Every finding on record at Ridgeway Post Acute

Based on observation, interview, and record review, the facility failed to protect four of 18 sampled residents' (Resident 47, Resident 62, Resident 69, and Resident 87) personal privacy when: 1. Resident 87's document, titled, Resident Functional Status Checklist, was posted on a dresser stored in a public facility hallway, 2. Resident 69's electronic medical record was left open and visible on a computer screen located on top of a medication cart in a public facility hallway, and; 3. The alternate meal requests for Resident 62 and Resident 47, which included protected health information, were disposed of in the regular kitchen trash without undergoing shredding or proper destruction procedures.These deficient practices had the potential to result in unauthorized disclosure of residents' protected health information and violated their right to personal privacy. 1. A review of Resident 87's admission record (facility demographic) indicated he was admitted to the facility in March 2025 with medical diagnosis which included fracture of unspecified part of neck of the left femur (a break in the upper portion of the thigh bone) and diabetes mellites (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). Resident 87's admission record indicated he was discharged in November 2025. During an observation on 6/15/26 at 10:59 a.m. in Zinfandel hallway across from room [ROOM NUMBER] and next to room [ROOM NUMBER], a dresser was stored with a document titled, Resident Functional Status Checklist, posted on its side. The document disclosed Resident 87's name, room number, mobility status, and diet and feeding orders. During an observation and concurrent interview on 6/15/26 at 11:01 a.m., Certified Nurse Assistant D (CNA D) confirmed that the dresser in Zinfandel hallway had Resident 87's functional status document posted on its side. CNA D further confirmed that Resident 87's document was posted in a public hallway. CNA D stated Resident 87's privacy was not protected. During an observation and concurrent interview on 6/15/26 at 11:10 a.m., CNA E confirmed that the dresser in Zinfandel Hallway had Resident 87's functional status document posted on its side. CNA E further confirmed that Resident 87's document was posted in a public hallway. CNA E stated that Resident 87's private information was not protected and needed to be removed. CNA E confirmed it was a HIPAA (Health Insurance Portability and Accountability Act, a law designed to protect sensitive patient health information from being disclosed without the patient's consent or knowledge) violation. During an interview and concurrent photograph review on 6/18/26 at 11:34 a.m., the Director of Nursing (DON) reviewed the photograph taken of Resident 87's functional status document that was posted on the outside of a dresser stored in the hallway. The DON stated that staff should have ensured that Resident 87's functional status checklist was not in public view. The DON confirmed the document should not be accessible to the public and further stated it violated Resident 87's rights to privacy. The DON did not agree that Resident 87's posted document was a violation of HIPAA. 2. A review of Resident 69's admission record indicated he was admitted to the facility in September 2021 with medical diagnosis hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (stroke). During an observation on 6/18/26 at 4:33 p.m. in Chablis Court hallway outside of rooms [ROOM NUMBERS], an unattended medication cart was observed with a facility laptop on top, and the screen was open to Resident 69's medical record. During an interview on 6/18/26 at 4:35 p.m., Licensed Nurse E (LN E) exited room [ROOM NUMBER] and confirmed that the medication cart had been left unattended with Resident 69's medical record displayed on the facility laptop. LN E verified that the privacy screen was not enabled. LN E further stated that the purpose of the privacy screen was to protect resident information. During an interview on 6/18/26 at 4:50 p.m., the DON confirmed the privacy screen on the laptop should be enabled when the medication cart is left unattended. The DON further stated, Because, you have patient [resident] information there, and verified that this constituted a HIPAA violation. 3. During an observation on 6/18/26 at 2:27 p.m., the alternate meal request forms for Resident 62's and Resident 47's containing their names, room numbers, and personal requests, were found discarded in the kitchen trash. During an interview on 6/18/26 at 2:27 p.m., a Food Service Worker (FSW) confirmed that the alternate meal request forms for Residents 62 and 47 had been thrown away in the kitchen trash can. During an observation on 6/18/26 at 2:27 p.m., the Dietary Services Manager (DSM) instructed the FSW that the kitchen trash was not an appropriate location to dispose of private resident information and that such documents must be discarded in the shredder located in the office outside the kitchen. During an interview on 6/18/26 at 2:27 p.m., the DSM confirmed that the forms containing private, identifiable information for Residents 62 and 47 had been discarded in the kitchen trash. The DSM stated this was not appropriate practice and that these documents were required to be placed in the office trash designated for shredding. The DSM confirmed the expectation was for kitchen staff to protect residents' private, protected health information by disposing of these forms in the proper receptacle for shredding. A review of the facility's policy and procedures (P&P) titled, Confidentiality of Information and Personal Privacy, revised 2021, indicated, The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records.The facility will strive to protect the resident's privacy regarding his or her: accommodations; medical treatment; personal care. A review of the facility's P&P titled, Resident Rights, revised 2021, indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: privacy and confidentiality.All unauthorized release, access, or disclosure of resident information is prohibited. A review of the facility's document titled, Job Description: Registered Nurse [RN], Job Description: LPN [Licensed Practical Nurse]/LVN [Licensed Vocational Nurse], and Job Description: Certified Nursing Assistant [CNA], all dated 2024, indicated, Agree not to disclose resident's protected health information and promptly report suspected or known violations of such disclosure to the Administrator.

Based on observation and interview, the facility failed to ensure the rights of three of 18 sampled residents (Residents 11, 12, and 23) were considered when nursing staff did not inform them of the medications being administered during their medication administration process. This failure limited the residents' ability to participate in their care, ask questions, and make informed decisions regarding the medications they received. 1. A review of Resident 11's admission record (facility demographic) indicated she was admitted to the facility in January 2026 with medical diagnosis which included malignant neoplasm of the vulva (cancer that originates in the external female genitalia) and acute diastolic (congestive) heart failure (when the heart muscle becomes stiff and does not relax). A review of Resident 11's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 4/24/26, indicated her Brief Interview of Mental Status (BIMS-a cognition [the processes of thinking and reasoning] assessment) score was 12, which indicated her cognition was moderately impaired (a score of 1-7 indicates cognition is severely impaired, 8-12 indicates cognition is moderately impaired, and 13-15 indicates cognition is intact). During an interview on 6/16/26 at 9:30 a.m., Resident 11 stated on one occasion during medication administration the nurse did not tell her what she was given. Resident 11 stated she refused all the medications because the nurse would not explain to her what they were. Resident 11 further stated that she did not like not being educated in regard to her medications and stated it was her right to know. 2. A review of Resident 12's admission record indicated he was admitted to the facility in December 2025 with medical diagnosis which included metabolic encephalopathy (a disease of the brain that changes brain function or structure) and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). A review of Resident 12's MDS dated [DATE], indicated his BIMS score was two, which indicated his cognition was severely impaired. During an observation on 6/17/26 at 8:36 a.m., Licensed Nurse F (LN F) was observed mixing Resident 12's crushed medications in pudding. Resident 12 was difficult to arouse and LN F simulated Resident 12 until he opened his eyes. LN F stated, [Resident 12] I have your cookies. Eat your cookies. Resident 12 proceeded to eat the pudding. LN F did not inform Resident 12 that he received medications. 3. A review of Resident 23's admission record indicated he was admitted to the facility in August 2021 with medical diagnosis which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebrovascular disease (a condition that affects blood flow and blood vessels in the brain) and hypertensive heart disease (heart condition caused by unmanaged high blood pressure). A review of Resident 23's MDS dated [DATE], indicated his BIMS score was 15, which indicated his cognition was intact. During an observation on 6/17/26 at 8:36 a.m., LN F was observed administering Resident 23's his medications. LN F informed Resident 23 that his seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) medication was included but did not explain any other medications to him. Resident 23 proceeded to take his medication and stated, I don't know what I take- I just take them. During an interview on 6/18/26 at 8:23 a.m., LN A stated when medications were administered it was important to inform residents what they were receiving so that they were aware. LN A further stated, It is their [the resident] right to know. Even if they are non-verbal or don't understand, we are expected to still explain their medications to them. During an interview on 6/18/26 at 11:34 a.m., the Director of Nursing (DON) confirmed that nurse staff should inform residents of what medications they were receiving during medication administration. The DON stated, It's the patient's [resident] right to know what they are taking. A review of the facility's policy and procedures titled, Resident Rights, revised 2021, indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: be informed of, and participate in, his or her care planning and treatment.

Based on observation, interview and record review, the facility failed to store food in a sanitary manner for a census of 74 residents when:1. A kitchen staff member prepared food without the required facial hair covering,2. The kitchen and food storage floors had blackened debris on painted, worn, and tiled surfaces, 3. Opened food containers requiring refrigeration were improperly stored on shelves in the food storage room,4. Raw poultry in the refrigerator was not properly labeled with preparation and expiration dates,5. Food items were opened, undated, and missing use by dates in the food storage area,6. Daily kitchen cleaning was not documented; the log had missing entries, and the kitchen equipment and environment were not clean,7. Expired paper test strips were used to test the sanitation solution concentration in the red buckets,8. Handwashed plastic food bins were stacked while still wet, preventing proper drying, and were left on an unclean sink surface, and;9. The dishwashing machine was not tested for quality assurance at the start of the day shift before first use.These failures had the potential to result in foodborne illnesses and spread of infections in a vulnerable resident population.During a concurrent observation and interview on 6/15/26 at 8:48 a.m. with the Dietary Services Manager (DSM), [NAME] 1 was observed preparing food without a required beard covering. The DSM stated that [NAME] 1 should have been wearing a beard cover and instructed him to put one on before continuing meal preparation.During a concurrent observation and interview on 6/15/26 at 8:50 a.m. with the Dietary Services Manager (DSM), the kitchen floors were observed with black debris buildup, areas of exposed concrete where the floor coating was missing, and raised sections of floor coating with debris underneath. Black debris was also noted on the floor tiles in the dry storage room. The DSM stated he had been in the position for only one month and was actively working with staff to ensure daily kitchen cleaning to prevent foodborne illness. The DSM added that the facility was aware of the floor condition and had plans for a kitchen renovation within the next year.During a concurrent observation and interview on 6/15/26 at 9:08 a.m. with the Dietary Services Manager (DSM), two opened containers of teriyaki glaze and two opened containers of barbecue sauce, each requiring refrigeration after opening per manufacturer instructions, were found stored on open shelves in the dry storage room. The DSM reviewed the labels, confirmed the items should have been refrigerated after opening to prevent foodborne illness, and stated they needed to be discarded.During a concurrent observation and interview on 6/15/26 at 9:12 a.m. with the Dietary Services Manager (DSM), raw poultry marinating in a stainless steel container was stored in the refrigerator without a labeled preparation date or an accurate expiration/use by date. The DSM stated staff should have labeled the poultry with the preparation date and an expiration or use by date before storing it to prevent foodborne illness.During a concurrent observation and interview on 6/15/26 at 9:16 a.m. with the Dietary Services Manager (DSM), an opened bag of bagels and an opened bag of bread were found resealed without labels indicating the date opened or a use by date. The DSM stated staff should have labeled both items when first opened with the date and included a use-by date. The DSM confirmed the bagels and bread needed to be discarded to prevent foodborne illness.During a concurrent observation and interview on 6/15/26 at 9:27 a.m. with the Dietary Services Manager (DSM), the June 2026 Kitchen Cleaning and Prep Log showed missing entries/blank spaces on June 3, 4, 10, and 11, 2026. Verification of cleaning and sanitizing the griddle, steam table, cook prep table, cook prep sink, can opener, and knives on June 11, 2026, was not recorded. The DSM stated the logs should have been completed daily on each shift to verify cleaning and sanitization. He added that he was working with staff and providing additional training to ensure routine daily cleaning to prevent foodborne illness.During a concurrent observation and interview on 6/15/26 at 9:30 a.m. with the Dietary Services Manager (DSM), [NAME] 1 demonstrated how he tested the sanitization solution in the red buckets. [NAME] 1 used a paper test strip from a container labeled with a 6/01/23 expiration date. After testing, [NAME] 1 stated the concentration was acceptable. When asked whether expired test strips were appropriate to use, the DSM stated they were not, that expired strips needed to be discarded, and that the sanitization solution had to be retested with non expired strips to ensure proper sanitization and prevent foodborne illness.During a concurrent observation and interview on 6/15/26 at 10:08 a.m. with the Dietary Services Manager (DSM), plastic food bins used for meal preparation were observed stacked while still wet after handwashing, preventing the interior surfaces from drying, and placed on an unclean sink surface. The DSM stated the bins should have been separated and air dried on a clean surface to prevent foodborne illness.During a concurrent observation and interview in the kitchen on 6/17/26 at 10:15 a.m. with the Registered Dietician (RD), the Dietary Services Manager (DSM) reported the dishwasher had not been tested for the required minimum water temperature and sanitization solution concentration prior to first use on the day shift after breakfast. The RD confirmed the dishwasher was required to be tested and documented at the beginning of each shift. The RD stated testing before first use was essential to ensure proper sanitization of dishes and to prevent foodborne illness.During a review of the facility's policy titled, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, revised November 2022, the policy indicated, Hair nets or caps and/or beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens.During a review of the facility's policy titled, Sanitization, revised November 2022, the policy indicated, The food service area is maintained in a clean and sanitary manner . All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use of proper cleaning. Food preparation equipment and utensils that are manually washed are allowed to air dry.During a review of the facility's policy titled, Food Receiving and Storage, revised November 2022, the policy indicated, Non-refrigerated foods. are stored in a designated dry storage unit. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded.During a review of the facility's DRY GOODS STORAGE GUIDELINES, dated 2023, the guidelines indicated the following in regard to the storage of barbecue sauce, This storage length is to be followed unless you have manufacturer's recommendation indicating otherwise. BBQ sauce. UNOPENED ON SHELF. 1 year. OPENED ON SHELF. N/A. OPENED, REFRIGERATED. 4 months. Storage guidelines are based on the [app for U.S. Department of Health and Human Services].During a review of the facility's policy titled, REFRIGERATED STORAGE GUIDE, dated 2023, the guidelines indicated the following in regard to the storage of poultry, Meat Taken From Freezer to Thaw. Poultry. Maximum Refrigeration Time Once Meat Has Thawed. 2 days. Storage guidelines are based on the [app for U.S. Department of Health and Human Services].During a review of the facility's employee training materials titled, Labeling and Dating for food safety, presented to kitchen staff by the facility's Registered Dietician (RD) during the Labeling and Dating, employee training on 1/22/26, the document indicated, From [a nationally recognized food and beverage safety training program]: Here are the guidelines for labeling and dating food to keep it safe: Dating. Dating food reduces the risk that you serve food that may be potentially unsafe if kept for too long. For time-temperature control for safety (TCS) foods, mark the date or day by which the food needs to be sold, eaten, or thrown out if it will be held for longer than 24 hours. You can store TCS foods for up to seven days, with the day you opened the container or package counting as day 1. Serving food after seven days can potentially make someone sick since bacteria have had plenty of time to grow to unsafe levels from time-temperature abuse. For multi-ingredient dishes, mark the date of the earliest - or first-prepared ingredient.During a review of the facility's kitchen employee training material multiple choice test dated 6/11/26, indicated, 1. What must be on every food label? . B. Product name, prep date, discard date. 2. When does Day 1 start for the 7-day rule? . C. The day the food is prepared/opened. 4. What should you do if a food item has no label? . D. Throw it away.During a review of the facility's Dietary Aide job description, dated February 2024, indicated, Check and record chlorine concentration and water temperature of dishwashing machine at the beginning of shift. Sweep, mop and maintain floors.During a review of the facility's Cook job description, dated October 2016, indicated, Maintain kitchen and cooking area in a safe, orderly, clean and sanitary environment. Maintain quaternary solution in sanitizer buckets. make sure all cleaning schedules are followed.During a review of the facility kitchen staff training titled, CLEANING LOGS TRAINING, dated 3/31/26, indicated, Importance of Cleaning and Proper Documentation. Why cleaning is important. Prevents foodborne illness. Keeps residents safe. Meets health regulations. Maintains professional standards. Risks of Not Completing Logs. Food safety risks. Why Logs Matter. Proof of completed tasks. Helps track compliance. How to Fill Logs Correctly. Complete daily. Use initials/signature .During a review of the [Name of laboratory] manufacturer guidelines for the paper test strips used by the facility to test the efficacy and safety of the sanitization solution concentration in the red bucks in the kitchen indicated the following, The shelf life of [brand of test strips] pH paper is 3 years from the date of manufacture. The color chart is marked with the expiration and lot number for that specific roll. Our pH paper will remain accurate until the expiration date listed.

