Every finding on record at Ridgecrest Healthcare and Rehabilitation Center

Based on observations, interviews and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents, by failing to ensure that one (Resident #73) of two residents reviewed for smoking, was assessed for safe smoking to prevent accidents prior to smoking on the facility premises. There were 14 residents in the facility who were active smokers.The findings include:On 1/25/26 at 3:30 PM, Resident #73 was observed in the smoking area in the company of three other residents. She was smoking cigarettes and there was no staff member providing supervision.During an interview on 1/26/26 at 11:09 AM, Resident #73 stated she was permitted to smoke between 8:00 AM and 8:00 PM. She mentioned that they (smoking residents) were not normally supervised by facility staff. She stated smoking supplies were to be given to the receptionist after smoking. On 1/26/26 at 3:00 PM, Resident #73 was observed outside smoking. No staff member was supervising.During another observation on 1/27/26 at 11:00 AM, Resident #73 was observed smoking in the facility's designated smoking area. No staff member was supervising.A review of the medical record revealed that Resident #73 was admitted to the facility on [DATE]. Her diagnoses included but were not limited to: Type 2 diabetes mellitus with hyperglycemia, needs for assistance with personal care, chronic pain syndrome, fibromyalgia, nicotine dependence and restless leg syndrome. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/17/25 revealed that the resident had a brief interview for mental status (BIMS) score of 15/15, indicating intact cognition. She had no impairment to her upper or lower extremities noted. A review of the active care plan (revised 12/31/25) revealed that the resident was a smoker based on her history of smoking per the hospital history and physical. Interventions included: Instruct the resident about tobacco use risks and hazards and about smoking/tobacco use cessation aids that were available. Observe clothing and skin for cigarette burns. The care plan also indicated that the resident was able to smoke unsupervised. Smoking supplies were stored at the reception desk.A review of the smoking assessments revealed no smoking assessment for Resident #73.A review of the facility's active smoking list, dated 1/25/26, revealed that Resident #73 was not included on the list.In an interview on 1/28/26 at 2:58 PM, Certified Nursing Assistant (CNA) M stated she was assigned to Resident #73. She explained that the resident was alert, oriented and able to make her needs known. She required a mechanical lift with two-staff member assistance for transfers. She added that the resident smoked unsupervised between 8:00 AM and 8:00 PM.On 1/28/26 at 3:18 PM, Licensed Practical Nurse (LPN) N/Unit Manager, stated the residents were assessed for safe smoking on admission, annually and with any change in condition. She confirmed that Resident #73 was an active cigarette smoker and smoked unsupervised. When she was asked Resident #73's smoking assessment, she confirmed that she could not find a smoking assessment for this resident.In an interview with the Director of Nursing (DON) on 1/28/26 at 4:14 PM, she stated the smoking assessments were conducted on admission, quarterly and with any change in condition. She further stated the smoking assessment determined whether or not residents were safe smokers. She added that most of the active smokers in the facility were deemed safe and smoked unsupervised between 8:00 AM and 8:00 PM. When she was asked if Resident #73 was an active smoker, she said, Yes, she smokes unsupervised and she is always out on the smoking porch. When the DON was asked for the smoking assessment verifying that Resident #73 was a safe smoker, she confirmed that no assessment was available for Resident #73. A review of the facility's policy and procedure titled Safe Smoking Policy (revised 1/1/2021), revealed:Standard: It is the policy of this facility to provide a smoke-free environment for all residents and staff. Visitors and Residents are prohibited from smoking inside any facility buildings. All children and adolescents under the age of 18 are prohibited from smoking. The use of illegal paraphernalia is completely prohibited.Smoking by residents is restricted to a minimum and intended to:- Reduce risks to residents who smoke, including possible adverse effects on treatment;- Reduce risks of passive smoking for others; and- Reduce the risk of fire.Guidelines: Written notice of the smoking policy will be provided and explained to each resident and/or responsible party upon admission and as needed.SMOKING PRIVILEGES:This facility respects resident rights and provides an opportunity for an independent homelike environment that permits the residents to smoke; however, smoking will occur in the designated locations that are environmentally separate from all resident care areas. The designated area is located outdoors with appropriate shelter from excess sun or rain. Electronic vapor cigarettes will be addressed and accommodated per the same guidelines as noted below for actual cigarettes.SMOKING ACCOMMODATION:Smoking should occur in the facility's designated area.The facility accommodates supervised smoking opportunities for residents who require supervision. NOTE - Facility staff may request NOT to participate in smoking supervision duties.Residents that are smokers may not keep lighters/ignition material on their person or in their room unless provided by the nurse to be used during smoking opportunities. Lighters/ignition materials must be maintained at the resident's designated nurses' station or other centralized location specific for this.Smoking is discouraged for health reasons.Residents may not smoke while using ANY form of portable oxygen. The residents deemed as an unsafe smokers will be provided an opportunity to smoke with staff assistance/supervision to provide determined degree of supervision and protective gear.DESIRED OUTCOMES:Resident - The resident who smokes does so in a safe environment and in a safe manner.Staff Members - The IDT (Interdisciplinary Team) determines if a resident is a safe smoker or an unsafe smoker before the resident exercises the privilege to smoke.INTERVENTIONS:Screening - A Safe Smoking Screen is performed on admission for a resident who wishes to smoke.- Assesses the resident's cognitive status to determine if the resident is capable of safe smoking.- Interview the resident to determine their ability to verbalize their understanding that smoking materials are for use in designated areas only.- Observe the resident's ability to smoke in a safe manner.- Reassessment of the resident occurs annually and/or after a significant change in condition, as is needed.- The completed screen is placed in the resident's medical record.

Based on observation, interview and record review, the facility failed to ensure adequate monitoring and assessment of Resident #102's skin integrity to prevent further deterioration. There were two residents reviewed for skin condition from a total survey sample of 44 residents.The findings include:During a facility tour on 01/25/26 at 2:29 PM, Resident #102 was observed with her right hand wrapped with gauze (Kerlix wrap). Her right middle and ring fingers were smeared with blood. The blood penetrated through the gauze and an open area was observed on her lateral ring finger. The nail beds of the fingers of the left hand had red debris that appeared to be blood.In an interview on 01/25/26 at 2:31 PM, Resident #102 confirmed that her right-hand ring finger was bleeding. She could not state what happened or whether or not a dressing change was being done. She stated she had been bleeding for a while.During an observation on 01/26/26 at 12:55 PM, Resident #102 was observed in bed. Her right hand was uncovered; the lateral ring finger and lateral right thumb were bleeding and the resident was holding her hand with a tissue. She stated someone (could not recall the name) unwrapped the gauze and looked at her bleeding finger but never returned.On 01/27/26 at 12:43 PM, Resident #102 was observed in bed. Her right hand had no dressing on it, but the middle digit had blood on it. The resident had used a tissue to wipe the blood and placed the blood covered tissues on her food tray that was on the bedside table.In an interview on 01/27/26 at 12:45 PM, Resident #102 stated no one had provided treatment to her right hand.A review of the medical record revealed that Resident #102 was admitted to the facility on [DATE]. Her diagnoses included, but were not limited to: syncope and collapse, chronic respiratory failure with hypoxia or hypercapnia, CVA (stroke) and chronic obstructive pulmonary disease (COPD).A review of her active Physician's Orders revealed orders for: Clopidogrel 75 mg (milligrams), one tablet daily (QD) for blood clots, dated 12/13/24. Aspirin 81 mg, one tablet QD for anticoagulant, dated 12/13/24.No treatment for the resident's hand/fingers was noted. A review of the resident's Annual Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 11/19/25, revealed that the resident had a brief interview for mental status (BIMS ) score of 13/15, indicating intact cognition. There were no skin-related problems or major joint replacement/surgeries noted. A review of the resident's care plan (revised 08/27/25), revealed that the resident was at risk for abnormal bleeding related to the use of antiplatelet therapy and a history of cardiovascular accident (CVA - stroke). Interventions included: Advise resident/responsible party to report any symptoms of unusual bleeding or bruising. Daily skin inspection. Report abnormalities to the nurse. report to the physician signs and symptoms of bleeding or hemorrhage. Further review of care plan revealed that the resident had potential/actual impairment to skin integrity of the right ring finger, 4th digit. Interventions indicated that the resident had an appointment with a hand surgeon on 08/28/25 at 11:30 AM. Avoid scratching and keep hands body parts from excessive moisture. Keep fingernails short. Keep skin clean and dry.A review of the orthopedic surgeon's notes, dated 08/28/25, revealed: Resident has had right arm numbness as well as stiffness from possibly a stroke and from previous infections. She has numbness for the last several years. She does have a history of cervical spine surgery many years ago. Have recommended an EMG (electromyography) and nerve conduction study to the bilateral upper extremities. She picks at the excoriations causing them to worsen, and I have recommended an arthritis glove to the right hand to try to prevent her from picking at the scabs. Clean daily with soap and water. Follow-up after studies. Follow-up date noted as 10/02/25 at 4:15 PM.A review of the weekly skin checks dated 01/19/26 and 01/26/26 revealed no skin issues noted. In an interview on 01/27/26 at 4:04 PM, Licensed Practical Nurse (LPN) J/ Wound Care Nurse, stated she had been employed by the facility for about a year as the wound care nurse. She stated she was notified of skin issues in different ways such as reports from staff, resident admission notes, new orders reviews, weekly skin checks, and risk management notes. She further explained that once a new issue was identified, the assigned nurse should contact the provider and obtain the initial treatment, notify family and complete a skin note. She added that she reviewed any new issues by the next business day. When asked about Resident #102's wounds, she stated the resident had a deformity of her right hand and had no open wounds. She confirmed that the resident was not on her caseload for wound care. She explained that the resident preferred to have the hand covered for dignity reasons. When asked if the resident had been seen by the orthopedic provider for the deformity, LPN J stated she did not know. When notified that the resident was observed with an open area to her right hand for three days, LPN J reviewed the physician's orders and treatment administration record (TAR), and confirmed that there was no treatment in place or a risk management note about any incident having occurred. On 01/27/26 at 4:28 PM, the wound care nurse was accompanied to Resident #102's room. The resident was observed lying in bed with her right hand wrapped in a napkin. The resident unwrapped the napkin that was saturated with blood revealing her right ring finger and thumb with open skin and a bruise to the lateral and top of the finger near the palm. The resident stated it had been like that for several days and no one had done anything about it. The resident stated she was not sure what happened. The wound care nurse stated the assigned nurse should have obtained an order due to the active bleeding and then notified the family.During an interview on 01/28/26 at 2:15 PM, LPN L stated she was assigned to Resident #102 for the last three days. She further stated the resident was alert and oriented to place, person and time. The resident was incontinent and preferred to stay in bed . She stated she worked through an Agency and was not sure what was wrong with the resident's hand as it was always wrapped in something. She explained that the wound care nurse was responsible for providing any treatments. LPN L stated she was not aware of any follow up needed for Resident #102. She reviewed the physician's orders and stated there were no upcoming appointments.During an interview with the Director of Nursing (DON) on 01/28/26 at 4:14 PM, she stated Resident #102 had chronic wounds to her right hand. She stated the resident picked healed scabs until they bled. She added that the resident should be checked daily and if a wound was bleeding, it should dressed. When she was asked for the orthopedic follow up on 10/02/25, the DON stated she was not sure about that as there was no paperwork. She added that there was an upcoming appointment scheduled in February.A review of the facility's policy and procedure titled Skin and Wounds (revised 1/25/21), revealed:Standard: It will be the standard of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and the treatment of skin impairment.Guidelines:Skin will be assessed/evaluated for the presence of developing pressure injuries or other changes in skin condition on a weekly basis at least once each week or as needed by a licensed nurse.Nurses are to be notified to inspect skin if newly developed skin changes are identified.The admission evaluation may identify pre-existing signs (such as purple or very dark area that is surrounded by profound redness, edema or induration) suggesting that deep tissue damage/injury has already occurred and additional deep tissue loss may occur which may lead to the appearance of an unavoidable pressure injury or progression of skin impairment related to trauma or pressure prior to admission to the facility.The comprehensive assessment, which includes the Resident Assessment Instrument (RAI)/Minimum Data Set (MDS), may be used to evaluate the intrinsic risks, skin condition and other causal factors which place resident at risk for developing pressure injuries and/or experiencing delayed healing to which the resident may be subjected.Wound care procedures and treatments should be performed according to physician orders.Wound care treatment should maintain proper technique, as is indicated by the type of wound and physician orders.Preventative measures, such as barrier creams, can be employed to help maintain skin integrity as well as utilization of pressure relieving surfaces, floating heels, protective boots and use of positioning devices. Use of barrier creams may vary according to product and may be used following incontinent care for additional prevention, provided there is no clinical contraindication.Document in the clinical record when treatments are performed.Document the progression of the wound being treated. Such observations should include items size, staging (if applicable), odors, exudate, tunneling, etiology, etc.Contact the physician for additional order changes as is appropriate or to notify of skin condition changes or refusals of care.The presence of skin impairment should be denoted on the person-centered plan of care.

