nursing staff awareness before the pharmacy could provide more medication, they needed the test results. During an interview on 8/2/23 at 9:40 a.m., LPN-A stated when R1 refused to have his blood drawn the laboratory staff did not tell her. She added it was policy if a resident refused the blood drawn the laboratory staff was required to try on the next laboratory day and the staff did not have to submit an additional laboratory request form. She did not find out R1 missed a dose of Clozaril until 7/18/23, when she called the pharmacy and was notified, they were unable to refill his medication until they had a current neutrophil level. Since R1 already had the laboratory coming on 7/19/23 to draw his blood for different tests she would add on the neutrophil level. She documented on 7/26/23, she notified the facility NP because R1 refused to have his blood drawn and was out of Clozaril. She stated she never told RN-B they forgot to order the neutrophil test, but when she updated him on 7/26/23, he was more worried about having to do extra work. She confirmed information about R1's antipsychotic medication, target behaviors and required blood work associated with the medication should have been on the care plan. During an interview on 8/2/23 at 10:45 a.m., laboratory service staff (LSS)-A reviewed R1's laboratory history regarding all requests for a neutrophil level. She stated if a resident refused to have their blood drawn, the laboratory technician was responsible to notify the nursing staff and try again on the next laboratory day. She said most of the time facility's monitor for pending laboratory results and would call them to find out when the results would be ready for review. R1's facility had a contract with the laboratory to have blood drawn at the facility any day between Monday and Friday. She stated for the first week of July the facility did not request a neutrophil level for R1. The last time the facility ordered a neutrophil test was on 6/8/23. She stated her records showed each time R1 refused to have his blood drawn the laboratory technician did return to try again. Sometimes he agreed on the second attempt, but had he refused on the second attempt the facility would have to fill out another requisition form and fax it to the laboratory before they would come out again. According to her records R1 had an appointment for his blood to be drawn on 7/19/23, but according to the request form the box to order a neutrophil level was not checked. He did refuse to have his blood drawn on 7/19/23. The next neutrophil level was requested for 7/27/23, but later the facility canceled the test because R1 was in the hospital. She stated the facility has five laboratory days plus the capability to come out when a STAT (immediately) test is required. During an interview on 8/2/23 at 2:44: p.m., RN-B stated he is the nurse for psychiatrist(P)-A. He stated the nursing staff at the facility should have notified him immediately when he first refused to get his neutrophil level done. He stated they set up all of their patients who receive Clozaril with a company who draws the neutrophil level and if the level is within normal limits, they dispensed the medication. He was not sure why it became the facility's responsibility to order the neutrophil test and fax the results to the pharmacy. He said he was shocked to find out on 7/26/23 R1 did not receive his Clozaril for nine days and he felt the facility staff did not know what they were doing. he gave an example if a patient who received Haldol (another schizophrenic medication) every day and suddenly had no more medication what would you do? You would immediately call the pharmacy and if a laboratory test was needed you would do it right away to prevent any further missed dosages. He immediately reviewed the neutrophil level drawn on 7/25/23 and contacted a psychiatrist for new orders to titrate the medication up to the current 200 mg dose because he was off the medication for more than 48 hours. RN-B's main concern was R1's managed psychosis symptoms would worsen because he did not get the medication for nine days. R1's psychotic symptoms would include auditory and visual internal stimulation and paranoia, not the target behaviors identified at the facility. The facility staff should have notified P-A immediately when he did not get a neutrophil level prior to his next Clozaril refill, and the facility medical staff should have known the potential risk for abruptly stopping his antipsychotic medication. During an interview on 8/3/23 at 3:10 p.m., NP-B stated he did not have the qualification to order and monitor R1's Clozaril and instead the facility should have contacted R1's psychiatrist P-A During an interview on 8/3/23 at 3:59 p.m., the DON stated all consulting physicians to include psychiatrist should be identified with their contact information on the resident's face sheet. R1's psychiatrist was not identified because they did not know who it was, and they were waiting until the scheduled August appointment for a follow up visit to get their contact information. She stated the laboratory calendar book was a place for the staff to communicate with the laboratory staff for any new orders along with being a second check to ensure no orders were missed. When R1 refused to have his blood work drawn on 6/28/23, she did not force R1 to get his neutrophil level redrawn because it would only increase his agitation. She decided to wait until the next time he would have his blood work drawn which would have been on 7/19/23. She stated the Clozaril monitoring was set up by the hospital before he admitted to the facility in April. She stated she was unable to find R1's specific target behaviors so she asked her staff what behaviors they observed during his stay at the facility. The staff told her at times he can be physically or behaviorally aggressive. She said the nine missed doses could not have been a big deal since P-B wrote the titration to occur over three days. She was unaware of the consequences when a resident suddenly stops taking Clozaril until the pharmacy refused to send another refill. She added, the facility did not reorder the neutrophil test after 6/28/23 and 7/19/23, because they first needed R1's consent to do so. They were waiting for MHCM-A to be at the facility when they tried again. Once she was there and R1 consented they would have faxed a STAT request to the laboratory. During an interview on 8/3/23 at 8:15 a.m., LLS-B stated their laboratory does not accept any order to be done every four weeks. Instead, the facility was required to send a new requisition form every time. The facility laboratory book was for communication between the nursing and laboratory staff when any issue developed preventing them from drawing the residence blood. If a new order for additional blood work came in after the first requisition was faxed, they needed to send another requisition form to identify what test was needed. When a resident refuses to have his blood drawn two days in a row the order would be cancelled. The facility was required to submit another requisition form to get the laboratory staff to draw his blood. She added the 6/28/23, blood draw was refused, and the technician came back on 7/3/23 and successfully drew his blood. Because the facility failed to order a neutrophil test on the requisition form the lab only processed the test requested. During an interview on 8/3/23 at 9:00 a.m., MHCM-A stated the facility was responsible to manage his medical condition and follow doctor's orders. When R1 refused to get his blood drawn on 6/28/23 she did not know what laboratory test he refused but she did come in and talk to him and the test was redrawn successfully on 7/3/23. R1 probably refused the blood draw on 7/19/23 because he already had his blood drawn for the month because that is how it was set up in the past when he lived on his own. The SW called her on 7/20/23 to let her know R1 refused to have his blood drawn two days in a row. She did not know what test he refused, and she went straight to the facility to talk with R1. R1 told her he already had his blood drawn during the month. After talking to him he agreed to have his blood drawn the next time the laboratory staff came back to the facility. Had she known he needed a neutrophil test and his Clozaril was stopped on 7/17/23 she would have driven him to his psychiatrist office to get it drawn. She added the facility's target behavior monitoring only focused on one piece not the whole picture. During interview on 8/3/23 at 10:37 a.m., PH-A stated per FDA regulations any person receiving Clozaril required a monthly neutrophil test. He added people taking Clozaril did not get it by accident. Only people with severe schizoaffective disorder and did not respond to the standard antipsychotic medication were prescribe Clozaril as a last-ditch effort. In addition, psychotic symptoms would include hallucinations, delusions, paranoia, or hearing voices. He confirmed R1's psychiatrist not the facility's medical providers should have been updated when he stopped getting his medication. He first learned about the medication error when he overheard the DON talking with the facility medical director (FMD)-A during an intradisciplinary meeting at the facility on 7/27/23. Lastly, when the facility failed to get a neutrophil test on 7/19/23 and 7/20/23 after two refusals they should have done something before the hospital visit on 7/25/23. During interview on 8/3/23 at 10:56 a.m., facility's medical director (FMD)-A who is responsible for the standard of care provided to the nursing home residents stated any patient taking Clozaril required a monthly neutrophil test before receiving additional refills. Clozaril is a heavy-duty medication that does not eliminate psychotic symptoms like hallucination, paranoia, and delusions, but it subdues the symptoms to a level where the patient can manage his disease. He added