Based on interview and record review, the facility failed to provide services in accordance with professional standards of practice when:1. 72-hour monitoring was not performed as required for one of 18 sampled residents (Resident 34) following a change of condition (COC), and;2. Two Licensed Nurses (LN C and LN D) did not know how to check the function of the wander guard (an electronic wander management system) for a census of 74 residents. These failures had the potential to result in harm to residents by compromising their safety and well-being, as the lack of required 72-hour monitoring after a change of condition could delay the detection and response to health issues for Resident 34, and the inability of two licensed nurses to check the function of the wander guard system could put residents at risk of elopement or wandering without proper safeguards in place. 1. A review of Resident 34's admission record (facility demographic) indicated he was admitted to the facility in May 2026 with medical diagnosis which included cerebral infarction (stroke), and myelodysplastic syndrome (a group of bone marrow cancers where immature blood cells fail to mature). A review of Resident 34's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 5/13/26, indicated his Brief Interview of Mental Status (BIMS-a cognition [the processes of thinking and reasoning] assessment) score was 10, which indicated his cognition was moderately impaired (a score of 1-7 indicates cognition is severely impaired, 8-12 indicates cognition is moderately impaired, and 13-15 indicates cognition is intact). A review of Resident 34's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition [COC] among the residents) form, dated 5/29/26, indicated the change of condition reported was wandering and noted that Resident 34 was a danger to self or others. The SBAR further indicated that Resident 34 exited the building. A review of Resident 34's progress notes, type Nurse's Note, indicated no evidence that 72-hour (hr.) monitoring Q (every) shift was completed:5/30/26 and 5/31/26 evening shift (PM), and; 6/01/26 day shift (AM). A review of Resident 34's SBAR form, dated 6/10/26, indicated, [Resident 6] Attempting to leave the compound.Patient [Resident 34] was trying to leave stating that he does not want to be here. The form also noted that Resident 34 was a danger to self or others. A review of a subsequent undated SBAR form, indicated another change of condition reported was that Resident 34 fell during his attempt to leave the property on 6/10/26. The form further indicated, Ground level fall [witnessed] sustained while attempting to leave the facility on foot. A review of Resident 34's progress notes, type, Nurse's Note, indicated no evidence that 72 hr. monitoring every shift was completed on 6/11/26 for PM shift. A review of Resident 34's care plan initiated on 6/03/26 indicated, Elopement: [Resident 34] is at risk for elopement/exit seeking/wandering r/t [related to] dementia or other cognitive behavior, exit seeking behaviors .[staff were expected to] If wandering or elopement attempt occur follow facility policy.Monitor for delayed injury/pain.Increased observation and frequent safety rounds.A review of Resident 34's care plan initiated on 6/10/26 indicated, Falls: [Resident 34] had a witnessed fall and is at risk for change in neurological [related to the nervous system, which includes the brain, spinal cord, and nerves that control body functions, movement, and sensation] status, injury, loss of range of motion, pain, recurring falls. [staff were expected to] Monitor for complications related to the fall.During an interview on 6/17/26 at 6:10 p.m., LN C stated 72 hr. monitoring every shift began after a change in condition was initiated. LN C confirmed that 72 hr. monitoring was expected to be completed every shift. LN C stated that 72 hr. monitoring was completed so that if any changes were observed, such as adverse reactions or further decline, the changes were communicated to the doctor and the care team. During an interview and concurrent record review on 6/18/26 at 11:34 a.m., the Director of Nursing (DON) stated she expected 72 hr. monitoring every shift to be completed after a change in condition. The DON further stated the monitoring was expected to be documented in the form of a progress note. The DON stated the purpose of 72 hr. monitoring was that any issues related to the change in condition were monitored further to ensure that the resident received the right treatments and interventions as needed. The DON reviewed Resident 34's progress notes and confirmed that 72 hr. monitoring was not completed on 5/30/26 and 5/31/26 for PM shift, 6/01/26 during AM shift, and 6/11/26 during PM shift. The DON referenced Resident 34's form titled, Nursing- Daily Skilled Charting Form, dated 6/01/26 at 12:13 a.m., and stated that form covered AM shift monitoring. The DON further acknowledged the form made no reference to the change in condition reported and monitoring thereof. 2. A review of Resident 34's order recap report dated 5/6/26 through 6/30/26 indicated an order was placed on 5/29/26 for, Wander Bracelet r/t [related to] wandering/exit seeking behaviors. Nurse to check placement and function q shift. A review of Resident 34's care plan initiated on 6/03/26 indicated, Elopement: [Resident 34] is at risk for elopement/exit seeking/wandering r/t dementia or other cognitive behavior, exit seeking behaviors . [staff were expected to] Check function of wander alarm per manufacturer recommendations. During an interview on 6/17/26 at 6:05 p.m., LN D stated, If you want to check if the wander guard is working you would bring the resident close to a doorway and the alarm should go off. LN D confirmed that there was no device to check the function of the wander guard. During an interview on 6/17/26 at 6:10 p.m., LN C stated that there was no device used to verify whether the wander guard was functioning. During an interview on 6/18/26 at 8:23 a.m., LN A stated that a device to check the function of the wander guard was stored in the medication room. LN A further stated that if a resident had a wander guard, it was expected to be checked daily, every shift, especially at night. LN A stated the purpose of checking the wander guard function was to ensure that it was working properly. During an interview on 6/18/26 at 11:34 a.m., the DON stated it was expected that licensed nursing staff knew how to check the function of the wander guard. The DON further stated that she expected the function of the wander guard to be checked daily, or as ordered. A review of the facility's policy and procedure (P&P) titled, Elopement and Wandering Policy, dated 2023, indicated, This facility ensures that resident who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care.The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement.implementing interventions to reduce hazards and risk, and monitoring for effectiveness.Adequate supervision will be provided to help prevent accidents or elopements.A review of the facility's P&P titled, Falls and Fall Risk, Managing, revised 2018, indicated, The staff will monitor and document each resident's response to interventions intended to reduce falling or risks of falling.A review of an undated facility provided document titled, Instructions- Resident Wristband Transmitter, indicated, Testing.It is very important to test your Resident Wristband Transmitters on a regular basis.The manufacturer recommends testing Resident Wristband Transmitters DAILY.To test Resident Wristband Transmitters: 1. Take Tag Tester and pass tester within proximity of resident wearing Resident Wristband Transmitter.TEST RESIDENT WRISTBAND TRANSMITTERS REGULARLY. A review of the facility's document titled, Job Description: Registered Nurse [RN], and Job Description: LPN [Licensed Practical Nurse]/LVN [Licensed Vocational Nurse], both dated 2024, indicated, Ensure that all personnel operate nursing service equipment in a safe manner.

Based on interview and record review, the facility failed to report an allegation of abuse to the Department for one of 18 sampled residents (Resident 2).This had the potential to result in harm and continued risk of abuse to Resident 2 and other residents of the facility as a result of the Department being unable to initiate an investigation timely.Record review of Resident 1's admission record (facility demographic) indicated he was admitted on [DATE] with medical diagnoses which included left femur fracture (broken thigh bone) and chronic obstructive pulmonary disease (a progressive lung condition that makes it difficult to breathe).The Department received a report from an anonymous agency on 6/08/26 at 3:59 p.m., that indicated Resident 2 reported Certified Nursing Assistant F (CNA F) wanted him to wear a diaper and got frustrated with him and him on the left side of the face with the diaper.Record review of a facility document titled, SBAR [Situation, Background, Assessment, Recommendation, a standardized communication tool used in nursing and healthcare settings to facilitate clear, concise, and structured information exchange between team members] Communication Form, dated 6/16/26 at 9:30 p.m., indicated, @ [at] around 2100 [9 p.m.] [police department officer] came in to building & told that the pt. [patient] called & reported that he was hit in the face w/ [with] a brief by a lady CNA [CNA F].DON [Director of Nursing] made aware.During an interview with the Director of Nursing (DON) and Administrator (ADM) on 6/16/26 at 3 p.m., both confirmed their awareness of the allegation. They indicated that Reside3nt 2 had not informed any facility staff regarding the incident but did contact law enforcement, who subsequently notified them of the resident's allegation. The DON and ADM acknowledged that they had not reported the abuse allegation to the Department.During a second interview with the Administrator (ADM) on 6/16/26 at 3:26 p.m., he stated that the facility did not report the abuse allegation made by Resident 1 to the Department, as they believed it was the responsibility of the police department. This understanding stemmed from the fact that the allegation was not initially made to facility staff, but directly to the police. The ADM further stated that it was the police who subsequently informed the facility about the incident involving CNA F.Record review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, last revised in September, 2022, indicated, If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility.3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury.

Based on interview and record review, the facility failed to accurately document the controlled drug inventory count for a census of 74 residents when:1. The inventory count was not signed off every incoming and outgoing shift by nursing staff (Licensed Nurse [LN] or Registered Nurse [RN]),2. The total number of medication cards (medication blister card, a multi-compartment medication packing system) was recorded with mathematical errors, and;3. The forms were illegible.These failures increased the facility's potential for diversions (the unlawful removal or misuse of prescription or controlled substances from their intended path, from manufacturer to patient) and led to a lack of accountability for inaccurately documented controlled drugs. During a concurrent interview and record review on 6/18/26 at 3:15 p.m., the Director of Nursing (DON) confirmed the facility documents titled, Controlled Drug Inventory Count, dated 3/30/26 through 6/05/26 was not recorded to her expectations. The DON stated nurse staff were expected to count the controlled drugs during shift change to ensure that the counts were correct according to the controlled drugs administered and any new controlled drugs added. The DON confirmed that 54 nurse signatures were incomplete from the forms. The DON also confirmed that documentation was illegible and with math errors. The DON verified it was difficult to obtain an accurate account of the controlled drugs because some of the documentation was illegible. The DON stated the importance of obtaining accurate documentation was to ensure that residents received their medications as ordered. The DON further explained that accurate documentation served as a safeguard to ensure that drug diversion was not occurring within the facility. The DON stated no one had audited the controlled drug inventory count. The DON further stated that performing the audits was her responsibility.A review of the facility's policy and procedure titled, Controlled Substances, revised 2022, indicated, The facility complies with all laws, regulations and other requirements related to.documentation of controlled medications.Controlled substances are counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals sign the designated controlled substance record.Controlled substance inventory is monitored and reconciled to identify loss or potential diversion.Nursing staff count controlled medication inventory as the end of each shift, using these records to reconcile inventory count.The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services.The director of nursing services documents irreconcilable discrepancies in a report to the administrator.

Based on interview and record review, the facility failed to develop and revise care plans for one of 18 sampled residents (Resident 6) when:1. Resident 6 did not have a care plan that addressed a re-occurring infection and the ongoing administration of antibiotics (a medication used to treat or prevent bacterial infections) treatment, and;2. Resident 6 did not have a care plan that followed a change of condition.These failures had the potential to result in inadequate management of Resident 6's health needs, leading to possible worsening of the infection, delayed recovery, or other complications due to the lack of appropriate care planning for ongoing antibiotic treatment and changes in condition.A review of Resident 6's admission record (facility demographic) indicated he was admitted to the facility in March, 2020, with medical diagnosis which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (stroke), and Wernicke's encephalopathy (an acute neurological [related to the nervous system, which includes the brain, spinal cord, and nerves that control body functions, movement, and sensation] disorder). A review of Resident 6's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 6/2/26, indicated his Brief Interview of Mental Status (BIMS-a cognition [the processes of thinking and reasoning] assessment) score was three, which indicated his cognition was severely impaired (a score of 1-7 indicates cognition is severely impaired, 8-12 indicates cognition is moderately impaired, and 13-15 indicates cognition is intact). 1. A review of Resident 6's progress note type, Infection Note, dated 6/02/26 at 9:52 a.m. indicated, [Resident 6] was diagnosed with pneumonia [PNA, an infection/inflammation of the lungs] and started on PO [by mouth] Amoxicillin-Pot Clavulanate [an antibiotic] Oral Tablet 875-125 MG [milligram-metric unit of measurement, used for medication dosage and/or amount] on 4/26/26 but MD [Medical Doctor] change it to patient [Resident 6] still showing symptoms of PNA residual, following symptoms of cough and chest X-ray [an imaging test] findings of a left lower lobe/lingular [sections of the left lung] infiltrate [presence of abnormal substances that build up in the lung tissue] on the repeated xray on 5/15/26 and 5/29/26 still shows infiltration to left lower lobe. A review of Resident 6's order recap report indicated the following order with a start date of 5/29/26, Amoxicillin-Pot Clavulanate Tablet 875-125 MG Give 1 tablet by mouth every 12 hours for pneumonia, confirmed on xray + cough for 7 days. A review of Resident 6 's Medication Administration Record (MAR) dated 5/26 and 6/26 indicated the order for amoxicillin-pot clavulanate tablet 875-125 mg was administered 5/29/26 through 6/05/26. A review of Resident 6's care plan report with a print date of 6/18/26, indicated no evidence that a current antibiotic and/or pneumonia care plan was developed or revised. 2. A review of Resident 6's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition [COC] among the residents) form, dated 4/2/26, indicated the change of condition reported was, Resident [Resident 6] partially slide off the bed. The form further indicated, Resident [Resident 6] found by CNA [Certified Nurse Assistant] on his bedroom hanging down from the bed without touching the floor. His head was between the bed and the nightstand.A review of Resident 6's care plan report with a print date of 6/18/26, indicated no evidence that a care plan was developed after the change of condition [partially slid off the bed] was reported. During an interview on 6/18/26 at 4:35 p.m., Licensed Nurse E (LN E) stated that a care plan was expected to be initiated when a resident had an infection. LN E further confirmed that a care plan was also required when a resident was receiving antibiotic treatment. LN E stated, The purpose of the care plan is to discuss treatment with the team and how to implement care. During an interview and concurrent record review on 6/18/26 at 4:50 p.m., the Director of Nursing (DON) reviewed Resident 6's care plan report and confirmed that a care plan was not developed after he partially slid off the bed. The DON stated that she expected a care plan to follow the reported COC. The DON also confirmed that Resident 6's PNA and antibiotic treatment was not care planned. The DON stated she expected a revised care plan since the infection re-occurred and was previously care planned and documented as resolved. The DON stated that the purpose of initiating and revising a care plan was to review and address the underlying cause of the identified problem. The DON further stated that reviewing current interventions and considering additional interventions prevented that problem from happening again. A review of the facility's policy and procedures titled, Care Plans, Comprehensive Person-Centered, revised 2022, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change.The interdisciplinary team reviews and updates the care plans.when there has been a significant change in the resident's condition.when the desired outcome is not met. A review of the facility's document titled, Job Description: Registered Nurse [RN], dated 2024, indicated, Review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing needs. A review of the facility's document titled, Job Description: LPN [Licensed Practical Nurse]/LVN [Licensed Vocational Nurse], dated 2024, indicated, Review care plans daily to ensure that appropriate care is being rendered.Inform the Nurse Supervisor of any changes tht need to be made on the care plan. Review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing needs.

Based on interviews and record reviews, the facility failed to notify the Long Term Care Ombudsman (ombudsman, an advocate for residents of nursing homes, board and care centers, and assisted living facilities) for one out of two sampled residents (Resident 3) when Resident 3 was discharged from the facility and admitted to the hospital on [DATE] and again on 8/12/25. This failure put Resident 3 at risk for unsafe discharge. Findings:During an interview on 8/20/25 at 2:14 p.m., the Minimum Data Set coordinator (MDSC) stated the Ombudsman needs to be notified when a resident was sent or discharged to the hospital. The MDSC stated this was the residents' right and for their safety.During an interview on 8/20/25 3:27 p.m., the Director of Staff Development (DSD) stated the facility should notify the Ombudsman when residents are discharged to home or transferred to the hospital. The DSD stated if the Ombudsman was not notified of a discharge or transfer, it could leave the resident vulnerable to an unsafe discharge.During a concurrent interview and record review on 12/16/25 at 11:41 a.m. with the Director of nursing (DON), Resident 3's admission/discharge census record was reviewed. The DON verified Resident 3 was transferred to the hospital on 7/15/25 and 8/12/25. The DON stated the facility should notify the Ombudsman of discharges and transfers to the hospital per the facility policy. The DON stated the person responsible for notifying the Ombudsman of discharges and transfers was the Social Services Director (SSD). The DON stated if the Ombudsman was not notified of discharge or transfer to the hospital, residents would be at risk for unsafe discharge. During an interview on 12/16/25 at 12:40 p.m., the SSD stated it was their responsibility to notify the Ombudsman of a resident transfer or discharge. The SSD stated she did not have any documentation that indicated the Ombudsman was notified of Resident 3's transfers to the hospital on 7/15/25 or 8/12/25A review of the facility's policy and procedure (P&P) titled Transfer and Discharge Notices, revised 3/2025, the P&P indicated, . notice of transfer and discharge (emergency): notice of transfer is provided to the resident and responsible party (RP) as soon as possible before the transfer and to the long term care (LTC) ombudsman when practicable (in a monthly list that includes all notices.)A review of the All Facilities Letter (AFL) 25-17 dated 5/28/25, indicated,.before the SNF (Skilled Nursing Facility) transfers or discharges the resident, the SNF must. send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman.