Based on observations, interviews, medical record reviews, and a review of facility policies and procedures, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to 1) Remove visible soil from one (room [ROOM NUMBER]) of 23 enhanced barrier precautions (EBC)-designated resident rooms for two consecutive days, and 2) Follow hand hygiene practices consistent with accepted standards of practice during residents' lunch meal service.The findings include:1.On 1/25/26 at 11:26 AM, resident room [ROOM NUMBER] was observed with multiple areas of a brown-colored substance, resembling feces, on the floor in the center of the room that were visible from the hallway.On 1/26/26 at 10:00 AM, another observation of resident room [ROOM NUMBER] was made. The floor remained soiled with the same multiple areas of brown-colored substance in the center of the room as were there on 1/25/26 at 11:26 AM. On 1/27/26 at 1:50 PM, an interview was conducted with Housekeeper O, who reported that she had only been employed by the facility for a few months now. She confirmed that she was assigned to service resident room [ROOM NUMBER] and reported no trouble cleaning that room each shift she worked. On 1/28/26 at 1:04 PM, an interview was conducted with Certified Nursing Assistant (CNA) G, who stated she washed her hands, sanitized, and followed the guide on the door for EBP-designated rooms to decrease the spread of infection. She further stated the housekeeping staff were responsible for maintaining the overall cleanliness of the facility, including resident rooms.On 1/28/26 at 1:27 PM, Licensed Practical Nurse (LPN) I was interviewed. She stated any concerns with infection control were reported to the Assistant Director of Nursing (ADON), who was also the facility's Infection Preventionist. Activities of Daily Living (ADL) care for the residents was provided by the assigned CNAs and included getting the residents up and out of bed, showered, dressed, and linens changed. The housekeeping staff were responsible for cleaning the residents' rooms, collecting the trash and mopping the floors each day and when there was a spill or an accident - that should be cleaned up immediately. She further stated resident rooms were not being cleaned thoroughly or consistently as they should.On 1/28/26 at 3:48 PM, an interview was conducted with the Director of Nursing (DON), who reported that she was the facility's infection preventionist, and it was her expectation that resident rooms were cleaned daily to help prevent the potential spread of infection. She acknowledged the environmental concerns, and stated there was an Environmental Performance Improvement Plan (PIP) in place; however, infection control and prevention was not covered in that plan. She further stated she would be updating the current PIP to include resident room and care areas. On 1/28/26 while providing a copy of the facility's PIP documentation titled F584/Physical Environment Clean and Homelike/F585 Grievances (Environmental), the facility Administrator confirmed that infection control environmental concerns were not covered in the PIP. 2. On 1/27/26 at 12:15 PM, the lunch meal service was observed taking place in the main dining room and for the 200-hall nursing unit. In the main dining room, a rolling cart was observed with a grey-colored bin filled partially with ice. Three beverage pitchers of different colored liquid (with paper identifying labels) were resting inside the bin with the ice visibly surrounding the pitchers. The cart was situated at the front of the dining area. Staff were observed picking up the pitchers to pour drinks in resident cups and then placing the pitchers back into the grey bin with ice. Meal trays were observed on the 200-hall nursing unit at 1:00 PM. At 1:16 PM, trays were delivered to the dining room where nine residents were seated. At 1:25 PM, the ADON was observed coming into the dining room with her hands resting on her hips. She asked if there was anything she could do. A resident seated at the table asked for a straw. The ADON was observed picking up a paper-covered straw with her bare hands. She held the top of the straw with one hand and ripped the paper off the bottom of the straw with her other hand. She proceeded to place the bottom of the straw, that she was now holding with her bare hand, into a cup, when the Resident stated, Hey, you touched my straw with your hand. The ADON chuckled and replied, No, I didn't touch your straw with my hand, you're always playing. The ADON then left the dining room. On 1/27/26 at 1:39 PM, the ADON returned to the dining room. With her bare hands, she reached into the grey bin located on the nourishment cart with the three drink pitchers. She scooped ice from that bin, using a clear cup, into a white Styrofoam cup. She then took the pitcher that was labeled Tea and began pouring into the cup she just placed the ice into. She then walked out of the dining room.On 1/27/26 at 2:02 PM, an interview was conducted the ADON, who reported that she was training to be the facility's infection preventionist. She reported that during meal service, she would round and assist with tray deliveries. The CNAs usually passed drinks before the meal trays arrived using the nourishment cart that had the grey bin/container with ice, and drink pitchers provided by the kitchen staff at each meal service. They cleaned the bin, filled the bin with the ice, drink pitchers were also filled and placed in the ice, and then the kitchen staff brought the beverage cart to the floor. The ADON reported that the ice bin was used to keep the drink pitchers cold, but the ice we use if the resident request ice in their drinks. She was asked if it was normal practice to use bare hands and a plastic cup when providing beverages to residents with ice. She replied, Yes, we use that small plastic cup in the bin to scoop the ice from the bin. I was asked by a resident for a drink when I was walking by, so I came back, and that's when you saw me scoop the ice. Then I poured him some tea and provided him with the requested drink.On 1/28/26 at 1:04 PM, an interview was conducted with CNA G, who reported that the facility utilized a nourishment cart during mealtimes. The dietary team brought the cart to the nursing unit up to an hour before the meal service. Pitchers contained coffee, tea, water, and the cart also had hot chocolate packets on it. The ice she got from the ice machine located on the 100-hall, because the 200-hall's ice machine was broken. CNA G stated she would never grab ice from the grey bin that held the drink pitchers, because that ice was just to keep the drink pitchers cool. That's nasty and contaminated. She could not recall if she received training on this topic specifically, but she stated, I thought that was just common sense. On 1/28/26 at 1:27 PM, LPN I was interviewed. She stated the CNAs were responsible for passing out nourishments. Water was located on the nursing unit and was refilled throughout the day. The ice came in a cooler from the 100-hall unit because the ice machine on the 200-hall was not working. The kitchen staff brought drinks during mealtimes on a beverage cart. Juice, coffee and iced tea were poured in pitchers that were set in ice in a container/bin to keep the drinks cold. No cup should be sitting in the bin holding that ice, because that was dirty ice. That ice should never be served to a resident. She reported never seeing anyone use the ice in those containers/bins for resident drinks and would report it immediately if she did.On 1/28/26 at 3:48 PM, an interview was conducted with the Director of Nursing (DON), who confirmed that all staff, both clinical and non-clinical, received infection control and prevention training to include hand hygiene training prior to working on the floor with no exceptions. She reported that she was shocked when she was made aware of a hiccup during tray pass yesterday with hand hygiene, and that concern had now been incorporated into a PIP with education provided with the ADON.A review of the facility's policy and procedure titled Infection Prevention and Control Program Manual-Infection Prevention and Control Program (Revised 1/20/2024), revealed: The primary mission is to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The policy interpretation and implementation indicated: Page 1, 2) c. Standard and transmission-based precautions to be followed to prevent the spread of infections. h. The hand hygiene guidelines to be followed by staff involved in direct resident contact. Page 10. 2) Practices: b. Assure that products and guidelines for cleaning and disinfection of surfaces and equipment are appropriate. c. Managing food safety, including employee's health and hygiene, pest control, investigating potential food-borne illnesses.