target behaviors are required by the Federal Drug Administration (FDA) and useful to detect increased psychotic symptoms and the need for an early intervention. He said only a psychiatrist or a medical physician who was certified by the Clozapine REMS (Risk Evaluation and Mitigation Strategy safety program) are able to monitor and prescribe Clozaril. During interview on 8/3/23 at 11:22 a.m., P-A stated she first learned about the missing doses when she came back from vacation on 8/1/23. R1 suffered a psychotic decompensation and decline when he stopped receiving his Clozaril after nine days. She stated in the past R1 stopped taking his medication when he lived on his own. In the past year she had noticed a cognitive decline common with schizoaffective patients leading him to forget to take his medication. Last time he was hospitalized for not taking his Clozaril was sometime during 2022. She added she never heard of a facility medical provider, a nursing home and their pharmacy manage any antipsychotic medication. She stated MHCM-A's responsibilities never included receiving information or concerns from the facility for the purpose of updating her office. When R1 did not receive a neutrophil test or a medication refill for nine days they should have communicated their concerns directly to her staff. She added MHCM-A has cared for R1 for fifteen years and had she known about the missing blood work and Clozaril doses she would have driven him to the hospital herself to have his blood drawn. R1 was one of their special patients and the staff were terribly upset when they heard about the missing doses and his consequent decline. During interview on 8/3/23 at 1:33 p.m., SW-A stated she had worked with MHCM-A since 2018 with various residents. She contacted her on 7/20/23, related to R1 refused to have his blood drawn. She did not tell MHCM-A whi[TRUNCATED]

Based on interview on document review, the facility failed to accurately assess and review interventions placed for 1 of 3 residents (R1) reviewed for change in condition. This resulted in a delay of providing oxygen services and emergent care for R1. The deficiency was identified as past non-compliance and issued at Immediate Jeopardy (IJ). The IJ began on 3/30/22, when the facility failed to assess R1 for [CONDITION(S)] (low oxygen saturations) after R1 required continued monitoring after a change in condition was recognized and R1 was hospitalized . The administrator was notified of the IJ on 4/13/22 at 2:00 p.m. The facility had implemented immediate corrective action on 3/31/22 to prevent recurrence, so the IJ was issued at past none compliance. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R1's vital signs on 3/29/22, showed: -at 1:02 p.m. blood pressure (BP) 110/70, temperature 97.8, pulse 68, respiratory rate 18. -at approximately 8:00 p.m. BP 139/65, pulse 110, oxygen saturation 78% on room air (Normal oxygen saturation was 90% or greater), recheck with 2 liters (L) nasal cannula (NC) and was 92%. -at 10:00 p.m. oxygen saturations were 92% on 2L NC. A review of R1's vital signs on 3/30/22, showed: -at 12:00 a.m. oxygen saturation was 95% on 2L NC -at 2:00 a.m. oxygen saturation was N/A -at 4:00 a.m. oxygen saturation was N/A -at 6:00 a.m. oxygen saturation was 78% on 2L NC. -at 7:00 a.m. oxygen saturation was 77% on 2L NC and blood pressure was 82/40. R1's provider order dated 3/17/22, indicated nursing home standing orders in place. R1's provider order dated 3/29/22, instructed staff to initiate oxygen 2L/minute via nasal cannula to keep oxygen saturations above 90% and continued monitoring for [CONDITION(S)] and sedation every 2 hours for one day. Update primary provider in the morning. R1's progress note dated 3/29/22, at 8:23 p.m. indicated R1 had confusion and writer had obtained vital signs that showed BP 139/65, pulse 110, oxygen saturation 78% on room air. Furthermore, the progress note indicated the on-call provider was notified and orders for oxygen and continued monitoring obtained. R1's progress note dated 3/30/22, at 6:13 a.m. indicated three pulse oximeters had inconclusive readings of R1's oxygen levels. R1's fingers were cold with gray/bluish colors. Oxygen rate was increased to 3L NC. Orders in place for oxygen saturations to be monitored every 2 hours in coming nurse to update. R1's progress note dated 3/30/22, at 1:06 p.m. indicated R1's condition continued to deteriorate. Vitals obtained this morning included oxygen saturation was 77% on 2L NC and blood pressure was 82/40. Furthermore, the progress note indicated R1 was confused and was sent to hospital at 7:30 a.m. for a medical evaluation. R1's hospital discharge summary dated 4/3/22, indicated R1 was admitted for acute [CONDITION(S)] (confusion), acute kidney injury, and acute respiratory failure. R1 had returned to baseline for cognition and kidney injury and respiratory failure had resolved. During an interview on, 4/12/22, at 1:33 p.m. registered nurse (RN-B) stated he was notified of R1's change in condition in report at the start of his shift and was aware of orders to monitor R1 for [CONDITION(S)] and sedation every two hours. RN-B further stated when attempting to obtain R1's oxygen saturations at 2:00 a.m. the pulse oximeter would not read. RN-B stated another oximeter was tried and R1's oxygen saturation still had not registered. RN-B stated the pulse oximeter was attempted on his own finger and oxygen saturations had registered but had not on R1's finger. Furthermore, RN-B stated R1 was sleeping and had no signs of distress. RN-B stated sometimes oxygen saturations may not read when residents are sleeping. At 4:00 a.m. RN-B stated R1 was awake and sitting up in bed. Again, RN-B attempted to obtain R1's oxygen saturations but a number wasn't registering on the oximeter. Again, RN-B checked their own finger, and it registered an oxygen saturation. R1 had cold fingers that were a bluish gray color. R1 was cold, so I helped put a sweater on thinking R1 would warm up. About 6:00 a.m. RN-B attempted again to obtain R1's oxygen saturations and could not obtain a reading with two different oximeters. RN-B then obtained a third oximeter and R1's oxygen saturation read 76% on 2L NC. RN-B stated R1was alert, and the order stated to monitor the [CONDITION(S)] and update the next day and felt he was following the order. RN-B had not felt R1's assessments warranted sending her to the hospital or updating the provider, even though R1's oxygen saturation was below normal. During an interview on 4/12/22, at 1:44 p.m. medical director (MD) stated their expectation of staff would be to notify the provider if a resident's oxygen saturations were not registering, abnormal and had blue/gray fingers, even with an order to monitor in place. MD further stated he expected nurses to know the assessments and signs of [CONDITION(S)]. During an interview on 4/13/22, at 9:06 a.m. RN-C indicated RN-B had not followed policies and procedures for notification of change. RN-C had expected RN-B to initiate standing orders to increase oxygen and to notify the provider of the change. RN-C further stated staff are expected to reach out to leadership, including the overnight supervisor when unable to obtain oxygen saturations or similar situations happen. RN-C felt RN-B had poor nursing judgement in this situation. During an interview on 4/13/22, at 10:31 a.m. the director of nursing (DON) stated RN-B had not followed professional nursing standards of practice and verified RN-B had been reported to the nursing board. DON further stated R1 had fallen outside of the parameters of oxygen saturations being below 90% and the expectation would be for staff to notify the provider and look to the standing orders for direction. RN-B had identified changes in R1 but had not provided any interventions. A facility policy Change in Condition revised 12/219, directed an assessment for change in condition was to be completed for any resident who had a decline in their status that would not resolve by itself or without clinical interventions and impacts one or more of the residents physical, functional, emotional, or cognitive status. DON stated on 4/13/22 in the afternoon that RN-B was suspended on 3/30/22, pending facility investigation. Furthermore, RN-B had resigned his position on 4/1/22, while on suspension and the facility filed a report to the Minnesota Board of Nursing. On 4/13/22, a facility document titled Mitigation Plan dated 3/30/22, was reviewed and DON verified the corrective actions taken by the facility to prevent further noncompliance. The corrective actions on 3/30/22, included evaluation of all facility pulse oximeters and determined all were in working order. The 24-hour report (a facility report document showing any resident changes from shift to shift) was reviewed and found to have documentation of R1's change in condition on 3/29/22 through R1's transport to hospital on 3/30/22. Also, on 3/30/22, R1's medical record was reviewed and was determined standing orders (instructed steps to follow when a resident had a change in condition) were in place and reviewed medical records of all residents residing in the facility to ensure standing orders were in place. On 3/31/22, DON reviewed 24-hour sheets facility wide for any resident change in condition. Any resident identified was reviewed to ensure facility procedures were followed. DON further stated a daily review of the 24 hours sheets continued with the interdisciplinary team (IDT). During staff interviews on 4/12/22, between 10:00 a.m. -1:30 p.m. and on 4/13/22, between 8: 00a.m and 9:00 a.m. licensed practical nurse (LPN)-A, LPN-B, LPN-C, RN-A, RN-D, RN-Eand RN-F, stated signs and symptoms of [CONDITION(S)], that included blue or grey fingers or lips. Furthermore, the staff verified facility education and the process followed when residents had a change in condition, including implementing standing orders.