Based on observations, interviews and record reviews, the facility failed to ensure an abuse allegation between Residents 1 and 2 was reported to the state licensing/certification agency (the state) within 2 hours. This failure could put the residents at significant risk for continued harm, which could lead to severe physical and psychological trauma.Findings:A review of Resident 1's face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated an admission date in 12/2017 with a diagnosis of Schizophrenia (a mental illness that is characterized by disturbances in thought) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).A review of Resident 1's Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident), dated 6/27/25, score was 10 indicating Resident 1 had moderately impaired thinking and memory.A review of Resident 2's face sheet indicated an admission date in 9/2023 with a diagnosis of Dementia (a progressive state of decline in mental abilities) and Major Depressive disorder. A review of Resident 2s BIMS, dated 6/18/25, score was 10 indicating Resident 2 had moderately impaired thinking and memory.A review of the SOC 341 form (written report used by mandated reporters when abuse or neglect of an elder (65+) or dependent adult (18-64 with disabilities) is suspected), dated 7/31/25, indicated, .at around 5:10 AM. Resident states that he does not know why roommate hit him.and roommate just punched him in the face.resident hit roommate on the right temple.roommate retaliated by hitting resident back on the nose. The fax confirmation sheet indicated the SOC 341 form was sent to the state licensing/certification agency on 7/31/25 at 8:50 a.m.During an interview on 8/20/25 at 2:14 p.m., the Minimum Data Set coordinator (MDSC) stated abuse allegations should be reported to the state within 2 hours of discovery. MDSC stated if the abuse allegation was not reported to the state within 2 hours, residents' safety could be at risk.During an interview on 8/20/25 at 3:27 p.m., the Director of Staff Development (DSD) stated that abuse allegations should be reported to the state within 2 hours of discovery. The DSD stated if not reported to the state immediately, within 2 hours, resident could be at risk for continued abuse.During a concurrent interview and record review on 12/16/25 at 11:41 a.m., with the Director of Nursing (DON), the SOC 341, sent to the state on 7/31/25 at 8:50 a.m., was reviewed. The DON verified the facility was aware of the abuse allegation on 7/31/25 at 5:10 a.m. The DON stated that abuse allegations should be reported to the state within 2 hours of discovery. The DON verified that this abuse allegation was reported late to the state. A review of the facility's policy and procedure (P&P) titled Abuse, Neglect, Exploitation, or Misappropriation-Reporting and Investigating, revised 9/2022, the P&P indicated, .the administrator or the individual making the allegation immediately reports his or her suspicions to the following persons or agencies: state licensing/certification agency responsible for surveying/licensing the facility, local state ombudsman, law enforcement official.immediately is defined as within 2 hours of an allegation involving abuse or result in serious bodily injury.

Based on interview, observation and record review, the facility failed to provide a comfortable, homelike environment for one of four sampled residents (Anonymous Witness 1) when, after repeated complaints, the facility continued to use a floral-scented air freshener near Anonymous Witness 1's bedroom.This deficient practice resulted in Anonymous Witness 1 experiencing headaches and episodes of throat irritation and had the potential to offend or harm other residents of the facility. Findings:A review of Anonymous Witness 1's admission Record, dated 8/8/25, indicated Anonymous Witness 1 was admitted to the facility on [DATE], with diagnoses including respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in the body), acute bronchitis (an inflammation of the bronchial tubes, the airways that carry air to your lungs) & pulmonary hypertension (a condition where blood pressure in the pulmonary arteries [vessels carrying blood from the heart to the lungs] is abnormally high).A review or Anonymous Witness 1's Minimum Data Set, Section C (MDS - a standardized, comprehensive evaluation of residents in Medicare and Medicaid certified nursing homes), dated 6/11/25, it indicated Anonymous Witness 1 had a BIMS (Brief Interview for Mental Status- indicates a resident's cognitive (related to a resident's conscious intellectual activity such as reasoning, thinking or remembering) function. The score, ranging from 0 to 15, helps identify potential cognitive impairment and informs care planning) score of 14, indicating no cognitive impairment. During a telephone interview with Anonymous Witness 1 on 8/7/25 at 1:00 pm, Anonymous Witness 1 stated the facility used mechanical air freshener devices about a year prior, and after he complained they were removed. Anonymous Witness 1 stated after the ownership of the facility had changed, the new owner had resumed using air fresheners. Resident 1 described the air freshener scent as a heavy baby powder or clothing detergent smell, which caused Anonymous Witness 1 headaches and throat irritation. Anonymous Witness 1 stated he had complained about this to facility staff, but they had not done anything about it.During an observation on 8/8/25 at 10:35 a.m., a noticeable floral fragrance was noticed in the hallway outside [room [ROOM NUMBER]].During an interview on 8/8/25 at 12:25 p.m. with a facility housekeeper (HK), HK stated she used an air freshener spray in her routine cleaning duties. HK also stated there were several mechanical air freshener devices in the hallways that were maintained by the facility maintenance department. HK stated Anonymous Witness 1 specifically asked her not to use spray air freshener in his bedroom, so she didn't. HK stated she did not know any details about the filler ingredients or chemicals used in the mechanical air freshener devices.During an interview on 8/8/25 at 12:35 p.m. with the Maintenance Assistant ([NAME]), [NAME] stated he started working at the facility a month prior, and he knew nothing about the mechanical air fresheners or what the refills were made of. [NAME] stated that the Maintenance Director knew, but he was out on leave for about a month.During a record review of Anonymous Witness 1's Care Plan Report, printed 8/8/25, it indicated on 6/12/23, the following focus was created, claims that he is allergic (where your body reacts to something that's normally harmless like pollen, dust or animal fur. The symptoms can be mild, but for some people they can be very serious) to air fresheners but is not listed as one of his allergies and has not have/had any change of condition recently such as allergies. Interventions included the following, Air freshener was removed closer [sic] to resident's room.During a concurrent observation and interview on 8/8/25 with the Social Services Director (SSD) and [NAME], the SSD stated she could smell the floral odor in the hallway directly outside of [room [ROOM NUMBER]]. SSD and [NAME] pointed out one of the mechanical air fresheners (a two-inch x two-inch white plastic box) attached to the hallway wall near the ceiling, approximately six feet away from [room [ROOM NUMBER]]. [NAME] stated that he believed the device had a setting that controlled the amount of fragrance released, and it was set at the lowest setting due to a prior complaint.During a interview on 8/8/25 at 3:00 p.m. with the Director of Nursing (DON), she stated there were no issues with using air fresheners because there was no specific regulation prohibiting its use in facilities.A review of the facility policy titled, Homelike Environment, dated 2/2021, indicated, staff provides person-centered care that emphasizes the resident's comfort, independence, and personal needs and preferences.facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include.pleasant neutral scents, and The facility staff and management minimize to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting. These characteristics include.institutional odors.

Based on interview and record review, the facility failed to ensure one resident (Resident 1) of four samples residents was treated with dignity and respect when Licensed Nurse 1 (LN 1) made a humiliating comment to Resident 1 in front of residents and staff. This failure resulted in Resident 1 feeling embarrassed and humiliated. The findings: A review of Resident 1's admission record indicated admission to the facility in September 2016 with diagnosis which included chronic obstructive pulmonary disease (COPD, a progressive lung disease that makes it difficult to breathe), chronic pain syndrome (persistent pain), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the left knee, hoarding disorder (a mental health condition characterized by a person who excessively gathers things) and major depressive disorder (a mental health condition characterized by symptoms like sadness, loss of interest and low energy). A review of a Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 5/16/25, indicated Resident 1 had no memory impairment. During an interview on 6/17/25 at 12:07 p.m., Resident 1 stated while she was in the hallway in front of the nurses' station (an area of a health care facility where nurses and other health care staff work behind) and outside of the dining and activities room, LN 1, Stood there and announced- I am not going to give you your medication until you take a shower! Resident 1 stated the comment was made in the presence of other residents and staff members. Resident 1 stated, I don't think I've ever been so god-damned embarrassed. How would you feel if you were in my situation and a ranking nurse said something like that to you in front of everyone. I was humiliated! Resident 1 further stated she did not feel respected. During an interview on 6/16/25 at 12:50 p.m., LN 2 stated, It's important to be sure the resident is protected and to maintain their privacy . It's inappropriate to body shame, or to shame the resident at all . LN 2 confirmed resident care needs should be addressed in private to maintain dignity. During an interview on 6/16/25 at 1:06 p.m., the Assistant Activities Director (AAD) stated a nurse came to her and told her she did not want Resident 1 participating in activities until she [Resident 1] showered. AAD further stated, She (LN 1) brought it up to me a couple of times. She doesn't think the resident should be able to participate if she does not shower. AAD confirmed she heard LN 1 say out loud, You need to take a shower , to Resident 1, while Resident 1 was in the front hallway by the dining and activities room. AAD confirmed residents were seated in the area and staff were nearby. AAD stated it was disrespectful to the resident, and further stated, They [residents] all have their rights. They should all be able to participate in activities. Denying the resident of simple needs is not something we should be doing. During an interview on 6/16/25 at 1:20 p.m., the Director of Nursing (DON) stated it is her expectation staff are compassionate and respectful, and further stated, To speak in a manner that is respectful to residents. The DON confirmed it is not acceptable to tell a resident they can not participate in activities until they [resident] showered. The DON stated, If a patient needed to be changed or they smelled, we should ask that patient to walk back to the room to address the issue in private .It's important to maintain privacy. No one wants to be told in front of others that they need to be changed or what needs to be done. The DON confirmed it could be demeaning (causing someone to lose their dignity and the respect of others) to the resident. During an interview on 6/16/25 at 2:02 p.m., the Administrator (ADM) stated, I expect that they [staff] speak to them [residents] in a way that is respectful and compassionate of their situation. The ADM confirmed it is not acceptable to tell a resident they could not participate in activities until they [resident] showered. The ADM further stated, I would not allow it. I think there is a way to help them shower without holding something over their head. The ADM confirmed issues regarding resident's hygienic needs should be addressed in private to maintain the resident's dignity and respect. During a review of a facility's policy and procedure (P&P) titled, Resident Rights, dated 2001 indicated, Employees shall treat all residents with kindness, respect and dignity. During a review of a facility's P&P titled, Dignity, dated 2001 indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .Residents are encouraged to attend the activities of their choice .Staff speak respectfully to residents at all times .Staff promote, maintain, and protect resident privacy .Demeaning practices and standards of care that compromise dignity are prohibited Staff are expected to promote dignity . F550 Resident Rights Based on interview and record review, the facility failed to ensure one resident (Resident 1) of four samples residents was treated with dignity and respect when Licensed Nurse 1 (LN 1) made a humiliating comment to Resident 1 in front of residents and staff. This failure resulted in Resident 1 feeling embarrassed and humiliated. The findings: A review of Resident 1's admission record indicated admission to the facility in September 2016 with diagnosis which included chronic obstructive pulmonary disease (COPD, a progressive lung disease that makes it difficult to breathe), chronic pain syndrome (persistent pain), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the left knee, hoarding disorder (a mental health condition characterized by a person who excessively gathers things) and major depressive disorder (a mental health condition characterized by symptoms like sadness, loss of interest and low energy). A review of a Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 5/16/25, indicated Resident 1 had no memory impairment. During an interview on 6/17/25 at 12:07 p.m., Resident 1 stated while she was in the hallway in front of the nurses' station (an area of a health care facility where nurses and other health care staff work behind) and outside of the dining and activities room, LN 1, Stood there and announced- I am not going to give you your medication until you take a shower! Resident 1 stated the comment was made in the presence of other residents and staff members. Resident 1 stated, I don't think I've ever been so god-damned embarrassed. How would you feel if you were in my situation and a ranking nurse said something like that to you in front of everyone. I was humiliated! Resident 1 further stated she did not feel respected. During an interview on 6/16/25 at 12:50 p.m., LN 2 stated, It's important to be sure the resident is protected and to maintain their privacy . It's inappropriate to body shame, or to shame the resident at all . LN 2 confirmed resident care needs should be addressed in private to maintain dignity. During an interview on 6/16/25 at 1:06 p.m., the Assistant Activities Director (AAD) stated a nurse came to her and told her she did not want Resident 1 participating in activities until she [Resident 1] showered. AAD further stated, She (LN 1) brought it up to me a couple of times. She doesn't think the resident should be able to participate if she does not shower. AAD confirmed she heard LN 1 say out loud, You need to take a shower , to Resident 1, while Resident 1 was in the front hallway by the dining and activities room. AAD confirmed residents were seated in the area and staff were nearby. AAD stated it was disrespectful to the resident, and further stated, They [residents] all have their rights. They should all be able to participate in activities. Denying the resident of simple needs is not something we should be doing. During an interview on 6/16/25 at 1:20 p.m., the Director of Nursing (DON) stated it is her expectation staff are compassionate and respectful, and further stated, To speak in a manner that is respectful to residents. The DON confirmed it is not acceptable to tell a resident they can not participate in activities until they [resident] showered. The DON stated, If a patient needed to be changed or they smelled, we should ask that patient to walk back to the room to address the issue in private .It's important to maintain privacy. No one wants to be told in front of others that they need to be changed or what needs to be done. The DON confirmed it could be demeaning (causing someone to lose their dignity and the respect of others) to the resident. During an interview on 6/16/25 at 2:02 p.m., the Administrator (ADM) stated, I expect that they [staff] speak to them [residents] in a way that is respectful and compassionate of their situation. The ADM confirmed it is not acceptable to tell a resident they could not participate in activities until they [resident] showered. The ADM further stated, I would not allow it. I think there is a way to help them shower without holding something over their head. The ADM confirmed issues regarding resident's hygienic needs should be addressed in private to maintain the resident's dignity and respect. During a review of a facility's policy and procedure (P&P) titled, Resident Rights, dated 2001 indicated, Employees shall treat all residents with kindness, respect and dignity. During a review of a facility's P&P titled, Dignity, dated 2001 indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .Residents are encouraged to attend the activities of their choice .Staff speak respectfully to residents at all times .Staff promote, maintain, and protect resident privacy .Demeaning practices and standards of care that compromise dignity are prohibited Staff are expected to promote dignity . Based on interview and record review, the facility failed to ensure one resident (Resident 1) of four sampled residents was treated with dignity and respect when Licensed Nurse 1 (LN 1) stated to Resident 1, I am not going to give you your medication until you take a shower! in front of residents and staff. This failure resulted in Resident 1 feeling embarrassed and humiliated. Findings: A review of Resident 1's admission record indicated admission to the facility in September 2016 with diagnosis which included hoarding disorder (a mental health condition characterized by a person who excessively gathers things) and major depressive disorder (a mental health condition characterized by symptoms like sadness, loss of interest and low energy). A review of a Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 5/16/25, indicated Resident 1 had no memory impairment. During an interview on 6/17/25 at 12:07 p.m., Resident 1 stated while she was in the hallway in front of the nurses' station (an area of a health care facility where nurses and other health care staff work behind) and outside of the dining and activities room, [LN 1] Stood there and announced, 'I am not going to give you your medication until you take a shower!' Resident 1 stated the comment was made in the presence of other residents and staff members. Resident 1 stated, I don't think I've ever been so god-damned embarrassed. How would you feel if you were in my situation and a ranking nurse said something like that to you in front of everyone? I was humiliated! Resident 1 further stated she flet disrespected. During an interview on 6/16/25 at 12:50 p.m., LN 2 stated, It's inappropriate to body shame, or to shame the resident at all . LN 2 confirmed resident care needs should be addressed in private to maintain dignity. During an interview on 6/16/25 at 1:06 p.m., the Assistant Activities Director (AAD) stated LN 1 told her she did not want Resident 1 participating in activities until she [Resident 1] showered. AAD further stated, [LN 1] brought it up to me a couple of times. She doesn't think [Resident 1] should be able to participate if she does not shower. AAD confirmed she heard LN 1 say out loud, You need to take a shower , to Resident 1 while Resident 1 was in the front hallway by the dining and activities room. AAD confirmed residents were seated in the area and staff were nearby and could have overheard. AAD stated it was disrespectful to Resident 1 and further stated, [Residents] all have their rights. They should all be able to participate in activities. Denying the resident of simple needs is not something we should be doing. During an interview on 6/16/25 at 1:20 p.m., the Director of Nursing (DON) stated staff were expected to be compassionate and respectful, and further stated, To speak in a manner that is respectful to residents. The DON confirmed it was unacceptable to tell a resident they could not participate in activities until they [residents] showered. The DON stated, If a patient needed to be changed or they smelled, we should ask that patient to walk back to the room to address the issue in private .It's important to maintain privacy. No one wants to be told in front of others that they need to be changed or what needs to be done. The DON confirmed it could be demeaning (causing someone to lose their dignity and the respect of others) to the resident. During an interview on 6/16/25 at 2:02 p.m., the Administrator (ADM) stated, I expect that they [staff] speak to them [residents] in a way that is respectful and compassionate of their situation. The ADM confirmed it was unacceptable to tell a resident they could not participate in activities until they [residents] showered. The ADM further stated, I would not allow it. I think there is a way to help them shower without holding something over their head. The ADM confirmed issues regarding resident's hygienic needs should be addressed in private to maintain the resident's dignity and respect. During a review of a facility's policy and procedure (P&P) titled, Resident Rights, dated 2001 indicated, Employees shall treat all residents with kindness, respect and dignity. During a review of a facility's P&P titled, Dignity, dated 2001 indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .Residents are encouraged to attend the activities of their choice .Staff speak respectfully to residents at all times .Staff promote, maintain, and protect resident privacy .Demeaning practices and standards of care that compromise dignity are prohibited Staff are expected to promote dignity .