Based on observations, interviews and record review, the facility failed to ensure actions documented in a performance improvement plan (PIP) for pest control were implemented, measured for success, and tracked performance to ensure that improvements were realized and sustained, based on failure to maintain a sanitary, orderly, and comfortable interior free of pest for two (room [ROOM NUMBER] and #230) of four rooms sampled. There were 121 residents residing in the facility at the time of this survey. The findings include: On 06/12/25 at 11:03 AM, a live roach was observed in Resident #1's room (room [ROOM NUMBER]B), near the corner of the room. (Photographic evidence obtained) On 06/12/25 at 12:13 PM, a fly was observed on Resident #5's bed (room [ROOM NUMBER]B) along with live and dead roaches observed behind the resident's oxygen concentrator located in the corner of the resident's room. (Photographic evidence obtained) On 06/12/25 at 12:17 PM, the same fly was observed, unmoved and in the same location on the resident's bed. The resident and his roommate said that they informed the facility staff of insects in the room. (Photographic evidence obtained) On 06/12/25 at 2:18 PM, eight small ants were observed on the wall adjacent to Resident #1's bed (room [ROOM NUMBER]) and under the light fixture above the resident's bed. (Photographic evidence obtained) Resident interviews conducted on 06/12/2025 from 10:31 am to 11:03 am with four alert and oriented residents (Residents #2, #3, #4 and #5) noted pests have been observed in their rooms and staff were informed about the pests and they continue to see pests in their room. Staff interviews conducted on 06/12/2025 from 11:32 am to 11:57 am with Certified Nursing Assistant (CNA) A, Licensed Practical Nurse (LPN) B, and Contracted Aramark housekeeping staff member C noted they have seen pests in resident rooms and have noted their observations in the pest sighting binders located at the nurse's stations. On 06/12/25 at 4:00 PM, an interview was conducted with the Director of Maintenance. He reported that he worked at the facility for approximately one year. He stated that he had not noticed bugs in the facility, but this is Florida. He further explained that staff are supposed to write pest sightings in the binders at the nurse's stations. He said that he doesn't look in the pest sighting binders located at the nurses' stations, and that the pest control company is expected to review the pest sighting binders and treat the areas noted in the pest sighting binders. He further explained the facility and the pest control company have a comprehensive treatment plan to treat pests at the facility. Part of that plan included a recent treatment in March in which two holes were drilled into one resident's wall, and insecticide sprayed behind the wall. They began this process on the north side of the 200 hall and wanted to begin the process on one side of the facility. The process includes clearing out the entire wing and have residents out of the rooms for two hours. He stated that the process has only been done once because he has been pulled off to do other projects. On 06/12/25 at 5:15 PM, an interview was conducted with the Administrator. She said that she started employment with the facility on 08/31/23. She explained that a Performance Improvement Plan (PIP) for Pest Control, was created on 08/13/23, and is currently ongoing. She further explained that the PIP was initiated after the facility received grievances related to pest control and the facility was cited for lack of pest control. The PIP included changing pest control vendors. The pest control company comes to the facility twice a week or more after pest sightings. Treatments include spraying the outside and inside of building. The expectation is that the pest control company goes through the pest sighting logs located at the nurse's stations. Recently, the pest control company conducted an interior wall spray which requires moving the resident out of the room for three hours. Every hallway and common area of the building are sprayed. A while back, a deep spray was done overnight in the kitchen while it was closed. An internal wall spray is currently being done on the low side of the 100 hall. The pest control company is scheduled to do a wall spray on high side of hall 100. During the wall spray, two guys go into the room, drill a hole, the pest control company sprays, and maintenance closes the hole in the wall. She further explained that the facility had no had grievances related to pests since the beginning of the year. Review of the Performance Improvement Plan (PIP), dated 08/13/23, documented Objective and Goal: Pest Control - Improving knowledge on how to prevent pests, and how to report pests, and actions to be taken when pest or root causes of pest are identified. Areas noted for Improvement: -Knowledge of deficit related to prevention of pests -Knowledge of appropriate ways to report pests or root causes of pests -Knowledge of appropriate actions taken when pests are identified. Initiative: 1. Immediate interventions to ensure safety of affected residents. 2. Identification of any other residents who may be affected or at risk. 3. Interventions put in place to prevent future reoccurrences 4. Plan for future follow-up to ensure that interventions are working. Action Steps: Current Pest control company to inspect and review the facility for the following Facility assessment to identify vulnerabilities and action area Action plan and timeline to implement and added to this PIP Responsible Person(s): ED/Plant Ops. Target Date: Ongoing Status: Switched to pest control company .Unit by unit deep treatments being done beginning of 2024. 2/2024 full kitchen treatment. Action Steps: Room Audit. All rooms to receive observation audit to identify and report signs of pest . Responsible Person(s): ED/Plan Ops Target Date: Ongoing Status: Angel rounds ongoing, staff placing pest sightings of live bugs in pest books at nurses station Status: 2025 Plan Updates- Wall penetration treatment to be completed by [NAME] and Maintenance starting 05/2-25 starting with 200 hall All rooms internal deep treatments being done beginning of 2025 Outdoor treatment being done around perimeter of (blank). *Review of the facility's pest control invoices and other documents related to pest control, lacked documented evidence of the PIP related to Initiative: . 4. Plan for future follow up to ensure that interventions are working. *Review of Pest Control invoices lacked documented evidence of Action plan and timeline to implement and added to this PIP .Unit by unit deep treatments being done beginning of 2024. *Review of the Guardian Angel Checklist lacked documented evidence the Action Step titled, Room Audit. All rooms to receive observation audit to identify and report signs of pest was followed. Below is evidence of Guardian Angel Rounds Daily Checklist provided by the facility: Guardian Angel Rounds Daily Checklist Reviewed Guardian Angel Rounds for rooms: 206 207, 208 and 209, signed by the Director of Maintenance with the following dates: 01/10/25, 01/13/25, 01/20/25, 01/26/25 02/04/25, 02/12/25, 02/17/25, 02/24/25 03/04/25, 03/11/25, 03/17/25, 03/24/25, 03/31/25 04/07/25, 04/14/25, 04/21/25, 04/30/25 05/08/25, 05/12/25, 05/21/25, 05/24/25 06/04/25 Review of the PIP Action Steps: Room Audit (Guardian Angel Rounds) lacked documented evidence that all rooms received an observation audit to identify and report signs of pest. The Guardian Angel Rounds checklist contained the following information: DAILY CHECKLIST Call light within reach, check function Water pitcher filled with correct consistently, dated today Resident is clean, dry and odor free Glasses on and clean Hearing aid in Nails clean and trimmed Shaved Oral hygiene good Resident hair clean and combed No meds or creams at bedside Curtain drawn if treatment or care done, curtain stain-free No bedpans on handrail in bathroom Hygiene items labeled and separate from roommate No aerosol, chemicals, other non-approved items in room Ensure room is in good condition . check holes, painting, needs, rust (toilet, wheelchair, commode) Room and bathroom clean/unobstructed path Ensure no heaters or fans Cords are arranged to prevent trips and falls* WEEKLY RESIDENT INTERVIEWS : Does staff treat you in a kind and caring manner? Has anyone acted rude to you? Have you heard anyone spoken rudely to? Is your call light answered timely? Do you feel staff listens and responds timely? Do you get help when needed? Is the food good? Is the food at the appropriate temps? Do you have discomfort now or have you been having discomfort such as pain, heaviness, burning, or hurting with no relief? Are you offered an evening snack? Have there been any problems with a roommate or any other resident? Were they addressed? Were you encouraged by staff to bring in any personal items? Have you had any missing personal items? Did you report those missing items to staff? Resolved or still pending? Do you receive the fluids you want between meals? Can you get your money when you need it, including on weekends? Reviewed PEST PREVENTION SERVICE REPORT Service Date: 06/16/2025 Order Number: 65762426 Time In: 01:42 PM; Time Out: 02:04 PM General Comments / Instructions on 04/18/25 hall 200 rooms 201-215 all rooms where treated with liquid residual spot treat by drilling holes in wall and applying treatment between walls and between rooms the. holes being patched back up by maintenance for ongoing activity residents removed from rooms for 3 hours recommended by tech for treatment month of [DATE] week 1 treated lobby, common areas in wing 200 break rooms tv rooms and activity rooms wing 100 rooms and go backs to all areas at nurses station and common areas break rooms, activity rooms and patient rooms of wing 300 and request in book at nurses station week 3 Receiving, laundry, kitchen follow up and common areas of wing 100 and patient rooms nurses station book checked : 4 bunding of exterior 10 feet from building outside patio landscaping replacement of bait In rodent bait stations checked all nursed stations for request Pest Totals Pest Activity: 0 .

Based on observations, interviews, record review, and facility policy and procedure review, the facility failed to maintain an effective pest control program to ensure the facility is free of pests for two (room [ROOM NUMBER] and #230) of four rooms sampled. The findings include: On 06/12/25 at 11:03 AM, a live roach was observed in Resident #1's room (room [ROOM NUMBER]B), near the corner of the room. (Photographic evidence obtained) On 06/12/25 at 12:13 PM, a fly was observed on Resident #5's bed (room [ROOM NUMBER]B) along with live and dead roaches observed behind the resident's oxygen concentrator located in the corner of the resident's room. (Photographic evidence obtained) On 06/12/25 at 12:17 PM, the same fly was observed, unmoved and in the same location on the resident's bed. The resident and his roommate said that they informed the facility staff of insects in the room. (Photographic evidence obtained) On 06/12/25 at 2:18 PM, eight small ants were observed on the wall adjacent to Resident #1's bed (room [ROOM NUMBER]) and under the light fixture above the resident's bed. (Photographic evidence obtained) Resident interviews conducted on 06/12/2025 from 10:31 am to 11:03 am with four alert and oriented residents (Residents #2, #3, #4 and #5) noted pests have been observed in their rooms and staff were informed about the pests and they continue to see pests in their room. Staff interviews conducted on 06/12/2025 from 11:32 am to 11:57 am with Certified Nursing Assistant (CNA) A, Licensed Practical Nurse (LPN) B, and Contracted Aramark housekeeping staff member C noted they have seen pests in resident rooms and have noted their observations in the pest sighting binders located at the nurse's stations. Review of the facility's 2024 and 2025 pest sightings log for halls 100, 200 and 300 documented 13 roach sightings in resident rooms in the 100 hall, 12 roach sightings in resident rooms in the 200 hall; and 14 roach sightings in resident rooms in the 300 hall. Further review of the pest sighting log documented roach sightings were observed in room # 230 on 08/22/24, 08/23/24, 01/13/25 and 02/05/25. Review of the Pest Control Service Agreement dated 03/09/23, documented monthly pest prevention service agreement, Scope of Work: roaches, ants, mice, rats and fire ants. Areas to be serviced: initial service to include- German roach cleanout of kitchen and 30 rooms on level 2 with (3) 2-week follow-ups, 4 x a month, regular service including. First visit [NAME], common areas, and ¼ of rooms. Second visit kitchen and ¼ rooms. Third visit: exterior of building up to 10 feet with rodent stations services, common areas spot treated for fire ants, and entryways swept for reachable spiders, and wasps and ¼ rooms. Fourth visit kitchen and ¼ rooms. Every visit to include inspection of logbook and no change callback services. Review of monthly invoices lacked documented evidence rooms identified in the pest sighting log located at the nurses were treated for pests. Review of Service Special Agreement dated 10/21/24, documented the pest control company will provide a special treatment for the pests in the kitchen: Roach Cleanout. Review of monthly invoices for 12/18/24 documented, common pest prevention for each month. Invoices were dated 1/15/25 , 2/5/25, 3/26/25, 4/2/25 and 5/7/25. Review of Pest Prevention Service Report dated 05/24/25 documented: exterior rodent bait station, and boundary inspection Point total: 13. Inspection Point Detail: perimeter. Pest Activities Totals: 0. Areas of Concern (Conditions, Avenues ;and Sources Identified as Potential Pest Activity: was blank. Review of Pest Prevention Service Report dated 05/29/25 documented the main interior was treated. General comments: inspected service applied liquid residual spot treat and gel bait to interior rooms, kitchen and common area applied. Pest Activity Totals: 0. Areas of Concern (Conditions, Avenues and Sources Identified as Potential Pest Activity: was blank. Review of Pest Prevention Service Report dated 05/16/25 documented the main interior was treated. General comments: inspected service applied liquid residual spot treat to patient rooms and gel bait in sink areas as needed treated. Pest Activity Totals: 0. Areas of Concern (Conditions, Avenues and Sources Identified as Potential Pest Activity: was blank. Review of Pest Prevention Service Report dated 05/16/25 documented the exterior perimeter was treated. Pest Activity Totals: 0. Areas of Concern (Conditions, Avenues and Sources Identified as Potential Pest Activity: was blank. Review of Pest Prevention Service Report dated 04/02/25 documented the exterior perimeter was treated. Pest Activity Totals: 0. Areas of Concern (Conditions, Avenues and Sources Identified as Potential Pest Activity: was blank. Review of Pest Prevention Service Report dated 3/28/25 documented the exterior perimeter was treated. Pest Activity Totals: 0. Areas of Concern (Conditions, Avenues and Sources Identified as Potential Pest Activity: was blank. Review of Pest Prevention Service Report dated 02/19/25 documented an interior preventative treatment. Pest Activity Totals: 0. Areas of Concern (Conditions, Avenues and Sources Identified as Potential Pest Activity: was blank. Review of Pest Prevention Service Report dated 02/05/25 documented the exterior perimeter was treated. Pest Activity Totals: 0. Areas of Concern (Conditions, Avenues and Sources Identified as Potential Pest Activity: was blank. Review of Pest Prevention Service Report dated 01/25/25 documented an interior preventative treatment. Pest Activity Totals: 0. Areas of Concern (Conditions, Avenues and Sources Identified as Potential Pest Activity: was blank. Review of the facility's policy and procedure entitled, Pest Control Program dated 3/01/2021 read: It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Definition: Effective pest control program is defined as measures to eradicate and contain common household pests (e.g. bed bugs, lice, roaches, ants, mosquitos, flies, mice and rats). Guidelines: 4. Facility will utilize a variety of methods in controlling certain seasonal pests i.e., flies. These will involve indoor and outdoor methods that are deemed appropriate by the outside pest service and state and federal regulations. (Copy obtained) .