Based on observation, interview and document review, the facility failed to develop an adequate behavioral health care plan to support a resident's anxiety and alcohol use disorder for 1 of 3 (R2) reviewed for behavioral health services. R2 had a known history of alcohol dependence and he continued to drink on the facility premises, which lead to emergency services for his behavior and aggression. Additionally, there were no other interventions implemented after R2's hospitalization to help his anxiety and alcohol. Findings: Facility video surveillance from [DATE] indicated at approximately 9:40 p.m. R2 came around the corner to the elevator lobby with a bag in his hands and stopped in front of the nursing station. The administrator stated R2 did not fully have the bag over his head and R2 took the bag on and off from approximately 9:40 p.m. until 9:44 p.m. Nursing assistant (NA)-B came out and spoke to R2 from a distance. At approximately 9:49 p.m. R2 went on the elevator than got off the elevator and went around the corner. The administrator stated R2 went to his room where staff watched him until help arrived. The administrator stated R2 was aggressive and tried to fight off the police and paramedics. The administrator further stated they had to strap R2 down onto a gurney due to his behaviors to escort him out. The administrator stated R2 was found intoxicated. The administrator stated the facility took this incident as a behavior with his alcohol intoxication and not suicide. During an observation and interview on [DATE], at 11:46 a.m. R2 had his eyes partially open and slurred when he spoke. R2 stated he felt crabby, was anxious, stated if felt good for him to drink alcohol as drinking helped with the nerves. R2 stated he drank since he had been back from his hospitalization on [DATE], but would not indicate where he got his [NAME]. During an observation and interview on [DATE], at 2:29 p.m. R2 appeared to sweat while he gazed across his room with his eyes not fully open. When R2 spoke, it was slow, slurred, and he would stop mid-sentence. R2 stated he was anxious and demanded to be pushed to cigarette land. R2 left his room and yelled for an anxiety pill. During an observation and interview on [DATE], at 3:15 p.m. R2 sat in his wheelchair outside the facility entrance next to R6. R2 had only a sock on his left food while his right foot was exposed with a small scab that bleed. R2 stated he was going out of his mind with anxiety and was upset that he was not allowed to receive his anti-anxiety medication. R2 stated this was bull[OBSCENITY]as they told him they would not give it to since he appeared drunk. R2 raised his tone in his voice and stated, I want a damn anxiety pill now! since he had so much anxiety. R2 stopped talking and looked in the distance past R6. R2 continued to state he had so much anxiety since he was dying, his family died , and he was getting killed in the facility. R2 further stated his anxiety continued to [OBSCENITY] ing peak. R2 also stated on the night he was hospitalized he was drunk, being stupid, and [OBSCENITY] ing around. R2 further stated he just needed someone to help him with his anxiety as it was going throughout the roof. Throughout this conversation R2 had slow, slurred speech. R2's hospital history and physical note dated [DATE], indicated R2 had a blood alcohol level of 1 g/dL (should be less then or =0.000g/dL). R2 reported he had been drinking heavily since his discharge from the hospital on [DATE] for his father's burial. R2's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility Vulnerable Adult (VA) Evaluation dated [DATE], indicated a history of alcohol abuse. R2 was considered a VA and staff were directed to remove physically from any potentially harmful situation while reassuring R2 mentally. Additionally, staff were to ensure a safe environment before R2 was left alone. R2's admission Care Area Assessment (CAA) dated [DATE], indicated an admission on [DATE]. R2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The CAA also indicated R2 had little interest or pleasure in doing things, feeling down, depressed, or hopeless, trouble sleeping, and feeling tired. R2's Provider Note dated [DATE], indicated R2 had a low mood related to his father dying of COVID-19, a fight with his sister, losing his housing, excessive alcohol use and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 was open to speaking with a therapist. The provider note indicated R2's last drink was a couple weeks ago and had no interest in alcohol dependency treatment. R2's progress note (PN) dated [DATE], at 1:22 p.m. indicated R2 had a 2-liter bottle of fruit punch which had a significant odor of alcohol in his garbage can. The plan was to provide education on alcohol consumption with medication and offer treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] R2's PN dated [DATE], at 5:03 p.m. indicated registered nurse (RN)-B approached R2 of his alcohol consumption while at the facility. RN-B asked R2 if he would consider treatment and R2 stated, show me the paperwork. RN-B told R2 she would update the social worker on his request. R2's Provider note dated [DATE], indicated nursing staff reported R2 had a cocktail drink brought in for him which was removed. R2 stated he would not stop drinking as he was in constant pain from his [CONDITION(S)] to his bones and would be dying soon. The provider went over facility no alcohol protocol, continued [MEDICATION(S)], reinforced abstinence and recommended in house psychologist. R2's PN note dated [DATE], at 9:20 a.m. indicated R2 made a complaint to registered dietitian (RD)-E that a nurse took a bottle of vodka from his room. RD-E explained to R2 that he could not have alcohol on the premises. R2's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] R2's provider note dated [DATE], indicated staff were concerned R2 used alcohol despite the continued administration of [MEDICATION(S)]. The plan was to continue with [MEDICATION(S)] for R2's alcohol use disorder. R2's PN note dated [DATE], at 11:37 a.m. indicated licensed practical nurse (LPN)-C told R2 she was informed R2 had been drinking. LPN-C reminded R2 of the facility drinking policy and offered R2 chemical dependency treatment. R2 declined as he was going to be dead in a year and did not see why he needed to spend the time he had left in rehab. R2's care plan dated [DATE], indicated R2 had behaviors related to verbal aggression and alcohol abuse. The goal was that R2 would not be a threat of harm to self or others. Staff were to observe behaviors, look for triggers to why he may be aggressive and work through strategies to mitigate aggression. The care plan also indicated R2 was considered a vulnerable adult related to history of alcohol abuse. The goal was for no abuse through the review period which staff were to investigate any suspicion of abuse and report as necessary; provide one-to-ones as needed to allow the opportunity to vent any thoughts or feelings; Remove R2 physically from any potential harmful situations; Ensure a safe environment before R2 was left alone. R2's Psychology Consult Treatment Plan and Updates dated [DATE], indicated R2 had feeling of depression and anxiety, sleep disturbance and low energy. R2 drank a pint of alcohol a day. R2's treatment recommendations indicated it could be of value for staff to observe R2's behavior and look for possible triggers that could lead to aggression. R2's aggression would likely be reduced if his triggers were removed or mitigated. R2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The plan indicated it could be help for staff to validate R2's distress, listen to him and have visits from volunteers. R2's PN dated [DATE], at 6:43 p.m. indicated R2 was intoxicated. R2 screamed and yelled that he needed his anxiety pill around 5 p.m. RN-C explained to R2 that it was too early to receive another anxiety pill. R2 stated he needed his anxiety pill. R2 screamed load, cursed, yelled, and left the floor to his room. About 30 minutes later R2 came back half naked; screamed yelled and cursed loudly. R2 disturbed other residents on the floor. Staff were unable to calm R2 down. R2 continued to scream, curse, yell and use the F and N word. RN-C called 911 and two police came and spoke to R2. An email dated [DATE], at 8:10 p.m. from Social Services (SS) -A to the administrator and director of nursing (DON) indicated R2, R6, R5, R8, R9, and R10 possibly drank alcohol outside on the facility patio. These residents poured a substance into bottles or cups. R6 appeared intoxicated and caused a scene at the front desk. R2 brought the alcohol or had someone drop it off. R2, R6, R5, R8, R9, R10 were all seen passing a bottle or filling their containers with it. R2 was observed to empty a 2 liter of Sprite onto the sidewalk when he thought nobody was watching and took another bottle wrapped in a brown paper bag and filled sprite bottle with liquor. The other residents helped hide the bottle. R2's PN note dated [DATE], at 11:12 p.m. indicated at approximately 9:30 p.m. R2 was verbally abusive to staff and was very loaded. R2 put a plastic bag over his head and threaten suicide. LPN-C called 911 and paramedics took R2 the hospital at 10:00 p.m. R2's emergency room Labs dated [DATE], at 10:41 p.m. indicated a blood [MEDICATION(S)] level of .197 g/dL (should be less then or =0.000g/dL). R2's Hospital Discharge Summary dated [DATE], indicated R2 admitted to the intensive care unit for altered mental status with alcohol intoxication, suicidal ideation, mechanical intubation due to [CONDITION(S)] and hypercarbia after sedation for worsening agitation and combativeness. R2 had a discharge diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 had no interest in treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] R2's progress note dated [DATE], at 12:44 p.m. indicated prior to R2's hospitalization daily room checks revealed multiple empty alcohol bottles and one ,d+[DATE] full bottle of alcohol. R2 was volatile when intoxicated, often threatening, screaming, and cursing at staff members. R2's provider note dated [DATE], indicated R2 reported he wanted to resume [MEDICATION(S)] (anti-anxiety medication) for his agitation. A discussion was made on the importance of maintaining sobriety as combining alcohol and prescribed medications could be unsafe. The note indicated to continue [MEDICATION(S)] (anti-addiction medication) for alcohol abuse. R2's Brief Mental Status dated [DATE], indicated intact cognition. R2' Vulnerable Adult Evaluation dated [DATE], indicated R2 had a recent hospitalization due to putting a bag over his head. R2 had behaviors which increased his risk of abuse to self or others. R2 had alcohol abuse which increased his agitation and aggression toward staff and others. R2's PN dated [DATE], at 11:18 a.m. indicated a ,d+[DATE] full bottle of suspected alcohol was removed from R2's room. R2's PN dated [DATE], at 11:29 a.m. indicated R2 had his eyes closed while he swayed back and forth. R2 kept his eyes closed while he yelled vulgar names at the top of his lungs to staff. 