Based on observation, interview and record review, the facility failed to provide one of three sampled residents (Resident 1) a homelike environment when the window sill and blinds were in need of repair and there was peeling paint on a wall in his room. These failures had the potential to negatively impact Resident 1's comfort and create an environment that was not homelike. Findings: A review of Resident 1's admission record indicated he was admitted in 10/24 with organ-limited amyloidosis (a condition characterized by the presence of proteins lodged in the body's tissues which can affect the entire body and cause a large range of varying symptoms, including appetite loss to bleeding). A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 3/18/25, indicated he had no memory impairment. During a concurrent interview and observation on 6/3/25 at 1:41 p.m. with Resident 1 in his room, the window sill of his room's window had two areas of missing or damaged wood, each approximately 6 inches (in., a unit of measurement) in length. Resident 1 stated staff had damaged it when they had moved beds in and out of the room. Horizontal blinds covering the window were missing approximately 4 in. of each blind strip along the right side of the blind and this occurred down two-thirds of the blind. Resident 1 stated that because the blinds were damaged they let more sun in the room and made it warmer. An area on the room's wall measuring approximately 12 x 12 in. above the television had peeling paint and areas where the peeling paint had been painted over. Resident 1 stated these conditions made him feel like he was, Living in a dump. During a concurrent interview and observation on 6/3/25 at 2:09 p.m. with Certified Nurse Assistant 1 (CNA 1) in Resident 1's room, CNA 1 confirmed the window sill and blinds were damaged and there was peeling paint above the television. CNA 1 agreed they were in need of repair, the room was not homelike and if this were her room she would not have wanted it to look like this. During an interview on 6/3/25 at 2:16 p.m. with the Administrator (ADM), the ADM stated he expected resident rooms were maintained in good repair. The ADM agreed the damaged window sill and blinds, along with the peeling paint in Resident 1's room needed to be addressed by the facility. During a review of the facility's policy titled, Homelike Environment, dated 2001, the policy stipulated, Residents are provided with a safe, clean, comfortable and homelike environment .

Based on observation, interviews and record reviews, the facility failed to ensure one out of three sampled residents (Resident 1) was provided foot care, including timely toenail trimming when Resident 1's toenails were allowed to grow too long. This failure resulted in Resident 1 acquiring cellulitis (a skin infection that causes swelling and redness) and ingrown toenails (occurs when the edge of the toenail grows into the surrounding skin, causing pain, redness, and swelling) to all toes, which led to the physician to perform matrixectomy (a surgical procedure that removes the growth area of an ingrown toenail) of all toenails on 4/10/25. This failure also resulted in Resident 1 experiencing pain and fear of further pain due to the long and ingrown toenails and the long wait before a physician could provide care for his toenails. Findings: A review of Resident 1s face sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 1 admitted to the facility in November of 2024 with diagnoses including intracerebral hemorrhagic stroke (when bleeding occurs in the brain) and muscle weakness. During a concurrent observation and interview on 4/16/25 at 10:56 a.m., Resident 1 was in bed, his feet were not covered in blanket, and his toenails on both feet were missing. Resident 1 stated the previous week a physician came and removed all his toenails. Resident 1 explained, prior to the removal of all his toenails, his toenails were so long they had curved, and he could not walk due to his toenails hitting the inside of his shoes and causing him pain. Resident 1 stated his toes became very tender and eventually he could not tolerate wearing shoes. Resident 1 stated even socks caused him discomfort as they would snag on his toenails. Resident 1 stated because his toenails grew so long, he acquired ingrown toenails which caused more tenderness and pain. Resident 1 stated he had communicated these issues and had requested help from staff on multiple occasions to address his long and ingrown toenails, but nothing was done. Resident 1 stated staff told him a nurse would cut his toenails, but they never did. Resident 1 confirmed he had no diabetes nor circulatory problems that would put him at a higher risk for toenail cutting. Resident 1 was told the physician had to cut his toenails, but he had to wait since the physician only comes once every 60 days. Resident 1 stated it was frustrating to ask staff to cut his toenails repeatedly only to have to wait for the physician for months. Resident 1 stated once the physician came, Resident 1 determined the best option was to have the physician remove all his toenails because of the fear the facility would allow his toenails to grow too long and he would get ingrown toenails again. Resident 1 stated he feared the pain and the prospect of a long wait time to get the footcare he needed. Resident 1 stated he felt lousy about the whole experience, but he did not wish to experience the same thing again. A review of the list of residents seen by the podiatrist (doctor who specializes in the care of feet) on 2/19/25 did not include Resident 1. A review of a wound care physician's note, dated 4/10/25, indicated Resident 1 had cellulitis and ingrown toenails of all left and right toes. The note further indicated, a matrixectomy was performed on all 10 toes on 4/10/25. During an interview on 4/16/25 at 11:12 a.m., the Medical Records Director (MRD) agreed when requested to provide documentation staff were providing toenail care and cleaning for Resident 1. During an interview on 4/16/25 at 12:47 p.m., the same request was made to the Director of Staff Development (DSD), however, the facility was not able to provide documentation to indicate the facility was providing toenail care and cleaning for Resident 1. During an interview on 4/16/25 at 11:12 a.m., the Medical Records Director (MRD) agreed when requested to provide documentation for the most recent visit from the podiatrist. During a telephone interview on 4/17/25 at 3:04 p.m., the same request was made to the Director of Nursing (DON), however, the facility was not able to provide documentation on when Resident 1 had last been seen by a podiatrist. A review of the physician notification text to Resident 1's primary care physician (PCP) dated 4/2/25 was provided by the DON. The notification text iindicated MRD spoke to the DON about Resident 1s toenails, that the DON reached out to the wound company surgeon who will be at the facility on 4/10/25. The PCP notification did not indicate Resident 1's complaints of pain due to long and ingrown toenails. During an interview on 4/16/25 at 11:16 a.m., Unlicensed Staff A stated staff should provide daily nail care and cleaning to residents. Unlicensed Staff A stated not cleaning the residents' foot and toes daily could contribute to fungal growth. Unlicensed Staff A stated not regularly trimming toenails could lead to long toenails. Unlicensed Staff A stated it was important residents' toenails were trimmed regularly as long toenails could cause the skin around the toes to get damaged. Unlicensed Staff A stated skin breakdown could result to pain, wound and infection. During an interview on 4/16/25 at 11:51 a.m., Licensed Nurse (LN) B stated staff was supposed to provide daily nail care/cleaning to residents and added, not doing so could result in development of fungus. LN B stated she was aware of Resident 1's complaint about the pain on his toes and his long toenails. When asked why Resident 1's toenails were not cut as he requested and was allowed to grow long, LN B was silent. LN B stated she did not know why the nurse was unable to cut Resident 1's toenails. LN B stated allowing the toenails to grow long could result in pain, ingrown toenails and infection. LN B stated if the facility had provided regular toenail trimming for Resident 1 or had they sent Resident 1 to another podiatrist, it could have prevented Resident 1s toenails from getting too long, developing ingrown toenails and experiencing pain due to the ingrown toenails. During an interview on 4/16/25 at 12:06 p.m., the Infection Preventionist (IP) stated the podiatrist only comes to the facility every 60 days. The IP stated he was aware of Resident 1's concern about his long toenails. When asked how long Resident 1 had been requesting staff to cut his toenails, the IP was silent. The IP stated if toenail care/cleaning was not being provided, or if a resident had long toenails and toenails were not being regularly trimmed it could result in pain, ingrown toenails, and subsequently toenail fungal infections. When asked why Resident 1 did not receive a regular toenail trim and why his toenails were allowed to grow long, the IP was silent. When asked if Resident 1 could have been sent to see another podiatrist when he was already complaining of discomfort or pain on his toes, the IP stated yes. During a telephone interview on 4/16/25 at 1:09 p.m., with the Surgeon who performed the matrixectomy on all of Resident 1's toes. The surgeon stated Resident 1 had fungal growth and ingrown toenails on all 10 toes. The surgeon stated initially he would only remove 4 toenails however, the decision to remove all of Resident 1's toenails was due to Resident 1's concern about the long wait time between the physician visit to cut his toenails and concerns the ingrown toenails might happen again since the podiatrist only comes in every 60 days. The surgeon stated Resident 1's toes were inflamed (body's response to injury or infection which can cause pain) and the toenails were long and added, imagine what your nails would look like if you don't cut them for 60 days. The surgeon stated Resident 1's long toenails contributed to the toe inflammation primarily due to the development of ingrown toenails. During a telephone interview on 4/17/25 at 3:04 p.m., the Director of Nursing (DON) stated it was always an option for residents to see another podiatrist if needed and added, Resident 1 could have been sent out to see another podiatrist prior to 4/10/25. The DON stated she believed the facility also tried to get him an appointment with an outside provider but there was no available appointment earlier than 4/10/25. The DON stated if there was no documentation to indicate a service was provided for a resident, then it meant the service was not provided. During this interview the DON agreed to provide the documentation the facility attempted to send Resident 1 to see an see an outside provider podiatrist for his painful, long and ingrown toenails before 4/10/25, however the requested documentation was not provided. During a telephone interview on 4/17/25 at 3:04 p.m., the DON agreed when requested to provide documentation that attempts were made to set up Resident 1 to see an outside provider or podiatrist for the painful long and ingrown toenails. However, the facility was not able to provide documentation that any attempts were made to set up an appointment for Resident 1 to see an outside provider or podiatrist. During a telephone interview on 4/21/25 at 10:35 a.m., the Director of Nursing (DON) verified Resident 1 was not seen when the podiatrist visited the facility on 2/19/25. A review of the facility's policy and procedure (P&P) titled, Fingernails/Toenails, Care of , revised 2/2018, the P&P indicated, . nail care including daily cleaning and regular trimming .proper nail care can aid in the prevention of skin problems around the nail bed .report to the nurse supervisor if there was an evidence of ingrown toenails, infections, pain. The following information should be recorded in the residents' medical record: date and time nail care was given, name and title of the individual who administered nail care, condition of the residents nails and nail bed .

Based on observations, interviews and record reviews, the facility failed to ensure two out of three sampled residents (Resident 2 and Resident 3) received services to maintain grooming and personal hygiene (the practices and habits that maintain cleanliness and promote health by preventing the spread of germs and disease) when: 1. Residents 2 and Resident 3 were not provided regular nail trimming and nail care , and 2. Resident 3 did not receive showers or bed baths as scheduled. These failures could result in discomfort, potential skin impairments, and infection. Findings: A review of Resident 2's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 2 was admitted to the facility in August 2023 with a diagnoses of multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord) and muscle weakness. A review of Resident 2's Activities of Daily Living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) flow sheet, dated 1/27/25, indicated Resident 2 needed assistance performing personal hygiene. During a concurrent observation and interview on 4/16/25 at 11:11 a.m., Resident 2 stated staff do not trim her fingernails regularly and she could not recall when the last time staff had trimmed her fingernails. Resident 2 showed her long fingernails and stated, it's been a while . Resident 2 stated she had requested staff to cut her fingernails for weeks, but they still were not cut. Resident 2 stated she disliked having long fingernails, they were uncomfortable being long. Resident 2 stated not only had she accidentally scratched herself, but she was also concerned she might accidentally scratch staff with her long fingernails. During an interview on 4/16/25 at 11:16 a.m., Unlicensed Staff A stated the facility did not have a set date nor frequency on when to trim residents' fingernails and added, nail care should be done daily to ensure residents' fingernails were kept short and clean. Unlicensed Staff A stated they would cut residents' nails when the residents request it. Unlicensed Staff A did not respond when asked what he would do if a resident was nonverbal and could not request a nail trim. Unlicensed Staff A stated there was no reminder to alert staff when to perform nail care/trim, and added, it would be good to have a schedule for when residents should receive a nail trim. Unlicensed Staff A stated, not cutting and caring for the residents nail regularly could lead to long fingernails where dirt and food particles could get stuck in them and could also put residents at risk for scratches. During an interview on 4/16/25 at 11:51 a.m., Licensed Nurse B (LN B) stated there was no set schedule for when staff should trim residents' fingernails. LN B stated certified nursing assistants (CNAs) were in charge of cutting residents' fingernails as long as they were not diabetic (a person who has been diagnosed with diabetes, a condition characterized by high blood sugar levels) or had problem with circulation. LN B stated she knew staff should clean residents' hands and nails daily. LN B stated residents having long fingernails or having blackish materials underneath the fingernails was unacceptable. LN B added, long and dirty fingernails could lead to skin breakdown and infections. During a concurrent observation and interview on 4/16/25 at 12:42 a.m., Resident 3 was in bed, unkempt, smelled of urine, fingernails of both hands were long with blackish materials underneath his fingernails. Resident 3 stated the blackish material underneath his fingernails was dirt . Resident 3 stated he could not remember how long the dirt had been under his fingernails and added, staff did not regularly ask to clean his hands nor trim his fingernails but he would like it if staff would. During an interview on 4/16/25 at 12:47 p.m., when shown a photo of Resident 3's fingernails, the Director of Staff Development (DSD) stated the blackish material underneath his fingernails looked like dirt. The DSD stated long fingernails was a breeding ground for bacteria (germs). The DSD stated having long fingernails or fingernails that had blackish material underneath was not acceptable. The DSD stated she was not aware of the facility policy on how often and when should staff trim residents' nails. The DSD was not able to provide documentations when asked on when was the last time Resident 2 or Resident 3 were given a nail trimming. A review of the facility's policy and procedure (P&P) titled, Fingernails/Toenails, Care of , revised 2/2018, the P&P indicated .nail care include daily cleaning and regular trimming . the following information should be recorded in the residents' medical record: date and time nail care was given, name and title of the individual who administered nail care, condition of the residents nails and nail bed . 2.A review of Resident 3's shower flow sheets (document that details when resident was offered and given shower or bed bath), dated 3/18/25 through 4/15/25, indicated Resident 3 only received four showers from 3/18/25 up to 4/15/25 on dates 3/18/25, 3/20/25, 3/27/25 and 4/5/25 and received only two bed baths on dates 4/1/25 and 4/10/25. A review of Resident 3s shower flow sheet, for March 2025 and April 2025 (through 4/15/25), the flow sheets indicated Resident 3 refused a bed bath or shower on 3/29/25 and 4/3/25 but the facility was not able to provide documentation on why Resident 3 refused shower or bed bath. During an interview on 4/16/25 at 11:16 a.m., Unlicensed Staff A stated residents were scheduled for showers two to three times a week or as needed (PRN) per facility policy. Unlicensed Staff A stated if a resident refused shower, the nurse should be notified, and a bed bath should be offered. Unlicensed Staff A stated it was the facility's policy that bed baths were done daily to ensure residents were clean and free of odor. Unlicensed Staff A stated not receiving showers as scheduled and not receiving bed baths could result in skin impairments. During a concurrent observation and interview on 4/16/25 at 12:42 p.m., Resident 3 was in bed, unkempt and smelled of urine. Resident 3 stated he had not received a shower nor bed bath today. Resident 3 was surprised to learn he should be receiving bed baths daily and stated he could not recall when the last he had a shower. Resident 3 stated he did not receive bed baths daily. Resident 3 stated he did not complain about not receiving showers or daily bed baths because he assumed staff were unable to give him showers or bed baths due to lack of staff or the staff were too busy. Resident 3 stated overtime some staff just stopped asking if he needed a shower or bed baths. During an interview on 4/16/25 at 12:47 p.m., the DSD stated residents were expected to receive showers three times a week as scheduled and should be receiving bed baths daily. The DSD stated shower refusals and the reason for refusals should be documented. The DSD stated in a month, residents should be receiving between 12 to 13 showers. The DSD stated not receiving showers regularly could lead to body odor, skin problems, and infections. During a telephone interview on 4/17/25 at 3:04 p.m., the Director of Nursing (DON) stated if residents refused a shower, then a bed bath should be given to the residents. The DON stated shower and bed baths refusal and the reasons for refusals should be documented. The DON stated it was the facility's policy and was a no brainer that bed baths were to be given daily. A review of the facility policy and procedure (P&P) titled Bath, Shower/Tub , revised 2/2018, the P&P indicated, . the purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin .documentation .all assessment data (e.g. any reddened areas, sores on the residents skin) obtained during the shower/tub bath .if the resident refused the shower/tub bath, the reason(s) .