Based on observations and staff interviews, the facility failed to ensure the ice machines in 3 of 3 dining rooms had clean and sanitary ice dispensers free from contamination. Failure to clean and sanitize the ice machines is important in health care settings serving nursing home residents due to the risk of serious complications from foodborne illness because of their compromised health status. Unsafe food handling practices represent a food safety hazard and a potential source of pathogen exposure for residents. Resource: 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned: (E) Except when dry cleaning methods are used as specified under S 4-603.11, surfaces of UTENSILS and EQUIPMENT contacting FOOD that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cleaned:(4) In EQUIPMENT such as ice bins and BEVERAGE dispensing nozzles and enclosed components of EQUIPMENT such as ice makers, cooking oil storage tanks and distribution lines, BEVERAGE and syrup dispensing lines or tubes, coffee bean grinders, and water vending EQUIPMENT: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold. United States Food and Drug Administration Food Code, U.S Public Health Service 2017 http://www.fda.gov/cder/approval/index.htm The findings include: During a tour of the [NAME] Unit dining room on 2/14/2023 at 11:45 AM, the ice machine dispensing shoot was observed to have a dark brown biological substance and a yellow biological substance growing inside of it. (Photographic evidence obtained) Residents on the unit were in the dining room waiting for the lunch meal to be served. Three certified nursing assistants (CNAs) were observed dispensing ice from the machine into the glasses and serving the residents the drinks. On 2/14/2023 at 11:50 AM, an interview was conducted with Employee F, CNA who was working in the [NAME] Unit dining room at lunch. After being shown the biological growth on the shoot of the ice machine, she confirmed it was a biological growth, and said, That should not be there, I was not unaware of it, Oh, that's gross! She stated, they could not give the residents ice out of the machine until it was cleaned. She stated, We can get ice from the ice machine in the kitchen and put it in a cooler until they clean it. She was not sure who was responsible for cleaning the ice machine or when it was cleaned last. During an interview on 2/14/2023 at 11:52 AM with Employee D, CNA, she looked up into the ice machine shoot and expressed disgust at the sight of the biological growth. She stated, she had no idea that it was there. She confirmed, she was not responsible for the cleaning of the ice machine and that they use it to dispense ice for the residents' drinks at meal time and for the water cups in their rooms. 30969 During an inspection of the ice machine in the main dining room on 2/14/2023 at 12:20 PM, the clear plastic chute of the machine was coated with copious amounts of pink, orange, brown and black slimy biological growth. (Photographic evidence obtained) On 2/14/2023 at 12:55 PM, an inspection of the ice machine on the 300 hall was attempted, however, the maintenance assistant had disassembled the machine and was cleaning it. He confirmed he was made aware of the condition of the ice machines. When asked who was responsible for cleaning the machines on each unit and how often they were to be cleaned, he said, maybe maintenance, maybe housekeeping. He did not know. During an interview with the Maintenance Director on 2/14/2023 at 2:34 PM, he stated, he was not aware of the ice machines having biological growth in the shoots. He was not sure if the facility had a contract with any company to clean the ice machines. He stated, he thought it was the maintenance department's duty to clean them on a quarterly basis but he did not keep a log of the cleanings. He explained that he had a tool to clean the shoots and he would clean them all today. When asked if there was an ice machine cleaning/maintenance policy, he replied, No. Review of the 2022 U.S. Food and Drug Administration Food Code found it states under section 204.17: Ice Units, Separation of Drains. Liquid waste drain lines passing through ice machines and storage bins present a risk of contamination due to potential leakage of the waste lines and the possibility that contaminants will gain access to the ice through condensate migrating along the exterior of the lines. Liquid drain lines passing through the ice bin are, themselves, difficult to clean and create other areas that are difficult to clean . The potential for mold and algal growth in this area is very likely due to the high moisture environment. Molds and algae that form on the drain lines are difficult to remove and present a risk of contamination to the ice stored in the bin.

Based on observations, interviews, record review, and facility policy and procedure review, the facility failed to maintain an effective pest control program to ensure the facility was free of pest. Failure to maintain an environment free of pests may lead to transmission of disease and infection. The findings include: On 2/14/2023 at 11:30 AM, a live cockroach (roach) was observed in the bathroom of room [ROOM NUMBER]. (Photographic evidence obtained) On 2/14/2023 at 11:35 AM, a live roach was observed crawling on the floor in room [ROOM NUMBER] next to the A bed. (Photographic evidence obtained) During a tour of the [NAME] Unit dining room on 2/14/2023 at 11:40 AM, dead roaches and live spiders were observed in cabinets under the counter where the food and drinks are placed and prepared for service. (Photographic evidence obtained) During an interview on 2/14/2023 at 11:50 AM with Employee F, CNA working in The [NAME] Unit dining room at lunch, she was shown the dead roaches and two live spiders under the counter where the food and drinks for the residents are placed for the meal service. She stated, they see live roaches in the dining room and in the resident rooms on this unit. They are supposed to report it when they see them and put it on the Pest Sighting Log. She did not think it was her responsibility to clean up the dead roaches. During an interview on 2/14/2023 at 11:53 AM with Employee D, CNA, she stated, she sees live roaches on a regular basis. They are supposed to write it on the Pest Sighting Log when they see them, so the pest control company knows where to spray. She was not told to clean up the dead roaches. She thinks housekeeping does that. During an interview on 2/14/2023 at 11:55 AM with Employee E, CNA, she stated, she also sees live roaches on a regular basis. She was unaware of the dead roaches and live spiders in the cabinets in the dining room. She was told to write it on the Pest Sighting Log when she sees them. During an interview with Employee C, Licensed Practical Nurse (LPN) on 2/14/2023 at 12:20 PM, she confirmed she sees roaches on The [NAME] Unit. She stated that the facility has a pest control company, they come out and spray, but she still sees them. A review of the Pest Sighting Logs for the facility dated from 12/01/2022 through 1/14/2023 revealed multiple staff sightings and family reports of sightings of roaches and ants in all areas of the building. Review of the contracted pest control contract for service dated 3/31/2021 revealed it read: Covered Areas: Interior and immediate exterior perimeter. Covered Pests: Cockroaches, ants, spiders, rats, mice, stinging insects and occasional invaders. General Scope Includes: Interior inspection and treatment of dietary and common areas, preventative baiting, dusts and crack/crevice treatment in common pest entry areas and harborages. Addressing any current pest issues and responding to work orders - Patient rooms as needed. Exterior service - 3 feet up and out liquid treatment, 6 feet out granular treatment, and removal of spider webs, wasps nests and mud daubers up to 15 feet. Extreme infestations may require additional services. Additional Notes: This facility requires an initial intensive inspection/treatment for German Roaches. Service Frequency - On property 2 times per month. 4. Customer's responsibility to correct conditions conductive to pest infestations: [Contracted Company] will notify customer of the need to correct or eliminate certain identified conditions in or around the facility that are conductive to an infestation by a serviced pest. (Copy obtained) Review of the contracted pest control last receipt for service dated 2/02/2023 revealed it read: Pest Activity: None noted. Multiple conditions requiring corrective action by the facility were noted on the receipt. The areas of concern were in the kitchen, back door, and outer perimeter of the facility. The Comments section read: Interior: Today I treated the interior and exterior of the establishment. I spoke with management who told me of room with roach concerns. Treated each callback for German roaches. Found two nests in room [ROOM NUMBER] and 233. With the assistance of [staff member] performed a clean-out in both rooms with vacuum and igr. Treated interior area with roach gel and preventative measures. Noticed many openings throughout business that were documented in the photo folder. You should expect to see minimal activity moving forward. Sealing gaps and openings throughout the business will help prevent pests form making nests in the future. (Copy obtained) Review of the contracted pest control receipts for service revealed the facility was serviced on 1/19/2023, 1/05/2023, 12/15/2022, 12/08/2022, 12/06/2022, 12/01/2022. Upon each service receipt the conditions requiring action by the facility were the same and no pest activity was noted. During an observation of Resident #2's room on 2/14/2023 at 2:30 PM, a family member came to visit him. During a brief interview, the family member reported the roaches in Resident #2's room come and go. During an interview with the Maintenance Director on 2/14/2023 at 2:34 PM, he stated, he had worked at this facility for one year. He confirmed, he was aware of the live roaches in the building. He acknowledged that residents and staff have told him about the roaches and that he had seen them as well. He was not aware of the live spiders in The [NAME] Unit dining room. He explained that the contracted pest control company is looking at the logbooks on each nursing unit to see which rooms have roaches. They then spray those rooms only. He confirmed the last time the pest control company treated for roaches was 2/03/2023. He is not happy with the pest control company and wants to get a different company. He wants them to treat a whole wing each time they are here instead of just the rooms on the log. He knows the roaches run to other rooms when a room is sprayed. You won't get rid of them just spraying the rooms where they are seen. He knows the building is infested with roaches. He stated it has been that way since he started here a year ago. He talked to the company on 2/11/2023 to have them start spraying a whole wing at time. They have not done it yet. He acknowledged there is a problem with the pest control program and that it is not effective. Review of the facility's policy and procedure entitled, Pest Control Program dated 3/01/2021 read: It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Definition: Effective pest control program is defined as measures to eradicate and contain common household pests (e.g. bed bugs, lice, roaches, ants, mosquitos, flies, mice and rats). Guidelines: 4. Facility will utilize a variety of methods in controlling certain seasonal pests i.e., flies. These will involve indoor and outdoor methods that are deemed appropriate by the outside pest service and state and federal regulations. (Copy obtained) 30969

Based on observations, interviews, record reviews, and facility policy and procedure review, the facility failed to ensure that drugs and biologicals used in the facility were safely stored for two (Resident #4 and #1) of nine residents sampled for unsecured medications. The findings include: 1. During an interview with Resident #4 on 2/14/2023 at 9:45 AM, a large white oval pill was observed on her overbed table. (Photographic evidence obtained) Resident #4 speculated it was her muscle relaxer. She stated, The morning nurse often leaves pills in my room. A medical record review for Resident #4 indicated she was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD) with chronic exacerbation, acute respiratory failure with hypoxia and unspecified fracture of the upper end of her left humerus. A review of physician's orders for Resident #4 included an order dated 2/8/2023 for Glucophage (Metformin) 1000 milligrams twice a day at 0900 (9:00 am) and 2100 (9:00 pm) for diabetes. No orders were found stating Resident #4 could self-administer her medication. On 2/14/2023 at 2:00 PM, an interview was conducted with Employee T, Unit Manager and Licensed Practical Nurse (LPN) concerning medications left in resident rooms. She stated, residents must have a physician's order to keep medication at bedside or to self-administer their medications. On 2/14/2023 at 2:05 PM, an interview was conducted with Employee R, Registered Nurse (RN) assigned to Resident #4. Employee R was asked to review Resident #4's medications to identify the white oval pill left on the overbed table this morning. Using the photographic evidence and pharmacy issued blister packs of medicines, Employee R positively identified the white pill as Metformin (a medication used to treat diabetes). When Employee R was asked if she was supposed to stay with her residents while they took their medication. She replied, Yes, always. Employee R had had no explanation why she left the pill in Resident #4's room. A review of Resident #4's medication administration record (MAR) found her morning dose of Glucophage (Metformin) was signed off as administered by Employee R on 2/14/2023. (Photographic evidence obtained) During an interview with the Director of Nursing (DON) on 2/14/2023 at 3:10 PM, she stated, she was unsure what the policy for self-administration of medication and medication storage was. After reading the policies and reviewing Resident #4's record, she confirmed that Resident #4 did not have an order for the self-administration of her medication. The DON also acknowledged that the medication should not have been left in the resident's room. 30905 2. On 2/14/2023 at 11:40 AM, a tube of zinc oxide ointment (a medicated cream) was observed lying on top of the Resident #1's dresser in his room. The medicated cream had no label from the pharmacy indicating it was for Resident #1's use. (Photographic evidence obtained) During an interview with Employee C, LPN on 2/14/2023 at 4:00 PM, she confirmed the tube of zinc oxide was in Resident #1's room. She went in his room and picked it up off the shelf on the dresser and confirmed the medicated cream did not have a label from the pharmacy indicating it was for Resident #1's use. (Photographic evidence obtained) She stated, We always have kept this in the resident's room. Is it supposed to be in the cart? She dropped it in a plastic storage bin on the resident's dresser and left the room without taking it to the cart. (Photographic evidence obtained) A review of physician's orders for Resident #1 included an order dated 1/1/2023 for house barrier cream. Apply to buttocks/coccyx as needed for preventative. (Photographic evidence obtained) A review of the facility's Standards and Guidelines: Medication Storage implemented, reviewed, and revised on 3/1/2021 revealed: 1. Medications, drugs and biologicals shall be stored in packaging, containers or other dispensing systems in which they are received, unless otherwise necessary. 2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner . 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing medications, drugs and biologicals shall be locked when not in use and trays or carts used to transport such items shall not be left unlocked if out of a nurse's view. (Photographic evidence obtained)