911 was initiated due to his change in condition and concern for safety. R2's PN dated [DATE], at 2:41 p.m. indicated R2 had slurred speech and yelled at the top of his lungs for an antianxiety medication. R2 was informed he would not get the medication as he appeared intoxicated. The note indicated R2's medication was held as he appeared intoxicated. R2's PN [DATE], at 6:25 a.m. indicated R2 had a 50 milliliter (ml) empty vodka bottle on his meal tray. During an interview on [DATE], at 10:27 a.m. NA-A stated R2 often drank alcohol outside the front of the facility near the entrance. NA-A stated he thought R2 got his alcohol from another resident who was more mobile. During an interview on [DATE], at 10:33 a.m. R5 stated she knew everything that went on outside the building since she was out there often. R5 stated R2 drank almost every night, and it was obvious when R2 was drunk. R5 also stated she was not sure what staff knew about R2's alcohol consumption nor what staff have done about it. R5 stated R2 got belligerent and obnoxious at night and at times had called her every awful name in the book. R5 stated the name calling got worse the past couple of weeks. R5 told R2 [OBSCENITY] you and would just walk away. R5 stated when she was outside, she would move away from R2 as he was irritating, loaded and obnoxious. R5 also stated she knew R2 had a runner to get R2 alcohol and thought it was another resident within the building. During an interview on [DATE], at 11:26 a.m. NA-B stated when R2 drank he would explode over everything, was aggressive and verbally abusive. NA-B stated R2 had friends that got him the alcohol as R2 was not able to propel himself to the liquor store. NA-B stated he knew when R2 drank alcohol as R2 did not make sense, was red in the face, had slurred speech, smelled of alcohol and was incoherent. NA-B further stated he left R2 be when he was drunk since R2 got angry. NA-B further stated on [DATE], the night R2 was sent to the hospital R2 had signs he was drunk. NA-B stated 911 was called because R2 threatened to kill himself and was very aggressive. NA-B stated there was no way to prove R2 continued to drink after he came back from the hospital, but he suspected it. NA-B stated just prior to R2's hospitalization R2 was very angry, aggressive, and showed signs he was intoxicated. NA-B stated he had to be cautious of his approach as he did not want to do or say anything that would aggravate R2 as NA-B knew R2's behaviors when he was drunk. During an interview on [DATE], at 12:51 p.m. NA-C stated R2 left the unit regularly around 4:00 p.m. or 5:00 p.m. and hung outside the front of the facility with other residents unattended. NA-C further stated R2 was usually verbally abusive when returned around 8:30 or 9:00 p.m. NA-C stated on [DATE], after R2's hospitalization R2 appeared intoxicated as his appearance changed and he acted differently. NA-C also stated he did not go around R2 when R2 appeared drunk and angry. During an interview on [DATE], at 1:31 p.m. the administrator and DON stated R2's drinking had built up over the past couple of months. The administrator and DON verified on [DATE], nursing staff called 911 due to R1's behavior and he was found intoxicated. They stated R2 was independent, and they could not stop him from drinking therefore they will continue to do room checks and offer chemical dependency treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on [DATE], at 2:43 p.m. lLPN-A stated he believed R2 hide his alcohol in Pepsi bottle or Sprit bottle, but it was hard to prove since there is no machine to test his blood alcohol. During an interview [DATE], at 3:05 p.m. LPN-B stated she found a bottle of alcohol in R2's possession after his recent hospitalization . During an interview on [DATE], at 3:18 p.m. R6 stated R2 was his friend and R2 really needed help for his anxiety. During an interview [DATE], at 3:23 p.m. LPN-B stated R2 did not receive his anxiety medication on [DATE] because R2 appeared intoxicated around 2:35 p.m. During an interview on [DATE], at 3:23 p.m. social services (SS)-A stated at times she suspected R2 drank alcohol when she worked the front desk near the area residents hung out outside. SS-A further stated on [DATE], she saw R2 with a brown paper bag, a bottle of Sprite and he had something hidden behind his back. SS-A further stated she saw R2 pour the Sprite out of a bottle and then poured another clear liquid into the sprit bottle. SS-A stated she called the supervisor who came outside to monitor R2 and the other residents. SS-A stated she got a report from another resident that a friend dropped off the alcohol bottle for R2. During an interview on [DATE], at 9:16 a.m. SS-B stated after R2 returned from the hospital she could not provide any new interventions that were put into place to help R2 with his anxiety and alcohol dependence. During an interview on [DATE], at 10:45 a.m. physical therapist (PT)-D stated R2 could ambulate down the street a block but would not be able to make it further. The closest liquor store was greater than a block away. PT-D stated R2 could not ambulate on his own to a liquor store as it was too far. During an interview on [DATE], at 10:53 a.m. R2 stated he had anxiety and needed his damn anxiety pill. R2 stated the facility had not done anything to help with his anxiety and wanted help. R2 wanted assurance that someone would help him. During an interview on [DATE], at 11:20 p.m. trained medication aide (TMA)-A stated R2 received medication for his anxiety and was not aware of any other interventions. During an interview on [DATE], at 11:22 p.m. NA-E stated each resident required different ways to get redirected for their behaviors and was not aware of interventions if R2 was anxious. During an interview on [DATE], at 1:53 p.m. NA-F stated when R2 was angry she tried to just be polite and provide him what he wanted as she was not sure of a specific approach for him. NA-F stated R2 drank often outside the building, and it is fine as he is independent. NA-A also stated when R2 drank alcohol he got angry therefore she just would let him be and would peak in quickly on him to ensure he was ok. During an interview on [DATE], at 2:02 p.m. SS-B stated the facility looked at residents' behaviors, psychology recommendations and what interventions worked when they created behavioral health care plans. SS-B also stated the facility would have interdisciplinary team meetings and on-going communication with nursing staff to know if the interventions worked. During an interview on [DATE], at 2:12 p.m. RN-A stated behavioral health care plan were made based on target behaviors. RN-A also stated R2 expressed he did not want to stop drinking and the facility was not able to control him therefore the facility would remove alcohol when they found it. When asked RN-A was not able to provide ways the facility was proactive to prevent R2 from drinking alcohol. During an interview on [DATE], at 11:10 a.m. SS-B stated the alcohol substance use policy in the resident handbook indicated a resident needed to have a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . SS-B verified she was not able to provide an answer on what the facility has done to help prevent R2 from drinking besides offering him treatment which he declined. SS-B was not sure if there was an investigation on to where R2 obtained the alcohol. During an interview on [DATE], at 2:30 p.m. the DON stated she was not sure of what R2's behavioral health plan consisted of. A policy on the facility behavioral health care plan was requested but not provided. The facility Alcohol Use Policy undated, indicated alcohol beverages were allowed only with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview and document review, the facility failed to properly store milk at the appropriate temperature, below 41 degrees Fahrenheit (F), to ensure food safety and served this milk to 8 of 8 residents (R13, R17, R70, R100, R124, R137, R145, and R159) who consumed the milk. This had the potential to affect 119 out of 165 residents who received milk from the main kitchen walk in cooler. In addition, the facility failed to discard time-temperature-control for safety (TCS) food within seven days for food safety. The IJ began on 6/23/21, at 6:40 a.m. when the facility failed to take appropriate action to ensure potentially hazardous food (milk) was preserved and served at the proper temperature when the facility was aware the cooler had malfunctioned where the milk was stored. The administrator and director of nursing (DON) were notified of the immediate jeopardy on 6/24/21, at 2:08 p.m. The administrator was notified that the immediate jeopardy was removed on 6/25/21, at 11:08 a.m. but noncompliance remained at a lower scope and severity level of E - pattern, scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: The U.S. Food & Drug Administration (FDA) Food Code dated 2017, indicated Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature Danger Zone of 5 [degrees Celsius] C to 57 degrees C (41 F to 135 F) too long. Up to a point, the rate of growth increases with an increase in temperature within this zone. The U.S. Department of Health & Human Services, referenced by the State Operations Manual (SOM), indicated milk should be discarded if thawed and held above 40 degrees F for more then 2 hours. The U.S. Department of Health & Human Services also indicated Refrigerated food should be safe as long as the power was out for no more than 4 hours and the refrigerator door was kept shut. Discard any perishable food (such as meat, poultry, fish, eggs, or leftovers) that has been at temperatures above 40° F for 2 hours or more (or 1 hour if temperatures are above 90º F). The 7th Edition ServSafe Manager from the National Restaurant Association dated 2018, indicated populations at high risk for foodborne illness include the elderly as peoples immune systems weaken with age. AND if you primarily serve a high-risk population, you cannot hold TCS food without temperature control. R13's Face Sheet dated 6/25/21, indicated R13 had diagnoses that included diabetes mellitus (DM) type 2, hypertension ([CONDITION(S)]), [CONDITION(S)] (CKD) stage two. R13's quarterly Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment. R13 was independent when he ate. R13's care plan dated 6/25/21, indicated R13 required staff to set up for eating. R17's Face Sheet dated 6/25/21, indicated diagnoses of adult failure to thrive, [CONDITION(S)] (CKD) stage three, [CONDITION(S)], DM type 2. R17's quarterly MDS dated [DATE], indicated intact cognition and was independent when he ate. R17's Physician Orders dated 6/25/21, indicated staff were to assist with meal set up. R70's Face Sheet dated 6/25/21, indicated diagnoses of protein calorie malnutrition, arterial fibrillation (AF), and [CONDITION(S)]. R70's 5-day MDS dated [DATE], indicated moderate cognitive impairment and was independent when he ate. R70's care plan dated 6/25/21, indicated R70 required set up for eating. R100's Face Sheet dated 6/22/21, indicated diagnoses of adult failure to thrive, dementia and severe malnutrition. R100's significant change MDS dated [DATE], indicated severe cognitive impairment and was independent when he ate. R124's Face Sheet dated 6/25/21, indicated diagnoses of [CONDITION(S)], constipation, and urine retention. R124 quarterly MDS dated [DATE], indicated moderate cognitive impairment. R124's quarterly MDS dated [DATE], indicated R124 was independent when he ate. R124's care plan dated 6/25/21, indicated R70 required staff to set up for eating. R137 significant change MDS dated [DATE], indicated intact cognition and required supervision at meals. R137 had diagnosis of DM. R145 annual MDS dated [DATE], indicated intact cognition and ate independently with set up. R145 had diagnoses of [CONDITION(S)], [CONDITION(S)], and DM. R159's Face Sheet dated 6/25/21, indicated diagnoses of [CONDITION(S)] heart disease, [CONDITION(S)], [CONDITION(S)], DM type 1. R159's quarterly MDS dated [DATE], indicated intact cognition and ate independently. R159's care plan dated 6/25/21, indicated R159 required staff to set up for eating. The facility Refrigerator Temperature Log dated June 2021, for the walk-in cooler, indicated on 6/23/21, at 6:40 a.m. the temperature of the cooler was 45 degrees F. A refrigerator temperature should be below 41 degrees F. During an observation on 6/23/21, at 11:42 a.m. the food service director (FSD) calibrated his thermometer and took the temperature of the hot food before the food was sent to the dining units. The FSD did not take the temperature of milk that was on a cart ready to be sent to the units, even though the FDS was aware of the malfunctioning walk-in cooler where the milk was stored. During an observation and interview on 6/23/21, at 11:49 a.m. chef manager (CM) stated the milk that was on the cart was ready to be distributed to the dining rooms upstairs. Upon request, CM took the temperature of a gallon of milk that had been pulled from the walk-in cooler. The temperature of one gallon of milk read 53 degrees F and CM stated the temperature of the milk was too high for safety. CM went into the walk-in cooler and took the temperature of another gallon of milk which read 47 degrees F. CM verified the milk should be less than 41 degrees F. CM stated there had been a problem with the walk-in cooler. CM proceeded to take the temperature of another gallon of milk, did not report the temperature although verified it was too high. Although the temperature of the milk was in the danger zone, CM did not stop the milk from being sent to the units for service. During an interview on 6/23/21, at 12:13 p.m. the food service director (FSD) stated he took the temperature of the walk-in cooler on 6/23/21, at 6:40 a.m.; at that time the temperature was 45 degrees F. The FSD stated he called maintenance to come and fix the walk-in cooler since the temperature was too high. The FSD stated he was unsure when the walk-in cooler stopped working since he had discovered the issue when he arrived to work that morning. The FSD also stated he tried to keep the door closed to keep the food cold and he did not implement any other interventions. The FSD verified the temperature of the cooler had gone down from its peak temperature and was currently at 48 degrees F. The FSD stated if the temperature would not come down in a few hours he would move the food from the walk-in cooler to another location to keep it cold. At this time, milk and other TCS foods continued to be in the walk-in cooler which was at an unsafe 48 degrees F for at an unknown amount of time. During an interview on 6/23/21, at 1:15 p.m. the FSD stated he notified maintenance when he realized the temperature of the walk-in cooler was too high when he arrived at work that morning. The FSD stated he was not aware when the walk-in cooler stopped working. The FSD verified the milk that was sent up to the units and served to the residents for the noon meal came were from the malfunctioning cooler. The FSD also stated he did not have documentation of the monitoring of the food temperatures and would throw the rest of the milk. Although it was unknown how long the milk was stored at greater than 41 degrees F and the temperature of the milk from the walk-in cooler was greater than 41 degrees F prior to delivery, the milk was still sent up to the floors. During an interview on 6/23/21, at At 1:24 p.m. the FSD stated he did not alert the floors that the milk had been stored above and greater then 41 degrees F. The FSD also stated when he realized the cooler was at 45 degrees F, he should have taken the temperature of the food inside the cooler to see if the food was still in a safe range. The facility Holding Temperature Logs dated 6/23/21, had no indication the temperature of milk had been checked for the morning or noon meal on 1 North, 2 North, 3 South, or 3 North kitchen units. The facility Holding Temperature Log dated 6/23/21, for the main kitchen had no indication of a temperature for the morning or noon meal. During an interview on 6/23/21, at 1:31 p.m. director of maintenance (DOM) stated he had to shut down the walk-in cooler while he worked on it. The DOM further stated the food and milk remained in the cooler while he worked to fix the walk-cooler. During an observation and interview on 6/23/21, at 12:22 p.m. on the 2 North dining room there was milk in a container of ice on a cart. Registered nurse (RN)-B stated the cart with the milk just arrived from the main kitchen and milk had been served to the 2 North residents. RN-B stated the temperature of the milk was not taken prior to service. There were glasses of milk in front of residents sitting in the 2 North dining room, ready to be consumed. During an observation on 6/23/21, at 12:25 p.m. on the 3 South dining room, R137 was served a glass of 1% milk and a glass of water for her meal. R137 was observed seated in the dining room awaiting the rest of her meal. During an observation and interview on 6/23/21, at 12:31 p.m. on the 3 South dining room, registered dietitian (RD)-B took the temperature of a gallon of milk. The milk was sitting in ice, yet the temperature of the milk was 42.2 degrees. RD-B verified the temperature was too high and the milk came from the main kitchen. At this point, the point of service, RD-B removed the milk. R137 and other unidentified residents in the 3 South dining room had already been served milk. During an observation on 6/23/21, at 12:37 p.m. on the 3 North dining room, R124 drank from a glass of milk in front of him; there was only 1/4 of the cup of milk left. R13 had a full glass of milk in front of him. R70, R145, R17, and R159 had empty glasses in front of them; the glasses had milk residue in them. R70's, R145's, R17's and R159's tray tickets indicated they were to be served milk. During an interview on 6/23/21, at 1:13 p.m. on 2 South dining area dietary server (DS)-D stated the milk came up to the unit at 7:30 a.m. and the milk temperature was at 42 degrees, and she served the milk since he thought it was okay to serve it. DS-D also stated he did not take the temperature of the milk that came up from the kitchen for lunch. During an interview on 6/23/21, at 1:35 p.m. nursing assistant (NA)-C stated on 6/23/21, he served the 3 North residents milk from the gallons of milk that were brought up from the kitchen for the noon meal. During an interview on 6/23/21, at 1:24 p.m. dietary aide (DA)-B stated she served 3 South residents milk that was brought milk from the main kitchen. DA-B also stated she did not take the temperature of the milk prior to distribution. During an observation and interview on 6/23/21, at 1:27 p.m. NA-A served R100 a cup of milk poured from a gallon of milk that