Based on observations, interviews and record reviews, the facility failed to ensure a pain management plan was developed for one out of three sampled residents (Resident 1) who was at a high risk of experiencing pain when he had ingrown toenails (occurs when the edge of the toenail grows into the surrounding skin, causing pain, redness, and swelling) and after he underwent matrixectomy (a surgical procedure that removes the growth area of an ingrown toenail) to of all his toenails on 4/10/25. This failure resulted to Resident 1 experiencing pain on his toes from the ingrown toenails and after the matrixectomy procedure to all toes. Findings: A review of Resident 1s face sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 1 was admitted to the facility in November of 2024 with diagnoses including intracerebral hemorrhagic stroke (when bleeding occurs in the brain) and muscle weakness. A review of the Interdisciplinary Team (IDT, a group of professionals from different disciplines who collaborate to provide comprehensive patient care) Functional Abilities Collaboration V2.0 form (a form usually completed by a health professionals to document a patient's functional abilities), dated 2/12/25, indicated Resident 1 had the ability to walk at least 150 feet (ft, unit in measure) in a corridor or a similar space with supervision or touching assistance. A review of a wound care physician's note, dated 4/10/25, indicated Resident 1 had cellulitis (a skin infection that causes swelling and redness) and ingrown toenails of all left and right toes. The note further indicated, a matrixectomy was performed on all 10 toes on 4/10/25. A review of Resident 1's care plans (CP, a roadmap for caregivers, detailing the tasks, interventions, and timelines needed to ensure the individual receives appropriate and effective care) indicated there were no care plans created for pain management when Resident 1 had ingrown toenails or after the matrixectomy procedures. A review of Resident 1s electronic medication administration record (EMAR, a digital system used to track and manage medications administered to patients), for the month of April 2025, indicated Resident 1 experienced and reported a pain level (on a scale of zero to 10, with zero being no pain and 10 being worst pain possible) of: 6 out of 10 and 8 out of 10 on 4/10/25 6 out of 10 and 7 out of 10 on 4/11/25 8 out of 10 on 4/13/25 and 4/14/25, and 6 out of 10 on 4/16/25. During a concurrent observation and interview on 4/16/25 at 10:56 a.m., Resident 1 was in bed, his feet were not covered by a blanket, and his toenails on both feet were missing. Resident 1 stated the previous week a physician came and removed all his toenails. Resident 1 was noted to be grimacing and stated his toes were in pain because the blanket was rubbing on his nail beds (the soft tissue located underneath the nail). Resident 1 stated when a blanket scratches or lays on his bare nail bed, the pain was very bad and ranged about 8 or 9 out of 10. Resident 1 stated he made sure not to lay a blanket on his bare nail bed, but his feet get cold. Resident 1 stated the cold and the pain was frustrating, he felt lousy and depressed. Resident 1 stated he was hoping staff could have done something or placed something on his bed to prevent the blanket from touching his bare nail bed. Resident 1 stated prior to the doctor removing all of his toenails, he had long and ingrown toenails that were painful. Resident 1 stated what frustrated and depressed him the most was prior to his toenails growing long and becoming ingrown, he was able to walk with the use of his walker but since his toenails grew too long became ingrown, it was too painful to walk and he had to use a wheelchair to move around the facility. During a concurrent observation and interview on 4/16/25 at 11:23 a.m. Unlicensed Staff C stated he was aware of Resident 1's previous complaints about his long toenails. Unlicensed Staff C stated having long toenails could lead to ingrown toenails which would be painful. CNA added the ingrown toenails made it difficult for resident to put on his shoes and walk comfortably. Unlicensed Staff C verified Resident 1 did not have a bed cradle (device that attach to your bed that keep sheets and blankets from touching and rubbing your legs or feet). Unlicensed Staff C stated allowing the blanket to lay/rub on Resident 1's bare nail bed would be very painful and acknowledged the facility should have placed a bed cradle to ensure the blanket did not touch Resident 1's bare nail beds to help prevent pain. During an interview on 4/16/25 at 11:51 a.m., Licensed Nurse (LN) B confirmed Resident 1 used to walk with a walker before but then was seen using a wheelchair about a week prior to the doctor removing all of his toenails. LN B stated having long toenails and ingrown toenails could be painful and cause discomfort wearing shoes. LN B acknowledged allowing a blanket to lay or rub on Resident 1's bare nail bed could also be painful. LN B stated they do not have any non-pharmacological interventions (NPI, healthcare methods that don't rely primarily on medication to address a health issue) an added, the facility could have put a bed cradle to prevent the blanket from laying or rubbing on his bare nail beds. During an interview on 4/16/25 at 12:06 p.m., the infection Preventionist (IP) stated allowing a blanket to lay/rub on a bare nail beds would be painful. The IP stated the facility could have used a bed cradle to ensure the blanket did not lay/rub on Resident 1's bare nail bed thus preventing pain. The IP stated having long toenails would make it uncomfortable to wear shoes and could also lead to painful ingrown toenails. The IP acknowledged, toe pain could result in difficulty walking and the resident feeling depressed. During an interview on 4/16/25 at 12:47 p.m., the Director of Staff Development (DSD) stated allowing a blanket to lay/rub on top of bare nail bed would be painful. The IP stated one of the things the facility could have done was to attach a bed cradle to protect Resident 1's feet and prevent the blanket to rub on his bare nail bed. The IP stated having long toenails could result to ingrown toenails which could be painful. The DSD stated the pain could lead to all kinds of problems such as difficulty in walking, overall decline, and refusal to participate in activities. During an interview on 4/16/25 at 1:17 p.m. Unlicensed Staff D stated Resident 1 used to walk with a walker but about a week prior to thedoctor coming in to see his foot, Resident 1 requsted he use a wheelchair due to difficulty walking with the long and ingrown toenails. A review of the facility's policy and procedure (P&P) titled Pain Assessment and Management , revised 10/2022, indicated, . pain management is defined as the process of alleviating the residents pain based on his or her clinical condition and established treatment goals .is a multidisciplinary care process that includes the following: assessing the potential for pain, recognizing presence of pain,. Addressing the underlying causes of pain, developing and implementing approaches to pain management, identifying and using specific strategies for different levels and sources of pain .possible behavioral signs of pain including changes in gait, depressed mood, decreased participation in usual physical and or social activities, loss of function or inability to perform ADLs due to the presence of pain, guarding, rubbing or favoring a particular part of the body .the pain management interventions are consistent with the residents goal for treatment which are defined and documented in the care plan. Pain management interventions reflect the sources, type and severity of pain .pain management shall address the underlying causes of residents pain .non pharmacological interventions may be appropriate alone or in conjunction with medications, some NPI include environmental such as smoothing a linen, repositioning, reducing pressure .

Based on observation, interview and record review, the facility failed to promote and enhance the sense of well-being for two residents (Resident 1 and Resident 6) of four sampled residents when facility staff did not verify Resident 1 and Resident 6 wore their own clothing. This failure resulted in Resident 1 showing up to a family party during the holidays wearing women ' s clothes and Resident 6 feeling disrespected and sad. Findings: A review of Resident 1 ' s admission record indicated he was admitted in 3/8/23 with diagnoses which included dementia (a group of conditions that cause loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of a Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 12/11/24, indicated he had severe memory impairment. A review of Resident 3 ' s admission record indicated he was admitted in 10/8/24 with diagnoses which included amyloidosis (a rare, inherited disorder characterized by the accumulation of abnormal proteins in the nerves, leading to progressive nerve damage). A review of an MDS, dated [DATE], indicated he had no memory impairment. A review of Resident 5 ' s admission record indicated he was admitted in 3/22/20 with diagnoses which included hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following cerebral infarction (stroke) affecting the right dominant side. A review of an MDS, dated [DATE], indicated he had moderate memory impairment. A review of Resident 6 ' s admission record indicated he was admitted in 1/7/25 with diagnoses which included atrial fibrillation (a condition where the upper chambers of the heart beat irregularly and rapidly). A review of an MDS, dated [DATE], indicated he had severe memory impairment. During a phone interview on 3/5/25 at 10:05 a.m., Family Member XX stated Resident 1 was picked up from the facility by another family member to spend Christmas with the family in 2024 and arrived to the celebration wearing women ' s pants. Family Member XX stated Resident 1 was unaware he was not wearing his own clothing because of his dementia. Family Member XX stated Resident 1 had been observed in previous occasions wearing clothing that did not belong to him. Family Member XX gave the Surveyor permission to check Resident 1 ' s clothing in his closet. During an interview and concurrent observation on 3/5/25 at 10:45 a.m., Housekeeper A stated housekeeping personnel were responsible for putting away resident clothing in their closets based on the label printed on each garment, which indicated the name of the resident. Housekeeper A also stated housekeeping or laundry personnel were responsible for labeling residents ' clothes with their name for identification purposes. Resident 1 ' s closet was found to store a sweater labeled with another resident ' s name. This observation was confirmed by Housekeeper A. During an interview on 3/5/25 at 11:40 a.m., Resident 3 stated he had observed Resident 5 wearing Resident 6 ' s shirt, which had the design of a famous football team. Resident 3 stated he knew this information because Resident 6 used to be his roommate, and he had witnessed when his family had brought this shirt to him, as Resident 6 was a fan of the football team. During a concurrent observation and interview on 3/5/25 at 12:05 p.m., Resident 5 was observed in the dining room wearing a shirt adorned with a famous football team ' s logo. Resident 5 stated he had purchased it at a thrift store for two dollars. The Surveyor observed the shirt was labeled with Resident 6 ' s name, in clear black handwritten letters. During a concurrent interview and observation on 3/5/25 at 12:20 p.m., CNA B confirmed the shirt Resident 5 was wearing did not belong to him and acknowledged he had not checked the label written on the shirt prior to dressing Resident 6 that morning. During an interview on 3/5/25 at 12:33 p.m., the Director of Nursing (DON) stated CNAs were supposed to check residents ' clothing to ensure the clothing belonged to them, prior to assisting them with dressing. During an interview on 3/5/25 at 3:45 p.m., Resident 6 stated he had seen other residents wear his clothing. Resident 6 stated he felt disrespected and sad when other residents wore his clothing, because they were gifted by his sister, so they were very special to him. During a review of the facility ' s policy titled, Dignity, revised 2/2021, indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .Residents are treated with dignity and respect at all times .Residents ' private space and property are respected at all times. Based on observation, interview and record review, the facility failed to promote and enhance the sense of well-being for two residents (Resident 1 and Resident 6) of four sampled residents when facility staff did not verify Resident 1 and Resident 6 wore their own clothing. This failure resulted in Resident 1 showing up to a family party during the holidays wearing women's clothes and Resident 6 feeling disrespected and sad. Findings: A review of Resident 1's admission record indicated he was admitted in 3/8/23 with diagnoses which included dementia (a group of conditions that cause loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of a Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 12/11/24, indicated he had severe memory impairment. A review of Resident 3's admission record indicated he was admitted in 10/8/24 with diagnoses which included amyloidosis (a rare, inherited disorder characterized by the accumulation of abnormal proteins in the nerves, leading to progressive nerve damage). A review of an MDS, dated [DATE], indicated he had no memory impairment. A review of Resident 5's admission record indicated he was admitted in 3/22/20 with diagnoses which included hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following cerebral infarction (stroke) affecting the right dominant side. A review of an MDS, dated [DATE], indicated he had moderate memory impairment. A review of Resident 6's admission record indicated he was admitted in 1/7/25 with diagnoses which included atrial fibrillation (a condition where the upper chambers of the heart beat irregularly and rapidly). A review of an MDS, dated [DATE], indicated he had severe memory impairment. During a phone interview on 3/5/25 at 10:05 a.m., Family Member XX stated Resident 1 was picked up from the facility by another family member to spend Christmas with the family in 2024 and arrived to the celebration wearing women's pants. Family Member XX stated Resident 1 was unaware he was not wearing his own clothing because of his dementia. Family Member XX stated Resident 1 had been observed in previous occasions wearing clothing that did not belong to him. Family Member XX gave the Surveyor permission to check Resident 1's clothing in his closet. During an interview and concurrent observation on 3/5/25 at 10:45 a.m., Housekeeper A stated housekeeping personnel were responsible for putting away resident clothing in their closets based on the label printed on each garment, which indicated the name of the resident. Housekeeper A also stated housekeeping or laundry personnel were responsible for labeling residents' clothes with their name for identification purposes. Resident 1's closet was found to store a sweater labeled with another resident's name. This observation was confirmed by Housekeeper A. During an interview on 3/5/25 at 11:40 a.m., Resident 3 stated he had observed Resident 5 wearing Resident 6's shirt, which had the design of a famous football team. Resident 3 stated he knew this information because Resident 6 used to be his roommate, and he had witnessed when his family had brought this shirt to him, as Resident 6 was a fan of the football team. During a concurrent observation and interview on 3/5/25 at 12:05 p.m., Resident 5 was observed in the dining room wearing a shirt adorned with a famous football team's logo. Resident 5 stated he had purchased it at a thrift store for two dollars. The Surveyor observed the shirt was labeled with Resident 6's name, in clear black handwritten letters. During a concurrent interview and observation on 3/5/25 at 12:20 p.m., CNA B confirmed the shirt Resident 5 was wearing did not belong to him and acknowledged he had not checked the label written on the shirt prior to dressing Resident 6 that morning. During an interview on 3/5/25 at 12:33 p.m., the Director of Nursing (DON) stated CNAs were supposed to check residents' clothing to ensure the clothing belonged to them, prior to assisting them with dressing. During an interview on 3/5/25 at 3:45 p.m., Resident 6 stated he had seen other residents wear his clothing. Resident 6 stated he felt disrespected and sad when other residents wore his clothing, because they were gifted by his sister, so they were very special to him. During a review of the facility's policy titled, Dignity, revised 2/2021, indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .Residents are treated with dignity and respect at all times .Residents' private space and property are respected at all times.