Based on observations, interviews, record reviews, and facility policy and procedure review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility failed to ensure the dishwashing machine was operating at the required temperatures, sanitizer was at correct levels, and thermometer was in tray line refrigerator. The findings include: On 03/07/22 at 3:00 PM, Employee I, Dietary Aide, was observed running the dishwashing machine. Employee I was asked what temperature the machine should be at for washing dishes, he stated, I have no idea. On 03/07/22 at 3:05 PM, the Certified Dietary Manager (CDM) entered the kitchen and was asked about the dishwashing machine. The CDM stated, it was a low temperature machine. The CDM was asked to check the sanitizer level and dish machine temperatures at this time. The sanitizer strip was observed at 10 PPM, wash temperature read 140 F, the rinse read 150° F, and final rinse gauge was at 190 °F. During this time, the dishwashing machines manufacturer's sticker was observed and read: wash tank minimum temperature 140° F and final rinse minimum temperature of 120° F. (Photographic evidence obtained) A review of the dishwashing machine temperature log for March 2022 revealed the wash temperatures ranged from 124° F to 127° F and rinse temperatures ranged from 126° F to 128° F (Photographic evidence obtained). The CDM was observed asking kitchen staff about the temperatures of the machine, but no one answered her. She stated, she would have to go to paper products if she couldn't figure out why the temperature of machine was high. She stated, she would call a repairman. On 03/7/22 at 3:20 PM, the Regional CDM was asked to show the thermometer in the tray line refrigerator. He was unable to locate it. He went to the office and returned with a thermometer for the refrigerator. On 03/7/22 at 3:45 PM, the CDM reported that she spoke with dishwasher repairman. He told her the final rinse should not be higher than 170° F and the temperature booster had been turned on. The CDM was unable to explain why the booster had been turned on. She reported, she turned off the booster and the dishwasher's temperatures were at normal levels. During a second visit to the kitchen on 03/09/22 at 12:10 PM, the CDM was asked about the dishwashing machine. She reported the staff had been looking at the wrong temperature gauges when filling out the temperature log form. She reported that an in-service was conducted with the staff on 03/08/22. On 03/09/22 at 12:30 PM, the CDM was observed running the dish machine. The dishwashing machine cycled 9 times before the machine reached the temperature of 140° F wash and 135° F at rinse. The CDM tested the sanitizer strip which turned a light purple color indicating a low sanitization level of 10 PPM. On 03/10/22 at 11:15 AM, the administrator was made aware of the ongoing dishwashing machine issue. He stated, he would go to the kitchen and check the machine himself. On 03/10/22 at 11:40 AM, the administrator reported the dishwashing machine was running normally after warming up for 10 to 15 minutes and the sanitizer was at the correct level. A review of facility's policy and procedure titled, Ware Washing (last revised 10/2019) read: It is the center policy that all dishware and service ware will be cleaned and sanitized after each use. Action Steps: 1. The Dining Services Director ensures that the nutrition service staff is knowledgeable in proper technique for processing dirty dish ware to clean through the dish machine and proper handling of sanitized dish ware. 2. The Dining Services Director ensures that all the dish machine water temperatures are maintained in accordance with manufacturer recommendations for high temperature or low temperature machines. (Photographic evidence obtained)

Based on observations, interviews, record reviews, and facility policy and procedure review, the facility failed to ensure that five (Residents #15, #75, #39, #94, and #121) of five residents receiving continuous oxygen therapy, received the correct number of liters of oxygen ordered by the physician, from a total sample of 37 residents. This could result in the resident not receiving appropriate care and/or clinical complications. The findings include: 1. On 03/07/22 at 1:00 PM, Resident #15 was observed lying in bed with oxygen (O2) via nasal cannula (n/c). Her oxygen concentrator was set at 3 liters per minute (LPM). A review of Resident #15's medical record revealed an admitted [DATE] and re-admitted [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating cognitively intact. The assessment indicated Resident #15 has shortness of breath or trouble breathing with exertion (e.g.: walking, bathing, transferring), shortness of breath or trouble breathing when sitting at rest, and shortness of breath or trouble breathing when lying flat. On 03/08/22 at 9:49 AM, Resident #15 was observed lying in bed with oxygen via nasal cannula. Her oxygen concentrator was set at 3 LPM. When the resident was asked if she ever changed the settings on her oxygen concentrator, she replied, No, I don't do that, I couldn't even reach it. (Photographic evidence obtained) On 03/08/22 at 12:29 PM, Resident #15 was observed lying in bed with oxygen via nasal cannula. Her oxygen concentrator was set at 3 LPM. When resident was asked how she was breathing, she replied, Oh, it's ok, I guess. On 03/09/22 at 9:21 AM, Resident #15 was observed lying in bed with oxygen via nasal cannula. Her oxygen concentrator was set at 4 LPM. When the resident was asked how she was breathing today, she replied, I'm ok, I guess. (Photographic evidence obtained) On 03/09/22 at 4:10 PM, Resident #15 was observed lying in bed with oxygen via nasal cannula. Her oxygen concentrator was set at 4 LPM. (Photographic evidence obtained) A review of the care plan for Resident #15, dated 12/15/21, revealed the resident had altered respiratory status with difficulty breathing r/t [CONDITION(S)], history of PNA, and sleep apnea. Interventions included administer medications/puffers as ordered; monitor for effectiveness/side effects; elevate head of bed as needed to facilitate breathing; and oxygen settings: 02 via NC 6 liters cont. humidified. On 03/09/22 at 4:15 PM, an interview was conducted with Employee A, LPN who was assigned to care for Resident #15. She was asked what the oxygen liter flow order was for Resident #15. After reviewing the orders, she stated, She should be set at 6 LPM. When she was asked how often she checks the oxygen concentrator to ensure the liter flow is set at the prescribed amount, she replied, Once a shift. When she was asked if Resident #15 could change her oxygen flow setting, she replied, No, she couldn't reach it. Employee A, LPN entered Resident #15's room and said, Oh, look at you, your oxygen is set on 4. Let's put you back on 6 now. 2. On 03/07/22 at 12:30 PM, Resident #75 was observed sitting up in bed with oxygen via nasal cannula. An observation of her oxygen concentrator revealed the flow rate was set at 4 LPM. A review of the medical record for Resident #75 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/08/22 at 10:41 AM, Resident #75 was observed sitting up in bed with oxygen via nasal cannula. Her concentrator was set at 4 LPM. An interview was conducted with Resident #75 concerning how much oxygen she was supposed to receive. She stated, It's supposed to be set at 3 liters. The resident was asked if she ever changes the liter flow on her oxygen concentrator. She replied, No, the nurses do that. (Photographic evidence obtained) On 03/08/22 at 12:27 PM, Resident #75 was observed sitting in her wheelchair in her room with oxygen via nasal cannula in place, her 02 concentrator was set at 4 LPM. On 03/09/22 at 4:11 PM, Resident #75 was observed sitting up in bed with oxygen nasal cannula in place, her 02 concentrator was set at 4 LPM. (Photographic evidence obtained) A review of the care plan for Resident #75, dated 2/9/21 for Resident #75 revealed the resident had altered respiratory status. Interventions included oxygen settings: 02 via n/c 3 LPM continuous humidified. On 03/09/22 at 4:20 PM, an interview was conducted with Employee A, LPN who was assigned to care for Resident #75. She was asked what the oxygen liter flow order was for Resident #75. Employee A, LPN said, She should be set at 3 LPM. When she was asked how often she checks the oxygen concentrator to ensure the liter flow is set at the prescribed amount, she replied, Once a shift. She was asked if the CNAs (certified nurses' aides) are responsible for checking the oxygen flow levels. She stated, No, the nurses are responsible for that. She was asked if Resident #75 changes her oxygen flow setting. She stated No, she wouldn't do that. She couldn't reach it, but she would ask us, she wouldn't move it. Employee A, LPN entered Resident #75s room and stated Oh, it's set on 4 LPM. I'm putting it on 3 LPM now. 3. On 03/08/22 at 9:43 AM, Resident #39 was observed lying in his bed. The oxygen concentrator was running, and he was wearing his n/c. The concentrator was set at 4 LPM. He stated, he thought it should be at 2.5 LPM. (Photographic evidence obtained). A review of the medical record for Resident #39 revealed an admitted [DATE] and re-admitted [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Photographic evidence obtained) A review of the MDS assessment dated [DATE] revealed the resident was assessed as receiving oxygen therapy and respiratory therapy 3 days out of the assessment period. He reported no shortness of breath, none observed. He reported shortness of breath or trouble breathing when lying flat. His Brief Interview for Mental Status (BIMS) score was 11 out of a possible 15, indicating mild cognitive impairment. A review of the care plan dated 12/31/21 revealed the resident has altered respiratory status/difficulty breathing related to acute respiratory failure with [CONDITION(S)], Congestive heart failure and end stage renal disease. On 03/09/22 at 8:51 AM, Resident #39 was observed seated in his wheelchair in the dining area on the 300 hallway. He stated he was waiting to go to his [CONDITION(S)] appointment. He did not have a n/c on, or an oxygen tank strapped to the back of his wheelchair. He stated he is supposed to always have oxygen but, They don't send it with me to [CONDITION(S)] very often. The [CONDITION(S)] clinic does not apply oxygen when he gets there either. He stated he does not know why. Employee F, RN was informed that Resident #39 did not have his oxygen running and was about to leave for his [CONDITION(S)] appointment. She stated, she was unaware of the fact that he did not have it. She immediately went and got him a tank and cannula and applied it. On 03/10/22 at 1:30 PM, during an interview and observation of Resident #39. He was lying in bed attempting to feed himself. His nasal cannula was on. The oxygen concentrator was set at 2.5 LPM. On 03/10/22 at 2:29 PM, an interview was conducted with Employee F, RN who was assigned to care for Resident #39. She was asked what the oxygen liter flow order was for Resident #39. After reviewing the oxygen order, she stated, he was supposed to receive 2 LPM. She was informed that the concentrator was set at 2.5 LPM. She stated, she was unaware of that and would change it right away. 4. On 03/07/22 at 12:00 PM, Resident #94 was observed lying in bed with oxygen via nasal cannula. The oxygen concentrator was running and set at 2 LPM. A review of the medical record for Resident #94 revealed he was admitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/09/22 at 9:20 AM, Resident #94 was observed lying in bed with his eyes closed. Upon approach he opened his eyes and greeted this surveyor. The oxygen concentrator was set at 2.5 LPM. The nasal cannula was lying on the floor in front of the oxygen concentrator. On 3/09/22 at 9:37 AM, the resident was observed lying in bed with oxygen nasal cannula applied. The concentrator was set at 2.5 LPM. On 03/10/22 at 9:45 AM, Resident #94 was observed lying in bed with his eyes closed with oxygen nasal cannula. The oxygen concentrator was set at 3 LPM. On 03/10/22 at 11:55 AM, Resident #94 was observed sitting in a wheelchair in the dining area on 300 hall. His head was down, and his eyes were closed. The nasal cannula was on his face. An oxygen tank was strapped on the back of the wheelchair. Employee H, LPN was asked to read the level of the oxygen on the tank. She stated it was at 4 LPM. She stated, The nurse practitioner was here, and she told us to crank it up a bit. His sats (blood oxygen saturation levels) were at 88 this morning. She stated, she thought his oxygen is usually set at 2.5 LPM. A review of the MDS assessment dated [DATE], revealed the resident was assessed as receiving oxygen therapy in the 14 days of the assessment period. A review of the care plan dated 02/11/22 revealed the resident has potential altered respiratory status/difficulty breathing related to acute respiratory failure related to history of left lower lobe atelectasis and modest cardiomegaly on admission. Interventions included administering medications/puffers as ordered. Encourage sustained deep breathes by using demonstration (emphasizing slow inhalations, holding end inspiration for a few seconds and passive exhalation). Using incentive spirometer (place close for convenient resident use). Oxygen setting: O2 at 2 LPM via NC with humidification. Further review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. On 03/07/22 at 11:00 AM, Resident #121 was observed in his room with oxygen via nasal cannula. His oxygen concentrator was set at 2.5 LPM. Resident #121 was asked if he was able to adjust his oxygen concentrator, he replied, I don't do anything with it. (Photographic evidence obtained) A review of Resident #121 medical record noted an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the admission MDS assessment dated [DATE] revealed a BIM's score of 14, indicating cognitively intact On 03/08/22 at 10:46 AM, Resident #121 was observed in his room with oxygen via nasal cannula. His oxygen flow was set at 3 LPM. On 03/09/22 at 9:00 AM, Resident #121 was observed in his room with oxygen via nasal cannula. His oxygen flow was set at 2.5 LPM. On 03/10/22 at 4:10 PM, Resident #121 was observed in his room with oxygen via nasal cannula. His oxygen flow was set at 3 LPM. The resident was asked if he had made any adjustments to his oxygen, he replied, No, I did not. A review of care plan revealed resident had altered respiratory status. Interventions included monitory for signs and symptoms of respiratory distress and report to Medical Doctor; Oxygen settings via cannula at 2 LPM humidified. A review of two weeks of O2 saturations (from 2/24/22 thru 3/10/22) revealed no oxygen saturations were below 92%. A review of the facility's policy and procedure titled, Standards and Guidelines: Respiratory Care and Oxygen Administration (1/15/21) stated: Standard: It is the standard of this facility to provide guidelines for respiratory care and safe oxygen administration. Guideline: 1. Verify there is a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on personnel record reviews and interviews, the facility failed to ensure appropriate certification for Personal Care Assistants (PCAs) within 4 months of the date of hire for 3 of 13 PCAs reviewed (Employees C, D, and E). The findings include: A review of the personnel records revealed that 3 PCAs had been working at the facility for over 4 months without obtaining certified nursing assistant certification: Employee C, hired as Personal Care Assistants (PCA) on 07/28/2021 Employee D, hired as Personal Care Assistants (PCA) on 09/29/2021 Employee E, hired as Personal Care Assistants (PCA) on 04/28/2021 On 03/09/2022 at 1:15 PM, an interview was conducted with the Director of Human Resources. She confirmed Employee's C, D, and E were not certified and were employed as PCAs. On 03/09/2022 at 1:20 PM, an interview was conducted with the Director of Nurses (DON) concerning the PCAs. She stated that their corporate human resources department indicated since the PCAs had attempted the exam prior to their 4 months, they were excluded from the rule. The DON explained that the employees were scheduled for their re-test later in the month. During a follow up interview with the DON on 03/10/2022 at 1:14 PM, she stated the three PCAs (Employee C, D and E) were released on 03/09/2022 from employment at the facility.