was taken out of the transitional care unit (TCU) refrigerator. NA-A stated this gallon of milk came up from the kitchen walk-in cooler that morning. The date written on the gallon was 6/23/21, and there was no time indicated. During an observation and interview on 6/23/21, at 1:34 p.m. dietary staff (DS)-C took the temperature of a gallon of milk from the TCU refrigerator which read 55 degrees F. The temperature was verified with RN-J and DS-C. The milk was then removed from the TCU kitchen area. The milk came from the kitchen walk in cooler that morning. During an interview on 6/23/21, at 1:45 p.m. R100 stated he asked NA-A for a cup of milk from the first floor TCU. R100 stated when he went back to his room the nurse took the cup away. R100 stated he drank some milk from the cup which contained the milk that came from the gallon of milk that temped at 55 degrees F. R100's progress note dated 6/23/21, indicated R100 drank milk with a temperature of 54.7 degrees F. During an interview on 6/23/21, at 2:25 p.m. the regional RD stated the current temperature of the walk in cooler was 44 degrees F which had been come down from 48 degrees F at around 12:00 p.m. At this point they continued to keep the walk-in cooler door closed to help the temperature come down to a safe range. During an interview on 6/24/21, at 11:56 a.m. the FSD stated the facility served 10 gallons of milk a day to the units for each meal; each unit got two gallons of milk. During an interview on 6/24/21, at 12:47 p.m. the DOM stated the condenser coils, which were located on top of the unit, were frozen which called the caused the walk-in cooler to shut down. The DOM stated he was not sure of the reason why the coils were frozen but speculated that it could have been the door was left open. The DOM stated he had to shut the unit down to get the ice out of the coils. The DOM stated at 8:30 a.m. he had to take the cooler out of service to get it defrosted which raised the temperature by the minute; especially since the guns powered heat to defrost the coils. The DOM stated at 9:30 a.m. the temperature of the unit peaked and maxed out the thermometer gage which measured far greater than 60 degrees F. The DOM also stated after the issue with the cooler was fixed it took a long time to cool the cooler back down to appropriate temperature range. The DOM stated at around 5 p.m. on 6/23/21, the cooler was back in range, and he gave the clear that the cooler was ok to use. The milk and food remained in the walk-in cooler while the DOM shut down and raised the temperature of the walk-in cooler to defrost the coils. During an interview on 6/23/21, at 2:12 p.m. RD-A stated she would have taken the temperature of the food in the cooler if she became aware the walk-in cooler was 45 degrees F at 6:40 a.m. RD-A stated she would have taken the temperature of the food to ensure it was in a safe temperature range since it was unknown when the cooler stopped working. RD-A verified bacteria would start to grow which increased the risk for food borne illness (FBI) and could cause residents to get sick if milk was not stored at less than 41 degrees. RD-A further stated the milk should not have been served to the residents since it was unknown the length of time the milk was stored incorrectly. RD-A also stated the milk should not have been served since the temperature of the milk from the cooler was at 47 degrees F and 53 degrees F. RD-A stated she had not been informed by the FSD, but had become aware of the issue after the milk had been served to residents. The facility Holding TCS Food: During Service policy undated, indicated to discard TCS cold foods if the starting temperature was not 41 degrees F or below or the starting temperature cannot be determined. The facility Storing: Food and Equipment policy undated, indicated if the refrigerator temperature was above 41 degrees F, keep door closed for 15 minutes. If the temperature did not decrease after 15 minutes or did not reach 41 degrees F after two hours, staff were to call maintenance and take food temperatures. If food temperatures was above 41 degrees F, staff were to recheck after two hours. If food temperature remained above 41 degrees F for more than four hours or if the food temperatures exceeds 70 degrees F, then staff were to discard the food. The immediate jeopardy that began on 6/23/21, was removed on 6/25/21, at 11:08 a.m. when the facility developed and implemented interventions to ensure food was stored at appropriate safe temperatures. The facility started daily rounding by nursing to check refrigeration temperatures on the unit kitchenettes. The facility reviewed guidance/procedure for safe food storage. Additionally, all dietary staff were educated on food storage procedure on refrigerator temperature monitoring and interventions when temperatures were out of range. The food servers started to take the temperature milk prior to service of food and would discard if greater than 41 degrees F; milk would be stored in ice baths during service and after meal service milk would be tempted again to ensure safe temperature range. All other facility staff received education on how to recognize unsafe temperatures and when to dispose of food/beverage items. All food/fluids disposed if stored in the cooler when it did not function appropriately, residents were monitored after consumption of the milk, and the cooler was fixed. Staff interviews were conducted on 6/25/21, from approximately 8:45 a.m. to 10:45 a.m. with staff that included nursing staff, dietary staff and management. Nursing identified the start to daily rounding of refrigeration temperature on the unit kitchenettes. Dietary staff identified their education on refrigerator temperature monitoring and interventions when out of range. Additionally, dietary staff identified to take milk temperatures prior/ post meal service and to discard if the temperature was greater then 41 degrees F. Additionally, milk would be stored on ice during service. All other facility staff were able to identify how to recognize unsafe temperatures and when to dispose of food/beverage items if stored in a cooler that did not function appropriately. Documentation was reviewed of resident who were monitored after consumption of milk. The cooler was identified to have been fixed and function correctly. FOOD STORAGE: During an observation and interview on 6/21/21, at 11:59 a.m. there was a refrigerator in the kitchen preparation room. In the refrigerator there was a container of coleslaw that was labeled 6/10. The CM verified the date was 6/10/21, and stated it should not be in the fridge as it should have been thrown after seven days. The refrigerator also had a large Ziploc back filled with fluid surrounding hot dogs. The Ziploc back with hot dogs was stored on top of a container covered with plastic wrap of coleslaw. The CM verified the hot dogs should be stored separately and not on top of the coleslaw. The refrigerator additionally had a large covered container of tomato paste which was dated labeled 6/13/21. The CM took the tomato paste out of the refrigerator and stated the tomato paste should have been thrown after seven days. The facility Labeling policy undated, indicated TCS, ready to eat foods, could be stored at 41 degrees F for up to seven days from the initial date of preparation or opening of container. TCS foods include dairy products, poultry, eggs, meat, fish, shellfish and crustaceans, baked potatoes, cooked rice, beans, and vegetables, cut tomatoes, sliced melons, and untreated garlic and oil mixtures.

Based on observation, interview, and document review, the facility failed to implement appropriate COVID-19 infection control practices related to the appropriate utilization of personal protective equipment (PPE) when providing personal care and treatment to residents and failed to quarantine for 12 (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12) of 22 recently admitted residents. These practices resulted in an immediate jeopardy (IJ) due the potential risk to affect all 22 residents residing in the transitional care unit (TCU). In addition, staff were not [MEDICATION NAME] hand hygiene, not ensuring social distancing in the smoking area, not wearing appropriate PPE or following infection control practices at the screening station. The IJ began on 11/3/20, when it was determined the facility failed to implement 14 days of quarantine with full PPE: gown, gloves, mask, and eye protection per the Centers for Disease Control and Prevention (CDC) COVID-19 guidelines. Staff were observed providing direct cares and repositioning residents without wearing gowns. Staff were also observed not [MEDICATION NAME] hand hygiene when entering and exiting rooms between quarantine and non-quarantine rooms. The administrator and director of nursing (DON) were notified of the IJ on 11/3/20, at 6:51 p.m. The IJ was removed on 11/4/20, at 4:55 p.m., but noncompliance remained at a lower scope and severity level of E: pattern which indicated no actual harm with potential for more than minimal harm that is not IJ. Findings include: RESIDENT CARE PPE USE: R2 Admission Face Sheet dated 11/4/20, indicated R2 was admitted on [DATE], from an acute care hospital. R2's Care Area Assessment (CAA) dated 11/3/20, indicated R2 was frequently incontinent of urine due to urge incontinence, required extensive assist for bed mobility and total assist with toileting. R2's [DIAGNOSES REDACTED]. R2's initial care plan was requested but not provided by facility at the time of the findings. During an observation on 11/3/20, at 1:49 p.m. nursing assistant (NA)-A performed hand hygiene and entered R2's room. NA-A donned gloves, removed an incontinent product, and provided perianal care. Upon completion of cares, NA-A removed gloves and proceeded to the bathroom and washed hands. NA-A had on face mask, face shield and gloves while providing high contact care to R2, however, a gown was not