Based on interview and record review, the facility failed to ensure three residents (Resident 1, Resident 2 and Resident 4) of four sampled residents who lost personal items at the facility had their items located, replaced or reimbursed. These failures had the potential to result in feelings of frustration, loss of control, and uncertainty, which could have affected the residents ' comfort at the facility. Findings: A review of Resident 1 ' s admission record indicated admission to the facility on [DATE] with diagnoses which included dementia (a group of conditions that cause loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of a Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 12/11/24, indicated Resident 1 had severe memory impairment. A review of Resident 2 ' s admission record indicated admission to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus (a chronic disease characterized by high levels of blood sugar). A review of an MDS, dated [DATE], indicated Resident 2 had no memory impairment. A review of Resident 4 ' s admission record indicated admission to the facility on [DATE] with diagnoses which included chronic kidney disease (a long-term condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood). A review of an MDS, dated [DATE], indicated Resident 4 had no memory impairment. During a phone interview on 3/5/25 at 10:05 a.m., Family Member XX stated Resident 1 had lost his dentures at the facility approximately a year and a half prior ago and she had notified the Social Services Director 1 (SSD 1) about it. The Family Member XX also stated Resident 1's dentures had not been located, replaced, or reimbursed. Family Member XX also stated she had been bringing clothes for Resident 1 throughout his stay at the facility. Record review of Resident 1's weekly progress note dated 4/5/24 at 3:12 a.m., indicated Resident 1 had dentures. During a concurrent interview and record review with the Administrator (ADM) on 3/12/25 at 3:50 p.m., a social services note for Resident 1 dated 4/18/24 at 9:03 a.m., was reviewed. The note indicated the SSD 1, LM (Left message) for Daughter RP (Responsible Party), regarding missing dentures. The ADM acknowledged this note and stated he would expect to see a missing items report for Resident 1 ' s dentures based on this information. The ADM also reviewed Resident 1's facility document titled, INVENTORY OF PERSONNAL EFFECTS (Inventory sheet) dated 3/13/23. The inventory sheet indicated the clothing Resident 1 was admitted with, but did not include any additional items obtained by Resident 1 after his admission. A review of the inventory sheet indicated no documented evidence it had been updated since 3/13/23 and had not included Resident 1's RP's signature. The ADM acknowledged Resident 1's inventory sheet had not been updated to reflect additional clothing the RP had brought for Resident 1 nor had it been signed by the RP. The ADM stated Certified Nursing Assistants (CNAs), Licensed Nurses (LNs) and Department heads were responsible for updating the inventory sheet when the resident received additional items. The ADM stated the Resident or RP and a staff member were required to sign the inventory sheet. Further review of the inventory sheet indicated, .Update as needed throughout the resident's stay by using the space provided. During an interview on 3/5/25 at 11:50 a.m., Resident 2 stated he lost all the original clothing he was admitted with because he was not notified he had to label his clothing with his name for identification purposes upon admission. According to Resident 2, his clothes were never returned after they were taken by staff to the laundry. Resident 2 stated he tried to tell the housekeeping personnel to look for his clothes, but they did not speak English and could not understand his request. Resident 2 stated he also told other facility staff about his missing clothes but he could not remember their names. Resident 2 stated his clothes were never located, reimbursed, or replaced. During a concurrent interview and record review with Resident 2 on 3/12/25 at 3:02 p.m., the document titled, INVENTORY OF PERSONAL EFFECTS with his name on it was reviewed. This document indicated Resident 2 had the following items in his possession upon admission on 12/3/24, BLUE HOODY JACKET .BLUE SHORTS .PAIR OF GRAY SLIPPERS .BLUE SHIRT .GRAY BLACK JOGGER .SOCKS. Resident 2 stated he had lost all these items at the facility and had notified staff about it but received no resolution. Resident 2 stated the blue jacket was the most significant loss because it was given to him by his mother. During an interview on 3/5/25 at 11:20 a.m., Resident 4 stated she currently had three dresses that went missing at the facility. Resident 4 stated she reported two of the three missing dresses about six months ago to SSD 1, but the dresses had not been located, replaced, or reimbursed. Resident 4 also stated laundry staff regularly delivered clothes which did not belong to her every two or three days. Resident 4 stated she has to alert staff to take them back because they are someone else's. During a concurrent interview and record review with Resident 4 on 3/12/25 at 2:40 p.m., the document titled, INVENTORY OF PERSONAL EFFECTS, with her name on it was reviewed. This document indicated Resident 4 had several dresses in her possession on 2/3/23 including a, Raspberry/white polka dot dress . [and] Raspberry/pink flower dress. Resident 4 stated these were the dresses she lost about six months prior. Resident 4 stated she filled out a theft/loss report and provided it to SSD 1 to report her missing dresses. Resident 4 stated she was not given a copy of her signed missing items report. Resident 4 still had not received a resolution to her missing dresses. During a concurrent interview and record review on 3/5/25 at 12:44 p.m., the Social Services Director 2 (SSD 2) stated she was recently notified of Resident 1 ' s missing dentures and was in the process of replacing them. The SSD 2 stated her employment as an SSD had just started a week prior, as the SSD 1 had left, and SSD 2 was promoted to the position. The SSD 2 stated the facility was supposed to replace or reimburse residents ' personal items lost at the facility. The SSD 2 stated there was only one missing items report on file and it belonged to Resident 1. The report titled Theft/Loss Report indicated Resident 1 lost two pairs of sweatpants on 7/13/23. The SSD 2 stated there was no documented evidence the facility reimbursed or replaced the items in the report. The SSD 2 stated she was unable to locate any other missing items reports. During an interview on 3/12/24 at 1:30 p.m., the Maintenance Director (MD) stated when residents reported missing items, he would try to locate the items first. If they were not found, the MD verbally notified SSD 1 but did not document this notification. During an interview on 3/12/25 at 2:06 p.m., Housekeeper A stated when residents reported missing items, she would first try to locate them. If they were not found, Housekeeper A verbally notified the MD. The Housekeeper A also stated she felt CNAs failed to bring resident clothing to the housekeeping department to be labeled which contributed to the missing clothing. Housekeeper A stated she received four bags of clothing to label for seven newly admitted residents in the last four weeks. A review of the facility's document titled Admission/Discharge To/From Report indicated seven new residents were admitted to the facility between 2/12/25 and 3/12/25. During an interview on 3/12/25 at 2:17 p.m., the CNA F stated when residents reported missing items, she would try to locate the items first. It they were not found, the CNA F verbally notified the MD. During an interview on 3/12/25 at 3:40 p.m., Licensed Staff G stated when residents reported missing items, he sent a communication message through the facility ' s electronic documentation system. All staff who had access to the system would receive the message and try to locate the missing items, but the message was not part of the residents' medical record. The Licensed Staff G stated there was no way to know if the SSD had read the communication messages he sent. The Licensed Staff G stated he had not documented residents ' reports of missing items in their progress notes. During a concurrent record review and interview with SSD 2 on 3/12/25 at 2:40 p.m., the file which contained missing items reports and grievances was reviewed. The last missing items report on file was dated April 2024. The last grievance on file was also dated April 2024. There were no missing items reports for Resident 2, Resident 4, or Resident 1's belongings. The SSD 2 confirmed the missing reports and grievance documents and who added, This is just ridiculous [regarding the lack of new or updated grievances of missing items reports since April 2024]. The SSD 2 stated she previously worked in the business office and did not know SSD 1 had not been filing or keeping records of the grievances. The SSD 2 also if residents filed grievances and the SSD 1 had not provided them with a copy of the grievance, then there was no way for residents to know if the information in the grievance was correct. A review of the Social Services Designee job description, signed by SSD 1 on 8/7/23, indicated, Essential Duties .Assist in inventory and tracking patient belongings .Coordinate response to reports of missing, lost or stolen belongings. A review of the facility's policy titled Lost and Found dated 1/2008, indicated, Our facility shall assist all personnel and residents in safe-guarding their personal property . Lost and found records will be maintained for one (1) year, then destroyed .Reports of misappropriation or mistreatment of resident property are immediately investigated. A review of the facility's policy titled Grievances/Complaints, Filing, last revised in 4/2017, indicated, Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances .The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative .Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care . theft of property, or any other concerns .Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and/or complaint .The results of all grievances files, investigated and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision. Based on interview and record review, the facility failed to ensure three residents (Resident 1, Resident 2 and Resident 4) of four sampled residents who lost personal items at the facility had their items located, replaced or reimbursed. These failures had the potential to result in feelings of frustration, loss of control, and uncertainty, which could have affected the residents' comfort at the facility. Findings: A review of Resident 1's admission record indicated admission to the facility on [DATE] with diagnoses which included dementia (a group of conditions that cause loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of a Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 12/11/24, indicated Resident 1 had severe memory impairment. A review of Resident 2's admission record indicated admission to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus (a chronic disease characterized by high levels of blood sugar). A review of an MDS, dated [DATE], indicated Resident 2 had no memory impairment. A review of Resident 4's admission record indicated admission to the facility on [DATE] with diagnoses which included chronic kidney disease (a long-term condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood). A review of an MDS, dated [DATE], indicated Resident 4 had no memory impairment. During a phone interview on 3/5/25 at 10:05 a.m., Family Member XX stated Resident 1 had lost his dentures at the facility approximately a year and a half prior ago and she had notified the Social Services Director 1 (SSD 1) about it. The Family Member XX also stated Resident 1's dentures had not been located, replaced, or reimbursed. Family Member XX also stated she had been bringing clothes for Resident 1 throughout his stay at the facility. Record review of Resident 1's weekly progress note dated 4/5/24 at 3:12 a.m., indicated Resident 1 had dentures. During a concurrent interview and record review with the Administrator (ADM) on 3/12/25 at 3:50 p.m., a social services note for Resident 1 dated 4/18/24 at 9:03 a.m., was reviewed. The note indicated the SSD 1, LM (Left message) for Daughter RP (Responsible Party), regarding missing dentures. The ADM acknowledged this note and stated he would expect to see a missing items report for Resident 1's dentures based on this information. The ADM also reviewed Resident 1's facility document titled, INVENTORY OF PERSONNAL EFFECTS (Inventory sheet) dated 3/13/23. The inventory sheet indicated the clothing Resident 1 was admitted with, but did not include any additional items obtained by Resident 1 after his admission. A review of the inventory sheet indicated no documented evidence it had been updated since 3/13/23 and had not included Resident 1's RP's signature. The ADM acknowledged Resident 1's inventory sheet had not been updated to reflect additional clothing the RP had brought for Resident 1 nor had it been signed by the RP. The ADM stated Certified Nursing Assistants (CNAs), Licensed Nurses (LNs) and Department heads were responsible for updating the inventory sheet when the resident received additional items. The ADM stated the Resident or RP and a staff member were required to sign the inventory sheet. Further review of the inventory sheet indicated, .Update as needed throughout the resident's stay by using the space provided. During an interview on 3/5/25 at 11:50 a.m., Resident 2 stated he lost all the original clothing he was admitted with because he was not notified he had to label his clothing with his name for identification purposes upon admission. According to Resident 2, his clothes were never returned after they were taken by staff to the laundry. Resident 2 stated he tried to tell the housekeeping personnel to look for his clothes, but they did not speak English and could not understand his request. Resident 2 stated he also told other facility staff about his missing clothes but he could not remember their names. Resident 2 stated his clothes were never located, reimbursed, or replaced. During a concurrent interview and record review with Resident 2 on 3/12/25 at 3:02 p.m., the document titled, INVENTORY OF PERSONAL EFFECTS with his name on it was reviewed. This document indicated Resident 2 had the following items in his possession upon admission on 12/3/24, BLUE HOODY JACKET .BLUE SHORTS .PAIR OF GRAY SLIPPERS .BLUE SHIRT .GRAY BLACK JOGGER .SOCKS. Resident 2 stated he had lost all these items at the facility and had notified staff about it but received no resolution. Resident 2 stated the blue jacket was the most significant loss because it was given to him by his mother. During an interview on 3/5/25 at 11:20 a.m., Resident 4 stated she currently had three dresses that went missing at the facility. Resident 4 stated she reported two of the three missing dresses about six months ago to SSD 1, but the dresses had not been located, replaced, or reimbursed. Resident 4 also stated laundry staff regularly delivered clothes which did not belong to her every two or three days. Resident 4 stated she has to alert staff to take them back because they are someone else's. During a concurrent interview and record review with Resident 4 on 3/12/25 at 2:40 p.m., the document titled, INVENTORY OF PERSONAL EFFECTS, with her name on it was reviewed. This document indicated Resident 4 had several dresses in her possession on 2/3/23 including a, Raspberry/white polka dot dress . [and] Raspberry/pink flower dress. Resident 4 stated these were the dresses she lost about six months prior. Resident 4 stated she filled out a theft/loss report and provided it to SSD 1 to report her missing dresses. Resident 4 stated she was not given a copy of her signed missing items report. Resident 4 still had not received a resolution to her missing dresses. During a concurrent interview and record review on 3/5/25 at 12:44 p.m., the Social Services Director 2 (SSD 2) stated she was recently notified of Resident 1's missing dentures and was in the process of replacing them. The SSD 2 stated her employment as an SSD had just started a week prior, as the SSD 1 had left, and SSD 2 was promoted to the position. The SSD 2 stated the facility was supposed to replace or reimburse residents' personal items lost at the facility. The SSD 2 stated there was only one missing items report on file and it belonged to Resident 1. The report titled Theft/Loss Report indicated Resident 1 lost two pairs of sweatpants on 7/13/23. The SSD 2 stated there was no documented evidence the facility reimbursed or replaced the items in the report. The SSD 2 stated she was unable to locate any other missing items reports. During an interview on 3/12/24 at 1:30 p.m., the Maintenance Director (MD) stated when residents reported missing items, he would try to locate the items first. If they were not found, the MD verbally notified SSD 1 but did not document this notification. During an interview on 3/12/25 at 2:06 p.m., Housekeeper A stated when residents reported missing items, she would first try to locate them. If they were not found, Housekeeper A verbally notified the MD. The Housekeeper A also stated she felt CNAs failed to bring resident clothing to the housekeeping department to be labeled which contributed to the missing clothing. Housekeeper A stated she received four bags of clothing to label for seven newly admitted residents in the last four weeks. A review of the facility's document titled Admission/Discharge To/From Report indicated seven new residents were admitted to the facility between 2/12/25 and 3/12/25. During an interview on 3/12/25 at 2:17 p.m., the CNA F stated when residents reported missing items, she would try to locate the items first. It they were not found, the CNA F verbally notified the MD. During an interview on 3/12/25 at 3:40 p.m., Licensed Staff G stated when residents reported missing items, he sent a communication message through the facility's electronic documentation system. All staff who had access to the system would receive the message and try to locate the missing items, but the message was not part of the residents' medical record. The Licensed Staff G stated there was no way to know if the SSD had read the communication messages he sent. The Licensed Staff G stated he had not documented residents' reports of missing items in their progress notes. During a concurrent record review and interview with SSD 2 on 3/12/25 at 2:40 p.m., the file which contained missing items reports and grievances was reviewed. The last missing items report on file was dated April 2024. The last grievance on file was also dated April 2024. There were no missing items reports for Resident 2, Resident 4, or Resident 1's belongings. The SSD 2 confirmed the missing reports and grievance documents and who added, This is just ridiculous [regarding the lack of new or updated grievances of missing items reports since April 2024]. The SSD 2 stated she previously worked in the business office and did not know SSD 1 had not been filing or keeping records of the grievances. The SSD 2 also if residents filed grievances and the SSD 1 had not provided them with a copy of the grievance, then there was no way for residents to know if the information in the grievance was correct. A review of the Social Services Designee job description, signed by SSD 1 on 8/7/23, indicated, Essential Duties .Assist in inventory and tracking patient belongings .Coordinate response to reports of missing, lost or stolen belongings. A review of the facility's policy titled Lost and Found dated 1/2008, indicated, Our facility shall assist all personnel and residents in safe-guarding their personal property . Lost and found records will be maintained for one (1) year, then destroyed .Reports of misappropriation or mistreatment of resident property are immediately investigated. A review of the facility's policy titled Grievances/Complaints, Filing, last revised in 4/2017, indicated, Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances .The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative .Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care . theft of property, or any other concerns .Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and/or complaint .The results of all grievances files, investigated and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision.

Based on interview and record review, the facility failed to follow physician's orders for one resident (Resident 1) of two sampled residents when licensed nurses did not communicate Resident 1's treatment orders written by a Wound Care Physician Assistant (PA - a licensed medical professional whose duties include ordering labs, medications, and treatments) for a wound on the left heel to the Attending Physician (a physician who is responsible for a patient's care in a hospital or skilled nursing facility) for approval and a signature. This failure decreased the facility's potential to ensure Resident 1's wound care treatments were ordered and carried out. Findings: A review of Resident 1's admission record indicated he was admitted on [DATE] with relevant diagnoses including: Type 2 Diabetes Mellitus (a disease that occurs when blood sugar is too high) with Diabetic Polyneuropathy (a complication of diabetes that affects nerves that branch out from the spinal cord to the arms, hands, legs, and feet), Unspecified Severe Protein-Calorie Malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), Essential Hypertension (a condition where blood pressure is elevated and there is no clear cause), Chronic Congestive Heart Failure (a long-term condition where the heart cannot pump enough blood throughout the body), and Peripheral Vascular Disease (a condition in which narrowed blood vessels reduce blood flow to the arms and legs). A review of Resident 1's clinical record included the following documents: A Skin and Wound Evaluation, dated 8/14/24, indicated Resident 1 was admitted to the facility with a stage 3 pressure wound (a deep wound that extends through the entire thickness of the skin) on his coccyx (a small bone located at the end of the spine). A Skin and Wound Evaluation, dated 8/15/24, indicated Resident 1 was admitted to the facility with a suspected deep tissue injury (a pressure injury where the underlying tissues are damaged without a visible open wound, often appearing as a purple or maroon discoloration on intact skin) on the left heel. A Progress Note written by the Wound Care PA on 9/11/24 indicated, debridement was performed today on the left heel wound .For the left heel wound add bacitracin [an ointment used to treat skin infections] to the treatment . A Progress Note written by the Wound Care PA on 10/16/24 indicated, wound bed noted with more slough [a layer of dead tissue that separates from the underlying healthy tissue], increase dressing frequency .Obtain wound culture please. An Order Summary Report, dated 9/11/24 through 12/1/24, did not include an order for bacitracin to be applied to the left heel nor a wound culture of the left heel. A Treatment Administration Record (TAR), dated September 2024 and October 2024 did not include bacitracin as a treatment administered to Resident 1's left heel. During an interview on 1/22/25 at 11 a.m., the Director of Nursing (DON) confirmed Resident 1 did not have an order for or results of a wound culture in his clinical records. The DON further stated it was the responsibility of the treatment nurse (the nurse responsible for accompanying with Wound Care PA to assess and treat residents) to report to and follow up with the Attending Physician when new wound care orders were received from the PA. During an interview on 1/22/25 at 12:44 p.m., Licensed Nurse A (LN A) stated the Wound Care PA ordered a wound culture if something questionable was observed during a wound assessment. LN A stated the usual process included the Wound Care PA verbally communicating with the treatment nurse during rounds or via e-mail transmission of the Wound Care PA's progress notes. During an interview on 1/23/25 at 11:16 a.m., Licensed Nurse B (LN B) stated the usual procedure had been for the Wound Care PA to communicate new orders to the treatment nurse either verbally or via e-mail transmission of the Wound Care PA's progress notes. LN B stated an order for a topical treatment (such as bacitracin) would have been in the TAR if the order was placed. LN B stated if no record was found for bacitracin, it meant the order had not been entered in the electronic medical system. During an interview on 1/23/25 at 11:30 a.m., Licensed Nurse C (LN C) stated if a wound care order from the Wound Care PA had not been communicated to the Attending Physician via electronic medical records or in person, then the physician's orders had not been followed. LN C further stated nurses were required to follow physician's orders. In an interview on 1/23/25 at 12:11 p.m., the Attending Physician confirmed it was not his standard practice to read the wound care notes. The Attending Physician also verified the Wound Care PA did not put orders into the electronic record system but instead communicated orders to the nursing team which then communicated those orders to the Attending Physician. A review of the facility's Policy & Procedure (P&P) titled Verbal Orders dated 2001 indicated, Verbal orders shall only be given .when the attending physician is not immediately available to write or sign the order .Verbal orders are those given by an authorized practitioner directly to a person authorized to receive and transcribe orders on his or her behalf .The individual receiving the verbal order must write it on the physician' order sheet as ' v.o.' (verbal order) .The individual receiving the verbal order will .read the order back to the practitioner to ensure that the information is clearly understood and correctly transcribed .record the ordering practitioner's last name and his or her credentials (MD [Physician], NP [Nurse Practitioner], PA, etc.); and .record the date and time of the order .The practitioner will receive and countersign verbal orders during his or her next visit.