Based on observation, interview and medical record review, the facility failed to ensure that it provided access to the resident call button to provide for reasonable accommodation of resident needs and preferences. Resident #1 who was a documented dependent resident, was denied the ability to call for assistance by not having a call button within reach at all times. This placed Resident #1 at risk for long wait periods for assistance, and denied Resident #1 the ability to call for assistance when needed. The findings include: An observation was made for Resident #1 on 03/26/2021 at 12: 38 PM during an interview. The call button for use was observed pinned to the nightstand on the right side of the bed out of reach. The bed was elevated somewhat and Resident #1 could not reach the call button for help. A second observation was made on 03/26/2021 at 12:58 PM and the call light remained pinned to the nightstand on the right side of the resident bed out of reach. (Photo submitted) An interview was conducted with Resident #1 on 03/29/2021 at 8:57 AM. He was asked to demonstrate use of the call button, he pushed it and it activated properly. He stated that it was not there before and he would use it to call for help if it was close by. An interviewed was conducted with Employee C, CNA on 03/29/2021 at 9:30 AM she reported that she cared for Resident #1 and stated that Resident #1 could use the call light and if the call light was pinned to the night stand, that was not allowed. The CNA stated that the call light should be placed within the resident reach at all times. An interview was conducted with the Director of Nursing (DON) on 03/29/2021 at 11:55 AM and she confirmed that the call light had to be within reach and confirmed that Resident #1 was dependent on staff to meet his needs. The DON was provided a photographic image of Resident #1's call button pinned to the night stand in the room. The DON confirmed that was not appropriate. A review of the Minimum Data Set (MDS) for Resident #1 indicated that the resident had a Brief Interview of Mental Status Score (BIMS) of 9 which indicated significant cognitive impairment. Resident #1 had a functional status documented as in need of extensive assistance for bed mobility, locomotion on and off unit, dressing, toilet use, personal hygiene with two-person physical assist. Resident #1 was also documented as total dependence for transfer and bathing. The review of care plan for Resident #1 indicated for the focus, Resident #1 has an activity of daily living self-care performance deficit related to ADL needs and participation vary. Limited mobility, stroke, weakness, spinal stenosis and [MEDICAL CONDITION]. The documented goal was Resident #1 will be free of complications related to ADL deficit through next review & The resident will maintain current level of function through the review date. The documented intervention included, Encourage Resident #1 to use bell to call for assistance.

Based on observation, resident and staff interviews and record review, the facility failed to properly store drugs and biologicals by leaving medications at bedside for one (Resident #1) of three residents sampled. The findings include: During the initial tour of the facility conducted on 12/23/2019 at 10:23 AM, an observation was made of Resident #1. He had a medication cup filled with multiple pills that remained on his over-the-bed table. Resident #1 was asked if he had taken his morning medications and he replied yes. When asked about the medication cup filled with pills on the table, he stated, I must have forgotten to take my medications. Employee B, Certified Nursing Assistant (CNA), was interviewed on 12/23/2019 at 10:25 AM, and confirmed that the medication cup with pills was on Resident #1's over-the-bed table and with no nurse present at that time. Employee B stated she would report that to the nurse. An interview was conducted with Employee D, CNA, on 12/23/2019 at 10:28 AM. The CNA acknowledged the medications in the cup and stated that the nurse made a mistake by leaving the medication unattended. An interview was conducted with Employee A, License Practical Nurse (LPN), on 12/23/2019 at 10:36 AM, who confirmed that Resident #1 was provided medications at 9:00 AM on 12/23/2019. Employee A also confirmed that she documented the medication administration as completed and was not aware that Resident #1 had not taken his medications. A review of Resident #1's medical record revealed [DIAGNOSES REDACTED]. A review of the Medication Administration Record [REDACTED] 1. [MEDICATION NAME] 10 MG 2. Duloxeline delayed 30 MG 3. Duloxeline delayed 60 MG (total 90 MG) 4. [MEDICATION NAME] Tablet 15 MG 5. [MEDICATION NAME] Capsule (Delayed release) 20 M[NAME] 6. Oyster Shell Calcium/Vitamin D Tablet 500-200 MG-Unit 7. [MEDICATION NAME] Tablet 10 MG 8. [MEDICATION NAME] Tablet 145 MG ([MEDICATION NAME]) 9. Carvedilol Tablet 6.25 MG 10. [MEDICATION NAME] Tablet 25 MG 11. Magnesium Oxide Tablet 400 MG 12. [MEDICATION NAME] Fiber Packet ([MEDICATION NAME]) 13. Acamprosate Calcium Tablet Delayed Release 333 MG 14. [MEDICATION NAME] Tablet 20 MG A review of the Medication Administration Audit Report revealed that each of the (14) medications were administered to Resident #1 by Employee A, LPN, on 12/23/2019 between 8:53 AM and 8:59 AM. An interview was conducted with the Assistant Director of Nursing (ADON)/Nurse Educator on 12/23/2019 at 10:39 AM. The ADON confirmed that medications should not be left on the over-the-bed table unattended. An interview was conducted with the Director of Nursing (DON) and the ADON/Nurse Educator on 12/23/2019 at 1:45 PM. Both individuals confirmed that Resident #1's 9:00 AM medications were documented as having been administered when the medication was still in the pill cup on the over-the-bed table. Both stated this was not acceptable practice. A review of a nursing note dated 12/23/2019 at 12:10 PM by Employee A, revealed that she documented Resident #1's medication as having been administered prior to administration occurring. A review of the facility's policy for Standards and Guidelines (SG) for Medication Administration was conducted. Documented under the guideline at line 9: The individual administering the medication must initial the resident's MAR indicated [REDACTED].

Based on observation, interviews and record review, the facility failed to provide the necessary treatment and services to promote the healing of a pressure injury for one (Resident #2) of two residents sampled for a review of pressure ulcers, from a total of seven residents in the sample. The findings include: A review of Resident #2's medical record revealed an admission date of [DATE] and a primary admitting [DIAGNOSES REDACTED]. The resident's functional status was impaired and he required assistance with activities of daily living. An admission nursing note, dated 12/4/2019, indicated three pressure injuries of varying stages to the coccyx, left buttock and right buttock. A subsequent wound assessment by the facility's wound care nurse, dated 12/4/2019, indicated a stage three pressure injury to the coccyx. The left and right buttock wounds were not referenced on this assessment. A review of the physician's orders [REDACTED]. There were no treatment orders noted prior to this order. A review of the resident's wound care plan revealed an intervention which read, Provide treatments as ordered by physician. See medication and/or treatment administration record. An observation of wound care was conducted on 12/11/2019 at 1:36 PM. The wound care nurse removed a dressing from the resident's sacral area, which was dated 12/9/2019. The wound was noted to be in various stages of healing with a concentration of devitalized (dead) tissue on the right side. The wound was cleansed, a [MEDICATION NAME] ointment was applied and the wound was covered with a foam dressing. An interview was conducted with the wound care nurse on 12/11/2019 at 2:05 PM. She was asked to review the current treatment order and acknowledged that the order was to be carried out daily. She acknowledged that the dressing she removed from the resident was dated 12/9/2019 and that she had not changed the dressing on 12/10/2019. When asked to describe the process for ensuring dressing changes occur in the event she was not able to carry them out, she stated she was responsible for dressing changes to stage three and four pressure injuries but that she didn't get to it yesterday. She was then asked to review the resident's physician's orders [REDACTED]. She acknowledged that no treatment orders had been implemented from the date of admission until 12/9/2019. An interview was conducted with the wound care nurse, director of nursing, and regional director of clinical operations on 12/12/2019 at 2:18 PM. The wound care nurse acknowledged a delay of five days between the date the wound was first identified after admission (12/4/19) and the implementation of treatment orders (12/9/19). The director of nursing expressed that her expectation was for treatment orders to be obtained upon admission.