used during this time. On 11/3/20, at 1:54 p.m. NA-A stated he had returned to R2's room to apply rash prevention topical cream to perianal area. NA-A had on a face mask, and face shield, performed hand hygiene, donned gloves and then applied topical cream to R2's perianal area. NA-A then doffed gloves, and performed hand hygiene. R2 did not use a gown for these cares. During an observation on 11/3/20, at 1:57 p.m. NA-A and NA-C entered R2's room to reposition R2 in bed. NA-A and NA-C both had on face masks and face shields. NA-A and NA-C performed hand hygiene and donned gloves. NA-A then explained to R2 that they would be moving R2 up in bed. NA-A and NA-C used the draw sheet under R2 to reposition up in bed. After repositioning, both staff doffed gloves and performed hand hygiene. Neither NA-A nor NA-C wore gowns for these cares. During an interview on 11/3/20, at 2:15 p.m. NA-C stated R2 was a new admit but NA-C was not assigned to R2. NA-C stated she went into the room to assist NA-A with repositioning R2 since they needed 2 staff for repositioning in bed. NA-C also stated that for new admits, staff are only required to wear face mask, face shield, or goggles and wear gloves when providing personal cares. When interviewed at 2:21 p.m. on 11/3/20, NA-A stated R2 is a new admit. She stated gown usage was not for everyone, however face mask, face shield, or goggles are used for all residents. If a resident is on contact precautions then gowns are used only when providing direct care. NA-A further explained that she only need to wear a face mask, face shield or goggles are required when entering R2's room. Gloves are only worn when providing direct personal cares. On 11/3/20, at 2:35 p.m. during an interview, the infection preventionist (IP) indicated new admits are placed in the back half of the transition care unit (TCU) for fourteen days and are monitored for respiratory symptoms, temperature and oxygen saturation monitoring, signs and symptoms monitoring and tested weekly during the facility wide Covis-19 testing. IP further indicated, staff are expected to wear a face mask and eye protection at all times for all resident but are not required to wear gowns for newly admitted residents during cares or entry into their rooms as facility has to preserve supplies or would run out. During interview on 11/3/20, at 4:15 p.m. the director of nursing (DON) indicated all new admits are placed on the Step Down unit on the TCU. DON further explained, when new admits are positive for Covid-19 they are placed on the Covid-19 isolation unit. New admits on the TCU are placed in quarantine for fourteen days on the Step Down unit, however staff are not expected to enter new admittion rooms gloved or gowned, and staff were not required to wear gowns during high contact cares with new admits on quarantine. R1 R1's face sheet, dated 11/4/20, indicated R1 had been admitted to the facility on [DATE]. R1's [DIAGNOSES REDACTED]. R1's Progress Note, 10/30/20, indicated R1 was admitted to the facility following a hospital admission for disseminated [MEDICAL CONDITION] (shingles). R1's Comprehensive Skin and Positioning Note, dated 11/3/20, indicated R1 had open lesion(s) but there was no description of the [MEDICAL CONDITION]. R1's Care Plan, dated 10/31/20, lacked care planning related to use of isolation or quarantine for either the disseminated [MEDICAL CONDITION] or for COVID-19 precautions for a new admission. During an observation on 11/3/20, at 9:00 a.m., R1 had a sign on her room door that read contact precautions. An isolation cart was inside her room with a box of gloves on top of the cart but no gowns were in the cart. During an observation on 11/3/20, at 12:42 p.m., R1's room door was open; nursing assistant (NA)-A entered R1's room with a food tray. NA-A's face shield was pushed back on top of his head and his mask was loosely on his beard, not covering his mouth or nose. NA-A did not perform hand hygiene upon entering the room and was not wearing a gown or gloves. NA-A placed the food tray on the bedside table in front of R1, who was not wearing a mask. NA-A did not perform hand hygiene when exiting the room. During an interview on 11/3/20, at 12: 45 p.m., NA-A stated he did not know why R1 was on contact precautions. NA-A indicated all new residents were on quarantine but NA-A did not know why there was a sign on R1's door and no other resident's door. NA-A verified there was no gowns in the isolation cart in R1's room and no gloves, but NA-A stated gloves were in the bathroom. NA-A stated they did not need to wear gloves or gowns unless they were providing direct care to a resident. R3 R3's face sheet, dated 11/4/20, indicated R3 had been admitted to the facility on [DATE]. R3's [DIAGNOSES REDACTED]. and restrict blood flow to the heart), and [MEDICAL CONDITION] (when the heart muscle does not pump blood as well as it should causing fluid to back-up in the legs and lungs). R3's Nursing Assessment: Admission/Readmission + Care Plan - V3, dated 10/30/20, lacked care planning related to COVID-19 precautions for a new admission. During an observation on 11/3/20, at 9:45 a.m. through 9:55 a.m., R3's room door was open; RN-B was at the medication cart preparing medications outside of R3's room. RN-B took medications into R3's room without performing hand hygiene. In addition, there was no sign on the door indicating R3 was in quarantine, and RN-B did not wear gown or gloves. There was no PPE cart near R3's room or inside R3's room. In the process of administering medications to R3, RN-B dropped one of the pills and it fell into the chair's cushion. RN-B left the room without performing hand hygiene, went to the medication cart, retrieved a new pill, and returned to R3's room without performing hand hygiene. RN-B then left R3's room, performed hand hygiene, and returned to the medication cart to prepare medications for R4. On 11/3/20, at 2:01 p.m. through 2:34 p.m. during continuous observations of R3 in R3's room: * Occupational therapist (OT)-A entered R3's room without performing hand hygiene, and without wearing gloves or a gown. OT-A was wearing a face mask but her face shield was pushed back to the top of her head and her eyes were not covered. * NA-A entered R3's room without gown or gloves and did not perform hand hygiene. R3 asked NA-A for coffee and NA-A left the room without performing hand hygiene. NA-A returned with coffee and no hand hygiene was performed upon entrance or exit to the room. * OT-A asked R3 to wear a face mask for an OT evaluation. Did R3 NOT have a mask on at the beginning of this observation? If so, let's put that above. * NA-C entered R3's room and R3 asked for pain medication. NA-C did not perform hand hygiene upon entering the room and did not wear gloves or gown but did have on a face mask and eye protection. * NA-C left the room and asked OT-A to press the call light to shut it off. OT-A pressed the call light once, reaching over R3. R3 then reached up and pressed the call light three times. RN-B entered R3's room, without gown or gloves and without performing hand hygiene while entering, and pressed R3's call light three times. * OT-A, still not wearing gloves, gave a hand grip to R3 and instructed him to squeeze it three times with his right hand. Once he did this, OT-A took the grip from R3 and wrote numbers on a piece of paper on R3's window sill. OT-A handed the grip to R3 to squeeze with his left hand. OT-A took the hand grip back and wrote on the same piece of paper. * RN-B entered R3's room without performing hand hygiene upon entering and not wearing gown or gloves. RN-B gave R3 a ½ tablet of pain medication and R3 stated that was not enough. RN-B left the room without performing hand hygiene upon exit to check the medication dose. * OT-A gave a sheet of paper and her pen to R3 and asked him to draw a clock. R3 placed the paper on his bedside table and when done, handed the paper and pen back to OT-A. * RN-B entered the room again without performing hand hygiene. RN-B gave R3 a whole pill for pain. RN-B exited the room without performing hand hygiene. * OT-A asked R3 to pull his pants down and then pull them up (testing his ability to do this task). R3 pulled his pants to his knees, then OT-A handed R3 a grabber so he could use it to pull up his pants. OT-A then moved her face shield down to cover her eyes and donned gloves to assist R3 with putting on his socks. OT-A removed gloves after R3's socks were off. During an interview on 11/3/20, at 2:34 p.m., OT-A stated R3 was on isolation for 14 days because he was a new admission. OT-A stated this meant he could not leave his room and they did therapy in the room. OT-A stated this meant he was on standard precautions and gloves were only used for close contact with the resident. R4 R4's face sheet, dated 11/4/20, indicated R4 had been admitted to the facility on [DATE]. R4's [DIAGNOSES REDACTED]. lungs), hypertension, type 2 diabetes mellitus, and abdominal aortic aneurysm (an enlargement of the largest blood vessel in the body that can lead to rupture). R4's Nursing Assessment: Admission/Readmission + Care Plan - V3, dated 11/2/20, revealed it lacked care planning related to COVID-19 precautions for a new admission. On 11/3/20, at approximately 9:50 a.m., R4's door was open and RN-B took medications into R4's room without performing hand hygiene. In addition, there was no sign on the door indicating R4 was in quarantine, RN-B did not wear gown or gloves and there was no PPE cart near R4's room or inside R4's room. R5 and R10 R5's face sheet, dated 11/4/20, indicated R5 had been admitted to the facility on [DATE]. R5's [DIAGNOSES REDACTED]. R5's Nursing Assessment: Admission/Readmission + Care Plan - V3, dated 10/19/20, showed the record lacked care planning related to COVID-19 precautions for a new admission or readmission. R10's face sheet, dated 11/4/20 indicated he was [AGE] years old and admitted to the facility on [DATE]. R10's [DIAGNOSES REDACTED]. Since R10 was not a new admission or readmission within 14 days, R10 did not need to be on any type of quarantine. During observation on 11/3/20, from 8:30 a.m. until 8:45 a.m. R5's room door was open. RN-A was preparing medications at a medication cart nearby and took R5 medications without performing hand hygiene and there was no sign on the door indicating R5 was in quarantine. Finally, RN-A did not wear a gown or gloves, and there was no PPE cart near R5's room or inside R5's room. Throughout this observation, RN-A's face shield was on the top of his head, not covering his eyes. After exiting R5's room and performing hand hygiene, RN-A returned to the medication cart and prepared medications for R10. RN-A did not perform hand hygiene upon entering R10's room, and RN-A's face shield remained on top of his head. During continuous observation on 11/3/20, at 1:46 p.m. through 1:55 p.m., speech therapist (ST)-A was in R5's room with mask and face shield, but no gown or gloves. The door to R5's room was open. ST-A was sitting on the floor within six feet of the resident who was not wearing a mask. ST-A rose and patted R5 on his back and then placed R5's call light near him. ST-A donned gloves to empty R5's urinal, then doffed gloves, but did not perform hand hygiene when she exited the room. ST-A left R5's door open. R6 R6's face sheet, dated 11/4/20, indicated R6 had been admitted on [DATE]. A progress note, dated 10/30/20, indicated R6 was readmitted after treatment for [REDACTED]. R6's [DIAGNOSES REDACTED]. R6's care plan, 1/24/20, showed the record lacked care planning related to COVID-19 precautions for a new readmission. During an observation on 11/3/20, at 11:23 a.m., R6's room door was open and RN-B was at the medication cart preparing medications. RN-B took medications into R6's room without performing hand hygiene, and without wearing a gown or gloves. In addition, there was no sign on the door indicating R6 was in quarantine. There was no PPE cart near R6's room or inside R6's room. RN-B gave the medications to R6 and performed hand hygiene upon exiting the room. R7's face sheet, dated 11/4/20, indicated R7 had been admitted to the facility on [DATE]. R7's [DIAGNOSES REDACTED]. deposits and calcium builds up in the walls of the blood vessels and leads to narrowing, blockage, or vessel spasms). A progress note, dated 10/23/20, indicated R7 was readmitted to the facility on [DATE], after being discharged to the hospital to receive a blood transfusion after sustained nasal bleeding. R7's care plan, dated 8/28/20, indicated the record lacked care planning related to COVID-19 precautions for a readmission. R8's face sheet, dated 11/4/20, indicated R8 had been admitted to the facility on [DATE]. R8's [DIAGNOSES REDACTED]. and weight). R8's Nursing Assessment: Admission/Readmission + Care Plan - V3, dated 10/27/20, had interventions related to R8's care had interventions of: 1) assistance with dressing and undressing; 2) assistance of an unspecified number of staff for toileting; and 3) assistance of unspecified number of staff for ambulation. A review of R8's medical record showed the record lacked care planning related to COVID-19 precautions for a new admission. R9's face sheet, dated 11/4/20, indicated R9 had been admitted to the facility on [DATE]. A progress note, dated 10/24/10, indicated R9 was readmitted to the facility on [DATE] after a short hospitalization for sudden onset of weakness. R9's [DIAGNOSES REDACTED]. pancreas does not create enough insulin), and asthma (a condition in which a resident's lung airways narrow and swell making breathing difficult and triggering coughing, a [MEDICATION NAME] sound known as wheezing, and shortness of breath). R9's Nursing Assessment: Admission/Readmission + Care Plan - V3, dated 4/25/20, had interventions related to R9's care had interventions of: 1) assistance with dressing and undressing; 2) assistance of an unspecified number of staff for toileting; 3) assistance of one staff for transferring; and 4) staff pushing wheelchair, but lacked care planning related to COVID-19 precautions for a readmission. No other care plan was produced other than the one mentioned above. R11's face sheet, dated 11/4/20, indicated R11 was [AGE] years old and was admitted on [DATE]. R11's [DIAGNOSES REDACTED]. R11's Nursing Assessment: Admission/Readmission + Care Plan - V3, not dated or signed, had interventions related to R11's care had one intervention of encouraging repositioning during rounds and observing skin during care but lacked care planning related to COVID-19 precautions for a new admission. R12's face sheet, dated 11/4/20, indicated he was [AGE] years old and was admitted to the facility on [DATE]. R12's [DIAGNOSES REDACTED]. R12's Nursing Assessment: Admission/Readmission + Care Plan - V3, dated 10/27/20, had no interventions related to R12's care. A review of R12's medical record showed the record lacked care planning related to COVID-19 precautions for a new admission. SMOKING PATIO: PPE USE AND SOCIAL DISTANCING During an observation of the resident's smoking patio on 11/3/20, at 12:00 p.m., RN-B exited out the dining room door onto the smoking patio where two unidentified residents were smoking. RN-B was not wearing a face mask or eye protection as he walked within three feet of the residents who had their masks under their chins. NURSING STATION: PPE USE During an observation on 11/3/20, at 12:31 p.m., RN-B entered the resident hallway from the dining room without a mask on and RN-B's face shield was pushed back on top of his head, not covering his eyes. RN-B pulled the mask under his nose as he walked into the nursing station, covering his mouth but not his nose. Then RN-B came out of the nursing station with the mask covering his nose and mouth but the face shield was still pushed back on top of his head. SCREENING DESK: PPE USE During an observation on 11/3/20, at 1:30 p.m., human resource staff (HR-A) was at the screening desk by the facility entrance without a mask and with eye protection pushed on top of HR-A's head. During interview on 11/3/20, at 8:45 a.m., RN-A stated all residents in the back (motioning with his hands) of the transitional care unit (TCU) were new admissions, and therefore on quarantine. RN-A stated they did not use signs because everyone just knows. RN-A stated they did not require any additional PPE unless there were performing personal care to residents. RN-A stated, it's just like standard precautions and the only difference with the residents on quarantine was they could not leave their rooms and if they did, they had to wear a mask. During interview on 11/3/20, at 12:54 p.m., RN-C stated new admissions were kept in quarantine for 14 days, which meant they were monitored for symptoms of COVID-19, they had to stay in their room, and staff wore masks and face shields when working with the resident in their room. RN-C stated gloves were only used if performing any care but gowns were not required for care. During interview on 11/3/20, at 1:55 p.m., ST-A stated all residents were in isolation during their first 14 days after admission. ST-A stated residents on isolation would stay in their rooms or wear masks outside their rooms. When asked how ST-A would determine if residents were on isolation, ST-A stated they were in the back part of TCU. ST-A also stated they don't do anything different for those in isolation; they use standard precautions and wear gloves if in close contact. During interview on 11/3/20, at 2:53 p.m., the infection preventionist (IP) stated staff did not use gowns with residents unless the residents were having symptoms of COVID. The IP stated they had to preserve equipment because they only had a week's worth of gowns. The IP stated they were getting the maximum amount from their supplier, McKesson. The IP stated they use redcap (a state emergency system to request PPE when no other resources are available). During interview on 11/3/20, at 4:15 p.m., the director of nursing (DON) stated new admissions went to the TCU, also known as the Stepdown Unit, where they are in quarantine for 14 days. She stated they were preserving gowns because they can't get more than their allotment. She had checked with the coalition and emergency collation, but had not checked recently. The DON stated staff were expected to wear mask and face shield at all times in care areas and gloves when providing direct contact care. The immediate jeopardy that began on 11/3/20, at 6:51 p.m. and was removed on 11/4/20 at 4:55 p.m, when the facility implemented corrected procedures for the appropriate quarantine and use of PPE for newly admitted or readmitted residents. Staff were provided education regarding the infection control procedures and the facility established daily auditing. The facility's Interim Step Down Units for SNFs Guideline (Guideline) dated 6/22/20, indicated staff would use gloves, masks, and face shields or goggles when providing care for the resident. Gowns were to be used for high contact activities: morning and bedtime cares including assisting to brush teeth, showers or baths, incontinence care including briefs changes and hygienic care, care of an indwelling medical device (IV lines, catheters, tube feedings and tracheostomies) wound care, direct physical contact for turning and repositioning or transfers. This did not include use of gowns for setting up oral care, brushing hair, meal deliveries, medication administration, toileting, and ambulation. Finally, the Guideline indicated the resident door should be closed both during and in between care. The Hand Hygiene policy, dated February 2020, indicated hand hygiene should be performed before donning and after removing gloves. The policy further indicated hand hygiene should be performed after touching a resident or touching the resident's surroundings, which included resident furniture or personal belongings and equipment in the environment.