Based on observations, interviews, and record reviews, the facility failed to ensure food safety and sanitation guidelines were followed when: 1. Proper handwashing was not followed in the kitchen; 2. The proper cool down process of food and Temperature Control for Safety (TCS) process were not monitored; 3. The facility's thawing process for food was not followed; 4. The potential for cross contamination was not prevented; 5. Cleaning cloths were not placed in sanitizing solution between use; 6. Hair restraints were not utilized; 7. Food storage guidelines were not followed; 8. Food preparation equipment and utensils were not clean and kept in good working order; 9. Kitchen cleaning equipment was not stored properly; 10. Kitchen equipment and the environment were not clean; 11. Ice packs intended for resident personal use were stored with food in the resident nourishment refrigerator and a medication temperature log was used to monitor the temperature of the resident nourishment refrigerator; and, 12. The posted time for immersion of dishes in a sanitizing solution during manual dishwashing was inconsistent with the manufacturer's immersion time listed on the instruction label of the sanitizer label or the immersion time specified in the facility's policy and procedure. These failures increased the risk for food borne illness for 76 residents who consumed food prepared in the facility's kitchen. Findings: A review of the facility document titled Diet Order Tally Report dated 9/23/24 indicated 76 residents received food prepared in the kitchen. 1. During an observation of food preparation on 9/24/24 at 11:05 AM, the [NAME] F removed one glove from her hand, immediately touched the lid of the trash can to discard trash with her ungloved hand, and continued food preparation without washing her hands. The [NAME] F was also observed to wipe sweat off her face more than twice with her bare hand without washing her hands and continued with food preparation. During an interview 9/26/24 at 10:11 AM, the Registered Dietician (RD) stated the [NAME] F should have washed her hands after touching the trash and after touching her face. 2. During the initial tour of the kitchen and concurrent interview with the Certified Dietary Manager (CDM) on 9/23/24 at 9:10 AM, the following were observed in the reach-in refrigerator: -cooked sausage patties in a plastic container with a temperature of 63 degrees Fahrenheit (F), dated 9/23/24; -cooked ham in a plastic container, dated 9/22/24; and, -cooked rice in a plastic container, dated 9/22/24. The CDM stated the sausage patties were left over from breakfast and would be used the following day. The CDM confirmed the ham and the rice were cooked on 9/22/24. A record review of a document titled, Cool Down Log, and dated September 2024 did not have a record of any food items monitored for the cool down process. During an interview on 9/25/24 at 9:52 AM, the [NAME] F stated the cool down process she usually did was to put the leftover food in an ice bath and wait for the temperature of the food to reach 40 degrees F. The [NAME] F confirmed she did not document the cool down process on the cool down log for the leftover food items. During an interview on 9/26/24 at 10:11 AM, the RD stated leftover cooked foods should be cooled to the appropriate temperature and monitored on the cooling log. A review of the facility's policy and procedure titled, Cooling and Reheating of Potentially Hazardous or Time/Temperature Control for Safety Food, dated 2023, indicated the cook should note the menu item, date, time, temperature, and cook's initials on the Cool Down Log. The policy further indicated the CDM, will visually monitor the food service employees and review and sign all logs prior to filing. During a concurrent observation and interview on 9/25/25 at 9:45 AM, the [NAME] F confirmed there was not a cooling log present for ambient (room temperature) items such as tuna salad and egg salad. During an interview on 9/26/24 at 9:23 AM, the CDM confirmed she had not added or conducted an in-service (training) on the ambient cool down log. During an interview on 9/26/24 at 10:11 AM, the RD confirmed the cool down process for ambient temperature foods was not monitored and documented on the cool down log. A record review of a document titled, Good for Your Health Menus, dated September 2, 2024, through September 29, 2024, included two dinner menus with salads made from ambient temperature foods. A review of the facility's policy and procedure titled, Cooling and Reheating of Potentially Hazardous or Time/Temperature Control for Food Safety, dated 2023, indicated, PHF (Potentially Hazardous Food) or TCS (Time/Temperature Control for Safety) food shall be cooled within 4 hours to 41 degrees or less, if prepared from ingredients at ambient temperature, such as reconstituted food and canned tuna. 3. During the initial tour of the kitchen and concurrent interview with the CDM on 9/23/24 at 9:10 AM, the following were observed in the reach-in refrigerator: -40 pounds of chicken thighs with a received date of 9/20/24; and, -20 pounds of frozen pork loin, undated. The CDM confirmed the chicken thighs did not reflect a date when they were removed from the freezer. When asked why the 20 pounds of pork loin did not have a date, the CDM asked [NAME] F to clarify. The [NAME] F stated the pork loins were pulled from the freezer today and put in the refrigerator. The [NAME] A further stated the pork loins were not dated because the wrapper had ice on it. A review of the facility's policy and procedure titled, Thawing of Meats, dated 2023, indicated meat can be thawed in a refrigerator of 42 degrees or colder. The policy also indicated staff should, Label defrosting meat with pull and use by date. 4. During an observation on 9/23/24 at 9:10 AM, the [NAME] F had a personal glass of water in the cooking space and a personal pen on a food preparation surface. During an interview on 9/23/24 at 10:11 AM, the CDM confirmed the personal water glass and pen belonged to the [NAME] F and there was no designated space for the employees' personal items or beverages. During an observation on 9/23/24 at 11:33 AM, the [NAME] F was drinking a beverage during food preparation. During an observation on 9/24/24 at 12:05 PM, the [NAME] F was drinking soda during the lunch meal tray service. During an interview on 9/26/24 at 10:11 AM, the RD confirmed there was no designated space in the kitchen for employees' personal items. The RD further stated employees should have put personal items in the employee break room or the refrigerator in the dietary services office. A review of the facility's policy and procedure titled, Employee Personal Items, dated 2023, indicated, Employees bringing in personal items from outside .will not be kept in the kitchen. During an observation and interview on 9/25/24 at 11:54 AM, the [NAME] F was cutting a cooked piece of chicken using the green cutting board. When asked if the green cutting board was for chicken, the [NAME] F stated she was in a rush and did not have time to use the correct cutting board for chicken which was the brown one. During an interview on 9/26/24 at 10:11 AM, the RD confirmed cooked chicken should only be cut on the brown cutting board. A review of the facility's policy and procedure titled, Sanitation, dated 2023, indicated, Separate cutting boards are to be used for preparing meats and vegetables. 5. During an observation of the lunch meal food preparation on 9/25/24 at 11:54 AM, the [NAME] F left a soiled cleaning rag on the food preparation counter, not stored in sanitizing solution. During an interview on 9/26/24 at 10:11 AM, the RD confirmed cleaning rags should be stored in the sanitizing solution between uses. According to the USDA Food Code 2022 Section 3-304.14 (B) (1), cloths in-use for wiping counters and other equipment surfaces shall be held between uses in a chemical sanitizer solution at a concentration specified under 4-501.114. 6. During an observation on 9/23/24 at 9:07 AM, the Dietary Aid K (DA K) had a full beard which was not covered by a beard net. During an observation of food preparation on 9/24/24 at 11:19 AM, the [NAME] F wore a chef's cap which did not contain her hair. The [NAME] F's hair was loose and fell to the middle of her back. In a concurrent observation and interview, the RD confirmed [NAME] F should have had a hair net on. During an interview on 9/26/24 at 10:11 AM, the CDM confirmed the facility did have hair and beard nets and all kitchen employees were expected to don appropriate hair restraints when they were in the kitchen. A review of the facility's policy and procedure titled, Dress Code, indicated, Hair net for hair, if hair is long (over the ears or longer) and, If applicable, beards and mustaches (any facial hair) must wear beard restraint. 7. During the initial tour of the kitchen and concurrent interview with the CDM on 9/23/24 at 9:10 AM, the following were observed in the reach in refrigerator: -a container of marinara sauce with the use by date of 9/20/24; -a container of pudding with the use by date of 9/19/24; and, -health shakes (supplemental shakes) in a bin undated. The CDM confirmed the above observations. During a continuation of the initial tour and concurrent interview on 9/23/24 with the CDM, the following were observed in the dry storage area: -a box of baking powder with an expiration date of 8/2023; -a large bin of flour that was not sealed, not clean, or dated; -a partially open, cardboard box of black eye peas, with an open date of 1/6/24 and use by date of 6/1/24; -an unlabeled bin of brown rice; -a bin of white rice with a use by date of 6/9/24; -a bin of pearled barley with a lid that does not fit tightly; -a dented can of tomato paste on the shelf with canned goods; -a small undated plastic container of thickener with a scoop stored inside the container. The CDM confirmed the above observations. A review of the facility's policy and procedure titled, Procedure for Refrigerated Storage, dated 2023, indicated, Supplemental shakes which are taken from the frozen state and thawed in the refrigerator must be dated as soon as they are place in the refrigerator. A review of the facility's policy and procedure titled, Storage of Food and Supplies, dated 2023, indicated, Dry bulk foods .should be stored in seamless metal or plastic containers with tight covers, or in bins which are easily sanitized .scoops should not be left in the containers .bins/containers are to be labeled, covered, and dated. 8. During the initial tour of the kitchen and concurrent interview with the CDM on 9/23/24 at 9:59 AM, the following were observed: -the knife holder was not clean; -the can opener was not clean and the blade was worn; -one small frying pan had thick black residue on the inside and outside which came off when touched, and the non-stick coating had peeled off; -three additional frying pans had thick hard black residue on the inside; -one additional frying pan had a greasy residue on the cooking surface; -two muffin pans had thick black residue on it; -three large baking pans had black residue on it; and, -the shelf storing all the pans was not clean. The CDM confirmed the above observations. During an observation and concurrent interview on 9/24/24 at 11:05 AM, the RD confirmed the green and the brown cutting boards were heavily marred and needed to be replaced. According to the USDA Food Code 2022, Section 4-601.11, Food Contact Surfaces, Nonfood Contact Surfaces, and Utensils (A) Equipment, food contact surfaces, and utensils shall be clean to sight and touch, (C) Nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to USDA Food Code 2022, Section 4-501.11, .Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate food when the container is opened. 9. During the initial kitchen tour with the CDM on 9/23/24 at 10:30 AM, the following were observed: -the chemical storage closet with no space to store mops or brooms; -a mop bucket with a dirty wet mop inside the bucket, stored on the pavement outside the kitchen door; and, -one squeegee and one broom stored on the ground outside the kitchen door. The CDM confirmed the above observations. During an observation on 9/25/24 at 10:24 AM, a broom and mop were stored outside the kitchen lying on the ground. During an interview on 9/26/24 at 2:25 PM, the CDM and the RD agreed it was not acceptable to store the brooms and mops outside. According to the USDA Food Code 2022 Section 6-501.113, .Maintenance tools such as brooms, mops, vacuum cleaners, and similar items shall be (B)Stored in an orderly manner that facilitates cleaning the area used for storing the maintenance tools. 10. During an observation and concurrent interview with the CDM on 9/23/24 at 10:11 AM, the wall adjacent to the food preparation sink was not clean, the paint was peeling, and a small hanging rack with measuring cups and thermometers was hung on the dirty wall. The CDM confirmed the wall was not clean and the paint was peeling. The CDM stated clean items should have been stored in a clean area. During an observation and concurrent interview with the CDM on 9/23/24 at 10:15 AM, three ceiling vents and the ceiling were not clean. The CDM confirmed the vents and ceiling were not clean. During an observation and concurrent interview with the RD on 9/24/24 at 9:20 AM, the plate warmer had visible debris on the interior of the warmer at the bottom of the metal enclosure. The RD stated the Maintenance Supervisor (MS) was been responsible for cleaning the plate warmer. During an interview on 9/25/24 at 9:35 AM, the MS stated he cleaned the kitchen and vents, but he did not clean the plate warmer. The MS also stated he tried to clean the vents every month, but it was only him and he had asked for assistance. The MS further stated he had not known it was his duty to clean the plate warmer. During an interview on 9/26/24 at 9:23 AM, the CDM stated cleaning duties were built into the job duties of the kitchen staff. CDM further stated there had not been a check list to determine if cleaning tasks had been completed. A review of the facility's policy and procedure titled Walls, Ceilings, and Light Fixtures, indicated, Walls and ceilings must be free of chipped and or peeling pain and walls and ceilings must be washed thoroughly at least twice a year. Heavily soiled surfaces must be cleaned more frequently, as necessary. It is important to repair peeling paint areas as soon as they appear. During a review of the facility's policy and procedure titled, Sanitation, dated 2023, indicated, The Maintenance Department will assist Food and Nutrition Services as necessary in maintaining equipment and the FNS Director [CDM is the title in this facility] will write the cleaning schedule in which they designate by job title and/or employee who is to do the cleaning task. 11. During an observation of the resident nourishment refrigerator with the CDM on 9/23/24 at 11:35 AM, personal care ice packs were stored in the freezer compartment adjacent to resident food items. A log titled, Medication Refrigerator Log was posted on the outside of the refrigerator. The CDM removed the ice packs from the freezer section of the refrigerator. During an interview on 9/23/24 at 11:42 AM, the Licensed Nurse M (LN M) confirmed he was responsible for checking the temperature in the resident nourishment refrigerator and recording the temperature on the log posted on the refrigerator door. The LN M confirmed the medication refrigerator log indicated temperatures must be at or below 46 degrees F but agreed the refrigerated food items must be at or below 41 degrees F. The LN M also stated it was not acceptable for personal care ice packs to be stored with resident food. A review of the facility's policy and procedure titled, Procedure for Refrigerated Storage, indicated the refrigerator temperature should be at 41 degrees F or less. 12. During an observation and concurrent interview with the CDM and the DA K on 9/24/24 at 9:35 AM, a poster above the manual dish ware sink indicated, Sanitize using hot water: dishes must be immersed in hot water for 45 seconds. The CDM and DA K both stated they had not known how long dishes needed to be immersed in the sanitizing solution during manual washing. A review of the facility's policy and procedure titled, 3-Compartment Procedure for Manual Dishwashing, indicated, The third compartment is for sanitizing .immerse all washed items for 1 minute. 48660

Based on observation, interview, and record review the facility failed to ensure residents were treated with dignity and respect when: 1. A staff member was observed standing while assisting a resident with meals; and, 2. Three staff were observed speaking a language other than English by the dining room of the facility during lunch hour. These findings had the potential for residents to experience feelings of sadness, frustration, and helplessness for a census of 76 residents. Findings: 1. During an observation in the dining room of the facility on 9/23/24 at 12:25 p.m., the Unlicensed Staff M was observed assisting Resident 67 with her lunch meal while standing. The Resident 67 sat in her wheelchair, while the Unlicensed Staff M was observed looking down at Resident 67 while assisting with her meal. After a few minutes of this process, another unidentified staff brought Unlicensed Staff M a chair to sit on. During an interview on 9/23/24 at 12:56 p.m., Unlicensed Staff M confirmed she was standing while assisting Resident 67. The Unlicensed Staff M also stated staff could stand or sit when they were assisting residents with meals, however they felt comfortable. The Unlicensed Staff M stated he had never asked residents if they felt comfortable with him standing while he assisted them with their meals. During an interview on 9/26/24 at 9:06 a.m., the Director of Staff Development (DSD) stated that staff were expected to be sitting when assisting residents with meals and stated in-services had already been conducted on this. 2. Record review of the July 2024 resident council minutes indicated the resident council had a meeting on 7/10/24, in which residents complained they could hear staff speaking in their native language in the halls and residents' rooms, and Resident 18 and Resident 61 were upset that staff were speaking in Spanish only. During a resident council meeting on 9/25/24 at 10:35 a.m., Resident 18 and Resident 61 complained staff continued to speak a language other than English in resident care areas, including in the residents' rooms and hallways of the facility. Resident 18 expressed, It is frustrating. Resident 61 stated, You get a feeling they are talking about you (when staff are speaking Spanish), they keep on talking and ignore you even when you speak to them. During a concurrent observation and interview on 9/24/24 at 12:19 p.m., in the hallway right in front of the dining room (which was a very trafficked area by residents and staff), Unlicensed Staff N, Unlicensed Staff O and Unlicensed Staff P were heard and observed speaking Spanish among each other. The conversation occurred during lunch time, when residents were actively entering and exiting the dining room and were in close proximity or crossing this hallway where the above staff were standing. Unlicensed Staff N, Unlicensed Staff O and Unlicensed Staff P were asked if they were allowed to speak a language other than English in the resident care areas. They stated they were allowed to speak Spanish to Spanish speaking residents only. During an interview with the DSD on 9/26/24 at 9:06 a.m., she stated staff were not allowed to speak a language other than English in resident care areas, unless they were speaking to a resident in his/her native language. The DSD stated the Administrator had recently in-serviced staff on this requirement. Record review of the facility policy titled, Dignity, last revised in February of 2021, indicated, Residents are treated with dignity and respect at all times .The facility culture supports dignity and respect for resident by honoring resident goals, choices, preferences, values and beliefs .When assisting with care, residents are supported in exercising their rights, for example, residents are: e. provided with a dignified dining experience.