Based on observations, interview and record review, the facility failed to ensure residents received treatment and care in accordance with the comprehensive person-centered care plan for one (Resident #3) of two residents sampled for care plan review, from a total of seven residents in the sample. The findings include: An observation of Resident #3 and her environment was conducted on 12/11/2019 at 11:15 AM. She was awake and lying in bed with tube feeding connected to her gastrostomy tube (feeding tube). A water flush bag was was observed hanging on the IV (intravenous) pole next to her bed, which was connected to her feeding pump. The bag was dated 12/11/2019 and timed 4:00 AM. There was a total of 1000 ml (milliliters) observed in the bag. The feeding pump auto-flush settings were set to 60 ml every 0 hours. The resident's lips were dry and cracked with substance buildup on the tip of her tongue. A review of Resident #3's medical record revealed an admission date of [DATE]. The resident's primary medical [DIAGNOSES REDACTED]. The resident's functional status was impaired and she required total assistance with activities of daily living. An observation of Resident #3 was conducted on 12/11/2019 at 1:15 PM. She was awake and lying in bed with the tube feeding connected. The water flush bag dated 12/11/2019 and timed 4:00 AM still contained a total of 1000 ml. The feeding pump auto-flush settings were set to 60 ml every 0 hours. A review of Resident #3's enteral feeding order revealed orders for auto-flush settings at 60 ml/hr (milliliters per hour) x (for) 20 hours. An observation of Resident #3 was conducted on 12/12/2019 at 11:00 AM. She was lying in bed with her tube feeding connected. A water flush bag dated 12/12/2019 and timed 5:30 AM was hanging on the IV pole and connected to the feeding pump. The bag contained a total of 1000 ml. The feeding pump auto-flush settings were set to 60 ml every 0 hours. An interview was conducted with Employee D, Licensed Practical Nurse (LPN), on 12/12/2019 at 11:15 AM. The nurse was asked to verify the auto-flush orders in the record for Resident #3. She confirmed the resident's order as 60 ml/hr X 20 hours and stated that's what the resident's pump was currently set to. The nurse was asked to verify the current settings on the pump. The nurse acknowledged the pump was set to 60 ml every 0 hours and changed the settings to 60 ml every 1 hour. The nurse stated she thought the settings were correct earlier in the day and she wasn't sure why there was an error in the settings.

Based on observation, interviews and record review, the facility failed to protect the resident's right to be free from neglect by first delaying care of a pressure injury for five days, and second, by failing to provide necessary and physician-ordered care to a pressure injury for one (Resident #2) of two sampled residents. The findings include: A 12/11/2019 review of Resident #2's medical record revealed an admission date of [DATE] and a primary admitting [DIAGNOSES REDACTED]. The resident's functional status was impaired and he required assistance with activities of daily living. An admission nursing note, dated 12/4/2019, indicated three pressure injuries of varying stages to the coccyx, left buttock and right buttock. A subsequent wound assessment by the facility's wound care nurse, dated 12/4/2019, indicated a stage three pressure injury to the coccyx. The left and right buttock wounds were not referenced on this assessment. A review of the physician's orders [REDACTED]. There were no treatment orders noted prior to this order. A review of the resident's wound care plan revealed an intervention which read, Provide treatments as ordered by physician. See medication and/or treatment administration record. An observation of wound care was conducted on 12/11/2019 at 1:36 PM. The wound care nurse removed a dressing from the resident's sacral area, which was dated 12/9/2019. The wound was noted to be in various stages of healing with a concentration of devitalized (dead) tissue on the right side. The wound was cleansed, a [MEDICATION NAME] ointment was applied and the wound was covered with a foam dressing. An interview was conducted with the wound care nurse on 12/11/2019 at 2:05 PM. She was asked to review the current treatment order and acknowledged that the order was to be carried out daily. She acknowledged that the dressing she removed from the resident was dated 12/9/2019 and that she had not changed the dressing on 12/10/2019. When asked to describe the process for ensuring dressing changes occur in the event she was not able to carry them out, she stated she was responsible for dressing changes to stage three and four pressure injuries but that she didn't get to it yesterday. She was then asked to review the resident's physician's orders [REDACTED]. She acknowledged that no treatment orders had been implemented from the date of admission until 12/9/2019. An interview was conducted with the wound care nurse, director of nursing, and regional director of clinical operations on 12/12/2019 at 2:18 PM. The wound care nurse acknowledged a delay of five days between the date the wound was first identified after admission (12/4/19) and the implementation of treatment orders (12/9/19). The director of nursing expressed that her expectation was for treatment orders to be obtained upon admission.

Based on record reviews and interviews, the facility failed to investigate injuries (bruises) of unknown origin, for one (Resident #3) of one resident sampled for injuries of unknown origin, from a total of seven residents in the sample. The findings include: A record review for Resident #3 revealed a [AGE] year-old, non-verbal, female resident, initially admitted on (MONTH) 18, 2005. Her current [DIAGNOSES REDACTED]. Further review of the record, including progress notes, skin checks, and change in condition assessments revealed that Resident #3 had bruises of unknown origin on her coccyx, right upper thigh and abdomen on 11/17/2019. An interview was conducted with the risk manager on 12/11/19 at 3:57 PM regarding an incident report for Resident #3 related to the bruising identified on 11/17/19. The risk manager stated she did not have an incident report. The resident just had a deflated mattress, and an incident report would not have been one completed for that. When asked about the resident's bruising and an investigation related to the cause of the bruises, she stated she was unaware of the circumstances, because the event occurred prior to her employment with the facility. She further stated that as far as she was aware, she had no incident reports for Resident #3, but she would look again. The Administrator approached at that time and was also asked for an incident report/investigation of the cause of resident #3's bruises. An interview regarding Resident #3's bruises was conducted with Employee C, Licensed Practical Nurse (LPN), on 12/11/19 at 4:37 PM. The nurse stated she had completed the Change in Condition form, but should also have completed an incident report. During a review of the Change in Condition assessment form, the nurse was asked whether she had notified the physician of the bruising, because the area on the form for notification of the physician was left blank. She stated she did call the physician, and he instructed her to continue to monitor the resident. She confirmed she had forgotten to document the call on the assessment form. When asked whether she had notified the resident's responsible party, the nurse stated the resident had none. When asked about the resident's sister, who was listed on the resident's facesheet, the nurse stated she had never seen any family in with Resident #3 and was not sure whether there was anyone to contact. An interview was conducted with the assistant director of nursing on 12/11/19 at 4:57 PM, regarding the facility's policy for completing incident reports. She stated they were to be completed for any adverse incidents, such as elopements, falls, skin tears and injuries of unknown origin. An interview was conducted with the administrator and director of nursing (DON) on 12/11/19 at 5:31 PM regarding Resident #3's documented bruising to her right upper thigh, abdomen and sacrum with no explanation of how they occurred. They stated they had not completed an investigation into the cause of the bruises. The DON reviewed photographic evidence documented in the wound care system and dated 11/25/19. She confirmed that it was indeed bruising on the resident's coccyx. The facility did not obtain any photographic evidence of the thigh or abdomen. The administrator confirmed they should have completed an incident report related to injuries of unknown origin. The DON stated the nurse should have completed an incident report and not the change in condition assessment. She further stated she had not heard about the bruising and this was the first time she had been made aware. They had discussed the bruising to the resident's knee in the morning meeting and related that to her brace. She confirmed that the bruises should have been reported and investigated, and admitted they had not been. A review of the facility's policies and procedures revealed the following: Manual: Nursing Section: Risk Management Standards and Guidelines: SG Event/Incident Reporting an d Documentation Issued: 10/1/2004 Revised: 1/1/2014; 12/1/16 Policy number: 12.08.013 Page 1 of 1 Standard: It is the standard of this facility that a formal risk management communication system will be used to ensure the flow of information concerning events occurring within the facility. The establishment of this system will facilitate the identification of potentially compensable events and clinical events with adverse outcomes. The system will allow the administrator/risk manager to identify, track and trend all events/incidents within the facility and develop opportunities to assist the facility to resolve or improve situations to prevent or diminish real and potential risk. An event/incident may be defined as: An unexpected occurrence not consistent with routine operation of the facility or care of the resident, visitor, volunteer, equipment, or staff. All events/incidents will be investigated by the DNS (Director Nursing Services) or designee to determine cause of the event, any witnesses to the event, and any corrective or proactive actions that need to be made to prevent or lessen another event from occurring. if the event qualifies as an Adverse Incident, the Risk Manager will be notified. Guidelines: 1. Ensure the incident/event report is completed timely for review. Manual: Nursing Section: Risk Management Standards and Guidelines: SG ANE and Investigations Issued: 11/1/2004 Revised: 11/1/2010; 3/1/2011; 3/1/2012; 11/1/2016; 11/1/2017. Policy number: 12.08.009 Page 1 of 4 Page 1 Standards: It will be the standard of this facility to honor residents' rights and to address with employees the seven (7) components regarding mistreatment, abuse, neglect, sexual misconduct, injuries of unknown source, involuntary seclusion, corporal punishment, misappropriation of residents property or funds or use of physical or chemical restraint not required to treat the resident's symptoms in accordance with Federal Law. It will be the standard of this facility to ensure that all alleged violations of federal or state laws, which involve mistreatment, neglect, abuse (verbal, mental, physical or sexual), injuries of undetermined source, involuntary seclusion, corporal punishment, misappropriation of residents' property or funds, or use of physical or chemical restraint not in accordance with regulation to treat resident's symptoms be reported immediately to the administrator/DON/designee. Appropriate agencies will be notified in accordance with existing laws. Page 3 of 4: 4. Identification: When any allegation or confirmed abuse, neglect, mistreatment or exploitation of a resident occurs including suspicion, the appropriate state agencies will be notified immediately including Adult Protective Services 1-800-96- ABUSE, Federal Reporting using the Immediate and 5 day Federal reports and the local police or Ombudsman if indicated. The supervisor, Administrator and/or Director of Nursing will be notified immediately. The resident's representative and physician shall be notified. Staff members involved will be removed from the schedule pending investigation. 5. Investigation: The facility will conduct their own internal investigation including but not limited to staff (work history and background screening), resident, and family/resident representative interviews, medical record reviews, 24 hour reports reviews, full body skin exam, etc. The resident's representative and physician should be notified that there is an on-going investigation regarding the alleged incident.

Based on facility record reviews and interviews, the facility failed to respond to grievances in a timely manner for three (Residents #11, #1 and #4) of three residents reviewed for grievances, out of a total sample of 16 residents. (Resident #11, Resident #1, and Resident #4). The findings include: A review of the facility's grievance log revealed the Power of Attorney (POA) for Resident #11 had filed a grievance regarding his care on 1/13/19, and again on 3/5/19. Further review revealed that no follow up had been completed according to the log for the 1/13/19 incident until 3/5/19, when the other complaint was filed. There was no documentation of any follow-up for the 3/5/19 complaint. On 4/1/19 at 4:28 PM, an interview was conducted with Resident #11's POA via telephone. She confirmed that the facility had not followed up with her regarding the grievances she had filed. Further review conducted of the facility's grievance log revealed Resident #1 had filed a grievance on 3/4/19. There was no documentation to verify that the facility had follow up on the grievance. On 4/2/19 at 8:37 AM, an interview was conducted with Resident #4's daughter regarding her grievances, and she confirmed that the facility had failed to respond to her. On 4/2/19 at 3:42 PM, an interview was conducted with the Director of Nursing regarding grievances, and she confirmed that follow-up documentation should be completed timely for all grievances. .

Based on observations, staff interviews, and resident and facility record reviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and their plan of care, by failing to provide medications in a timely manner and as ordered by the prescribing physician, for three (Residents #3, #4, and #7) of four residents observed receiving medications. The findings include: 1. An observation was made at 10:06 am on 1/7/19 on the 300 unit. Licensed Practical Nurse (LPN) B was observed entering room [ROOM NUMBER], and assisting Resident #7 with a breathing treatment. A record review for Resident #7 revealed [DIAGNOSES REDACTED]. The resident had a physician's orders [REDACTED]. Review of the current Medication Administration Record (MAR) for Resident #7, revealed LPN B signed the MAR for the [MEDICATION NAME] treatment in the 9:00 am signature box. 2. An observation of the 100 hall Unit Manager (UM) was made at 10:12 am on 1/7/19. She was at the medication cart, and stated she was preparing to provide medications to Resident #4. The UM dispensed several pills from their pharmacy-labeled blister packs into a small medicine cup, crushed the medications, then mixed them with chocolate pudding. She took the pudding and pill mixture into the resident's room at 10:15 am. A record review for Resident #4 revealed [DIAGNOSES REDACTED]. Resident #4 had physician's orders [REDACTED]. Aspirin EC tablet delayed release 81 mg, give 1 by mouth one time a day related to low back pain. Cerovite advanced formula tablet ,one by mouth one time a day for supplementation. [MEDICATION NAME] tablet 10 mg by mouth, one time day for essential hypertension. [MEDICATION NAME] 30 mg, three times a day for essential hypertension. [MEDICATION NAME] 100 mg, three times daily for [MEDICAL CONDITION] (nerve pain). [MEDICATION NAME] 20 mg, three times daily related to heart block. The Unit Manager signed the MAR on 1/7/19 for the above medications at 9:00 am. In an interview with the 100-hall Unit Manager at 12:08 pm on 1/7/18, she admitted she was late that morning with some of the medications. She explained she did not know she would have to work the medication cart until 8:00 am when she came in to work. Clinical record review for Resident #4 revealed a [DIAGNOSES REDACTED]. The resident had a physician's orders [REDACTED]. Review of the MAR found the patch was to be removed every 72 hours at 6:23 pm and replaced at 6:24 pm following removal. On 1/1/19 at 7:57 pm, the patch was signed off as removed by Registered Nurse (RN) A. She then noted on the MAR at 7:58 pm on 1/4/19, that the patch was not re-applied, and a code used to see the nurse's note. The corresponding nursing progress note explained the patch was not available for application. Neither the MAR nor nursing progress notes reflected the patch ever being ordered or applied on either 1/1/19, 1/2/19, or 1/3/19. On 1/4/18 at 8:28 pm, LPN C signed that he had removed the patch and applied a new one at the same time. An interview was conducted with the 100 hall Unit Manager at 3:19 pm on 1/7/19. She reviewed the records and researched the [MEDICATION NAME] for Resident #4, but could not determine whether the patch was ever applied between 1/1/19 and 1/4/19, when LPN C signed it as removed and re-applied. 3. LPN A was observed preparing medications at the medication cart on the 300 hallway at 10:22 am on 1/7/19. She drew up several syringes and dispensed multiple tablets into a small medicine cup. A brief interview with LPN A at 10:26 am, found she was preparing the medications for Resident #3. She did not enter Resident 3's room with all of the prepared medications until 10:30 am. Review of the clinical record found Resident #3 had [DIAGNOSES REDACTED]. The resident had physician's orders [REDACTED]. Aspirin chewable 81 mg, three times daily related to (r/t) essential hypertension. [MEDICATION NAME] sulfate tablet 325 mg daily for [MEDICAL CONDITION] unspecified. [MEDICATION NAME] prop 50 microgram (mcg), 2 sprays in nostril one time a day related to allergy. Folic acid, one time a day for [MEDICAL CONDITION]. [MEDICATION NAME] extended release (ER) 30 mg daily for hypertension. Montelukast Sodium 10 mg daily for allergy. Multivitamin adult, one daily for vitamin deficiency. Potassium Chloride ER 20 millequivalents (meq) daily for [DIAGNOSES REDACTED]. Umeclidinium [MEDICATION NAME] aerosol powder breath activated 62.5 mcg/inhalation, 1 inhalation orally one time daily for [MEDICAL CONDITIONS]. Apixaban 5 mg 1 tablet twice daily for chronic embolism and [MEDICAL CONDITION] of unspecified deep veins of unspecified lower extremity. Biofreeze gel 4% to legs, feet, right shoulder topically twice daily for pain. [MEDICATION NAME] (hcl) 30 mg, 1 tablet twice daily for hypertension. Ducosate Sodium 100 mg 1 capsule twice daily for constipation. [MEDICATION NAME] tablet 40 mg 1 tab twice daily for heart failure. Insulin Detemir solution 100 unit/ml inject 155 units subcutaneously twice daily for type 2 Diabetes Mellitus (DM). NAME] delayed release (DR) 40 mg twice daily related to GERD. Saline nasal spray, 1 spray each nostril twice daily for nose bleeds. [MEDICATION NAME] tablet 25 mg 1 twice daily for heart failure. [MEDICATION NAME] 600 mg, 1 three times daily for hereditary and idiopathic [MEDICAL CONDITION]. [MEDICATION NAME] solution 100 units/ml, inject 35 units subcutaneously with meals for DM. [MEDICATION NAME] 1 gram, 1 tablet 4 times daily for GERD. LPN A signed the MAR for the above medications for the 9:00 am dosing time. Further review of Resident #3's MAR found that on 12/5/18, LPN A held the medication [MEDICATION NAME] and used a code for other, see nurses note. The progress note for 12/5/18 indicated the medication was held per parameters. On 12/10/18 at 9:00 am, LPN A again held the medication per parameters, noting Resident #3's blood pressure was 105/57. On 12/29/18 at 9:00 am, the [MEDICATION NAME] was held again per parameters by an unsampled nurse. An interview was conducted with LPN A at 2:58 pm on 1/7/19. She pulled up Resident #3's electronic MAR and stated the parameters for holding this medication was in the notes. She pulled up the electronic administration note which relayed the order for [MEDICATION NAME] for I10. She explained that was a (systolic) blood pressure parameter for when the medication should be held. She did not realize that I10 was the ICD-10 (International Classification of Diseases, tenth edition) diagnostic code for essential hypertension. The 200 hall Unit Manager then reviewed the MAR and the physician's orders [REDACTED]. On Saturday, 12/29/18, Resident #3's [MEDICATION NAME] 5 mg, give every Wednesday and Saturday at 9:00 am for heart failure, was also noted as held. There was no note or rationale explaining why the medication was held. The [MEDICATION NAME] Hcl 30 mg twice daily for hypertension was also held at 9:00, with no rationale or written explanation. An interview and review of the record was conducted with the Administrator at 5:00 pm on 1/7/19. She confirmed the lack of documentation for why Resident #3's medications were held. She was not aware of late administration times on 3 units observed. 4. A closed record review for Resident #1 revealed physician's orders [REDACTED]. Review of the (MONTH) (YEAR) MAR found the Xarelto was not given on two consecutive days. It was signed by the nurse and coded with a '5' (hold, see nurse's note) on 11/28/18, and coded with a '9' (other) on 11/29/18. The nurse's notes indicated on 11/28/18 the medication was not available in OmniCelle (an automated medication dispenser utilized by the facility) by LPN D. On 11/29/18, the medication was noted to be On order by LPN E. There was no indication the resident's physician had been notified of the unavailable medication. In an interview with the Administrator at 5:00 pm on 1/7/19, she stated she was unaware of the unavailability of Resident #1's Xarelto for 2 days. 5. Review of the facility's Standards and Guidelines on Medication Administration policy 12/07.09.032 revised 11/1/16 found: Guidelines: .3. Medications should be administered in a timely manner and in accordance with the physician's orders [REDACTED]. .7. Medications should be administered within one (1) hour before or after their prescribed time . .16. Should a resident be away from his/her room or unavailable during the medication pass, it is permissible to return during the appropriate time frame to that resident at a later time to complete medication administration .

Based on resident and staff interviews, and record reviews, the facility failed to provide care in accordance with professional standards of practice by failing to ensure physician's orders [REDACTED].#174) of seven residents with medications reviewed in a sample of 56 residents. The findings include: During an interview with Resident #174 on 10/29/2018 at 12:05 PM, she stated she had not been receiving her potassium. She mentioned it to the nurse but had not heard a thing. Record review for Resident #174 revealed she was admitted on [DATE]. She had physician's orders [REDACTED]. During an interview with Resident #174's nurse (Employee A) on 10/30/18 at 2:42 PM, she provided the resident's lab reports dated 10/16/2018 and 10/19/2018 from the facility's computer. She stated she was aware of the orders for the potassium. Review of the lab report dated 10/16/2018, revealed Resident #174 had critical lab results for potassium at 2.3 (verified by repeat) with a range of 3.5-5.3 given. Handwritten on the report were orders dated 10/17/2018 for potassium (KCL) 40 milliequivalents (meq) three times a day for two days. Review of the lab report dated 10/19/2018, revealed low potassium results at 3.4 (verified by repeat) with a range of 3.5-5.3 given. Handwritten on the report were orders for potassium (KCL) 40 meq twice a day for two days. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The potassium 40 meq was documented as having been administered to Resident #174 on 10/17/2018 at 1:00 PM, 5:00 PM, and 9:00 PM. She was given the potassium again on 10/18/2018 at 9:00 AM, 1:00 PM, 5:00 PM, 9:00 PM and then again on 10/19/2018 at 9:00 AM. The physician's medication orders obtained as a result of the 10/16/2018 lab results were written on the MAR indicated [REDACTED]. The physician's orders [REDACTED]. On 10/30/18 at 3:02 PM, the Unit Manager (Employee B) was shown the lab reports and was asked for evidence the Potassium had been administered. During a follow-up interview with the Unit Manager (Employee B) on 10/31/18 at 1:47 PM, she stated the facility obtained stat (immediate) lab work yesterday, and then obtained a new order for potassium for two days. On 10/31/2018 at 2:24 PM, the Director of Nursing (DON) provided evidence of laboratory results obtained on 10/30/2018 at 7:50 PM, with results of potassium at 2.5 meq (flagged low due to a range of 3.5-5.1 meq/l). The DON also provided documentation of new physician's pharmacy orders on 10/30/2018 at 10:48 PM for potassium chloride ER (Extended Release) tablet, 20 meq for low potassium for two days.