Based on interview and record review, the facility failed to follow up on a stat (immediately, urgent) laboratory (lab, a facility that provides controlled conditions in which scientific or technological research, experiments, and measurement may be performed) order for one of two sampled residents (Resident 5) when a stat urinalysis (UA, a basic test that examines the contents of a urine sample to identify conditions that may need treatment) and culture and sensitivity (C&S, a lab test that checks which bacteria are in the urine and which antibiotic will kill the bacteria) specimen for Resident 5 was rejected by the lab on 7/15/24 and a new urine specimen was not collected. This failure caused a delay in diagnosis and treatment for Resident 5, which caused his health to worsen requiring hospitalization on [DATE] where he was diagnosed with septic shock (sepsis [a serious condition in which the body responds improperly to an infection] may progress to septic shock, a dramatic drop in blood pressure that can damage the lungs, kidneys, liver and other organs) and acute cystitis (bladder infection). Finding: During a telephone interview on 7/24/24 at 10 a.m., Family Member 2 (FM2) stated that after 7/9/24, Resident 5 laid lethargic (feeling a lack of energy or interest in doing things) for a few days. FM2 stated she then got a phone call from the nurse supervisor on approximately 7/13/24 that Resident 5 had blood in his urine, and they were waiting for the doctor to authorize cultures. FM2 stated that on Tuesday 7/16/24 she got a call from her son that Resident 5 was not well, Resident 5 was white, shivering, lethargic and curled up in bed in a fetal position. FM2 stated Resident 5 went to the hospital with sepsis. FM2 stated, I think if they hadn ' t called (911) because my son told them to he (Resident 5) would have been dead by the next day. When queried, FM2 stated the facility ' s nurses ' lack of action made her feel angry. During a record review on 7/24/24 at 10:45 a.m., Resident 5 ' s face sheet revealed an admitted [DATE] with multiple medical diagnoses including schizoaffective disorder (a mental health condition with symptoms that include delusions [false beliefs], hallucinations, depressed episodes, and manic periods of high energy), dysphagia (difficulty swallowing), and cognitive (relating to or involving the processes of thinking and reasoning) communication disorder, among others. Resident 5 ' s record indicated FM2 was his responsible party and his Health Care Decision Maker. Review of Resident 5 ' s SBAR form (situation, background, assessment, and recommendation; a communication tool), dated 7/14/24 at 4:26 p.m., indicated Resident 5 had increased confusion, required more assistance with ADLs (activities of daily living, such as bathing, dressing, eating, toileting), and had blood in his urine. The SBAR indicated that Licensed Nurse H had notified Resident 5's doctor, Physician J, of his change in condition, and Licensed Nurse H was awaiting a reply. Review of Resident 5 ' s physician order, dated 7/14/24, indicated, Obtain UA and C&S STAT. Review of Resident 5 ' s nurse progress note dated 7/14/24 at 11:54 p.m., indicated Licensed Nurse G had collected the urine specimen for a STAT UA and C&S and she notified the lab that the specimen was ready for pickup. Review of Resident 5 ' s nurse progress notes dated 7/15/24 at 4:40 a.m., 7/15/24 at 9:31 p.m., and 7/16/24 at 1:14 p.m. all indicated Resident 5 was being monitored for continued confusion and blood in urine, but there was no documentation that the nurses followed up with the lab for the results of the stat UA and C&S. Review of Resident 5 ' s lab results for the stat UA and C&S, dated 7/15/24 at 2:10 p.m., indicated, Specimen Requires Recollection and a New Order Placed if Results are Needed. The lab results also indicated the reason the test was not performed was, Specimen Mislabeled - Missing Info. During an interview on 7/24/24 at 2:39 p.m., when queried, Infection Preventionist (IP) stated she did not track Resident 5 ' s urine sample because she was busy doing Covid response testing. IP stated the stat order for the UA was put in on Sunday (7/14/24) and the lab picked up the urine sample on Monday morning (7/15/24). IP stated the UA was not performed due to missing information and the lab did not call her. She did not know if the lab called Resident 5's nurse (Licensed Nurse K). IP stated usually the lab would call for critical values or if a test needed to be redone. IP stated that before nurses come to shift, they should always check results and there should be endorsement (report of information for continuity of care) from nurse to nurse to follow up on results. IP stated that if the results do not come back the same day it was collected, the nurse should call the lab that day. IP stated that in Resident 5 ' s case the PM shift (3 p.m. to 11:30 p.m.) nurse (Licensed Nurse L) should have called the lab Monday (7/15/24) before they left and notified the doctor so they could tell us what to do next. During an interview on 7/30/24 at 3:12 p.m., Licensed Nurse G stated she cared for Resident 5 (3 p.m. to 11:30 p.m.) after Licensed Nurse H put in the change in condition note (7/14/24). Licensed Nurse G stated she collected the urine sample on 7/14/24. Licensed Nurse G stated Resident 5 was confused and he definitely had a fair amount of sediment (particles that make the urine cloudy) in his urine, so she encouraged fluids while they waited for the lab results. Licensed Nurse G stated it was the nurses ' responsibility to follow up with the lab. Licensed Nurse G stated that the nurse who was on when the results came in was responsible for following up on the results. Licensed Nurse G stated every nurse after the sample was sent out should follow up with the lab for results. When queried, Licensed Nurse G stated that if a sample was rejected the nurse should notify the doctor and the responsible party, and then get a new sample if they can, then make a new order for it to be picked up again. When asked how Resident 5 was acting when he was confused (on 7/14/24), Licensed Nurse G stated he was alert to self only (he did not know the date, time, where he was or why he was there). During an interview on 7/30/24 at 3:35 p.m., Licensed Nurse H stated that when she worked with Resident 5 on Sunday (7/14/24) he had hematuria (blood in his urine) and increased confusion. She stated she informed the doctor right away. Licensed Nurse H stated she endorsed to the oncoming shift, Licensed Nurse G, that she was waiting for a response from Physician J. Licensed Nurse H stated Resident 5 seemed more confused, he had some underlying confusion, just every now and then he would say something that was inappropriate, not lethargic just a marked change in mentation. Licensed Nurse H stated Resident 5 had the condom catheter (a urinary device that fits over the penis and drains urine to a collection bag) at that point to help heal the open skin on his scrotum. Licensed Nurse H stated she collected the urine specimen in a container and put it in the refrigerator, and then Licensed Nurse G put the urine in the tubes for the urine test. Licensed Nurse H stated that if there was a stat lab at change of shift, the oncoming nurse was responsible for following up on the results. Licensed Nurse H stated that with the lab it just depended on how busy they were, if it was a critical result they would call, but usually they would fax the results to them. Licensed Nurse H stated the lab should call if the specimen was rejected but the nurse is also responsible to follow up if results were pending. Licensed Nurse H stated that if the results had not been received by the end of her shift she would go online and see if the results were ready or not. When asked if it would it say online if the specimen was rejected, Licensed Nurse H stated it would say test incomplete and results not available see attachment and at that point she would just call. During an interview on 7/30/24 at 3:51 p.m., when asked how he monitored residents with a change in condition, Director of Nursing (DON) stated they did a daily clinical IDT (interdisciplinary team, typically includes the nursing leadership, social services, and medical records) to review all resident changes in condition. When asked if they reviewed Resident 5 on 7/15/24 and 7/16/24, DON stated he was out that week. When queried, DON stated the MDS (minimum data set, an assessment tool) nurse ran the clinical IDT when he was out or the Director of Staff Development (DSD). DON stated that in Resident 5 ' s case, follow up should have happened every shift with the lab results. When asked when the nurse should have called the lab, DON stated the nurse should have called by PM shift on 7/15/24, the day it was picked up and reported as rejected. During an interview on 8/13/24 at 2:49 p.m., when asked the facility process for clinical IDT meetings, DSD E stated the clinical IDT rounds are done after the daily stand-up meeting in the conference room. DSD E stated the medical records department brings all the documentation, and the IDT looked at anyone who had a change in condition, a fall, medication change, the new admits, hospitalization s. DSD E stated they reviewed everything, such as what happened in the previous 24-hours or over the weekend, then they came up with a care plan. When asked what the IDT would review for a resident with acute confusion and hematuria, DSD E stated they would look for lab results, see what happened, did a UA get done, do we have results, did they start antibiotics, get a culture, what symptoms the resident had. When queried, DSD E stated that if DON was not available it would be herself and the MDS nurse leading the clinical IDT rounds. During an interview on 8/13/24 at 2:54 p.m., when asked the facility process for clinical IDT meetings, MDS Nurse stated they did clinical IDT every day after the stand-up meeting. MDS Nurse stated they talked about resident changes in condition, was it care planned, reported to the doctor, reviewed new orders, was it documented in a progress note or was a SBAR done. MDS Nurse stated that if DON was not available the DSD would do the clinical IDT. MDS Nurse verified the clinical IDT discussed Resident 5 on 7/16/24. When asked if the IDT talked about the UA that was ordered for Resident 5 on 7/16/24, MDS Nurse responded, When they were waiting for the results, that was the time he was sent out (to the hospital). When reminded that Resident 5 was sent to the hospital in the evening of 7/16/24 and clinical IDT met in the morning, MDS Nurse stated there was an assistant to the DON that was supposed to follow up on these things like lab results. After multiple queries, MDS Nurse did not respond to what was discussed regarding Resident 5 ' s change in condition or lab results at clinical IDT on 7/16/24. During a phone interview on 8/20/24 at 11 a.m., Medical Director stated there were a lot of reasons a UA would be ordered if a resident had confusion and hematuria, such as blood clots in the bladder or urethra, infection, or a fistula (an abnormal connection between the urethra and another hollow organ). Medical Director stated the UA was usually ordered stat because it was the fastest way to get information and they typically got results in 24 hours or less. Review of Resident 5's nurse progress note dated 7/16/24 at 7:20 p.m., indicated, Pt's (patient's) grandson requested pt's LN (licensed nurse) to call pt's daughter immediately, he did not elaborate further. Three LN's assessed pt. Nurse progress note described outcome of head-to-toe assessment and vital signs (blood pressure, temperature, pulse, respirations, and oxygen saturation [a measurement of how much oxygen is being carried by red blood cells]). Vital signs were normal except oxygen saturation was 81% on room air (normal oxygen saturation is 90 to 100%), oxygen was applied. Further review of nurse progress note indicated, Lungs with diminished breath sounds . Condom catheter in place, gross hematuria noted . This nurse (Licensed Nurse L) called pt's daughter, [FM2 named], to report assessment. Pt's daughter stated she wanted pt to be transferred to the ER (emergency room ). This nurse (Licensed Nurse L) phoned and messaged MD (medical doctor) and then called 911. Review of the ambulance crew documentation on 7/16/24 indicated the 911 call came in at 6:36 p.m., the crew arrived at the facility at 6:41 p.m., and arrived at the hospital emergency department with Resident 5 at 7:03 p.m. The ambulance crew documented that they were responding to a call that Resident 5 had an altered mental status and crackles in his lungs (sounds heard through a stethoscope [a medical instrument for listening to the action of someone's heart or breathing], can be a sign of fluid in the lungs). The ambulance crew further documented that upon arriving to Resident 5 ' s room, Resident 5 was alert and sitting up in bed, he had shallow, labored breathing, rapid pulse, and his skin was hot and dry to the touch. Review of the hospital emergency department (ED) documentation dated 7/16/24, revealed Resident 5 ' s temperature at 7:16 p.m. (40 minutes after 911 was called) was 101.7 degrees Fahrenheit axillary (arm pit) and his pulse was 120 beats per minute (normal pulse is 60 to 100 beats per minute). Review of the ED document History of Present Illness, dated 7/16/24 at 7:12 p.m., indicated a Code Sepsis was called and Resident 5 was diagnosed with sepsis, hypoxia (low oxygen levels), and acute cystitis with hematuria. Resident 5 ' s respiratory rate was elevated in the ED, with a rate as high has 43 breaths per minute at 8:23 p.m. (normal respiratory rate is 12 to 20 breaths per minute). While in the ED, Resident 5 ' s blood pressure was dropping, by 8:50 p.m. (approximately 2 hours and 15 minutes after 911 was called) his blood pressure was 63/47, and he was started on a Levophed drip (an intravenous [directly into the vein] medication that treats low blood pressure) and sent to the intensive care unit (ICU). Review of the hospitalist ' s (a physician who only sees patients in the hospital) note dated 7/16/24 at 9:19 p.m., indicated one of Resident 5 ' s diagnoses was Severe sepsis with septic shock. Review of Resident 5 ' s hospital lab work, dated 7/16/24, indicated Resident 5 ' s white blood cell count was 20 K/uL (a unit of measure) (elevated white blood cells can indicate the body is fighting an infection, normal level is 3.5 to 11 K/uL), his arterial blood gas (measures the amount of oxygen and carbon dioxide in your blood) results showed an oxygen level of 42 mmHg (a unit of measure) (normal oxygen level in the arteries is 83 to 100 mmHg), and his UA indicated his urine had many bacteria (normally urine is sterile [has no bacteria]). Review of facility policy Request for Diagnostic Services, last revised 4/2007, indicated, Orders for diagnostic services will be promptly carried out as instructed by the physician ' s order. Review of facility job description Charge Nurse, dated 3/2019, indicated under Essential Duties section, Performs nursing assessments regarding the health status of the resident / patient.

Based on interview and record review, the facility failed to follow up on a stat (immediately, urgent) laboratory (lab, a facility that provides controlled conditions in which scientific or technological research, experiments, and measurement may be performed) order for one of two sampled residents (Resident 5) when a stat urinalysis (UA, a basic test that examines the contents of a urine sample to identify conditions that may need treatment) and culture and sensitivity (C&S, a lab test that checks which bacteria are in the urine and which antibiotic will kill the bacteria) specimen for Resident 5 was rejected by the lab on 7/15/24 and a new urine specimen was not collected. This failure caused a delay in diagnosis and treatment for Resident 5, which caused his health to worsen requiring hospitalization on [DATE] where he was diagnosed with septic shock (sepsis [a serious condition in which the body responds improperly to an infection] may progress to septic shock, a dramatic drop in blood pressure that can damage the lungs, kidneys, liver and other organs) and acute cystitis (bladder infection). Finding: During a telephone interview on 7/24/24 at 10 a.m., Family Member 2 (FM2) stated that after 7/9/24, Resident 5 laid lethargic (feeling a lack of energy or interest in doing things) for a few days. FM2 stated she then got a phone call from the nurse supervisor on approximately 7/13/24 that Resident 5 had blood in his urine, and they were waiting for the doctor to authorize cultures. FM2 stated that on Tuesday 7/16/24 she got a call from her son that Resident 5 was not well, Resident 5 was white, shivering, lethargic and curled up in bed in a fetal position. FM2 stated Resident 5 went to the hospital with sepsis. FM2 stated, I think if they hadn ' t called (911) because my son told them to he (Resident 5) would have been dead by the next day. When queried, FM2 stated the facility ' s nurses ' lack of action made her feel angry. During a record review on 7/24/24 at 10:45 a.m., Resident 5 ' s face sheet revealed an admitted [DATE] with multiple medical diagnoses including schizoaffective disorder (a mental health condition with symptoms that include delusions [false beliefs], hallucinations, depressed episodes, and manic periods of high energy), dysphagia (difficulty swallowing), and cognitive (relating to or involving the processes of thinking and reasoning) communication disorder, among others. Resident 5 ' s record indicated FM2 was his responsible party and his Health Care Decision Maker. Review of Resident 5 ' s SBAR form (situation, background, assessment, and recommendation; a communication tool), dated 7/14/24 at 4:26 p.m., indicated Resident 5 had increased confusion, required more assistance with ADLs (activities of daily living, such as bathing, dressing, eating, toileting), and had blood in his urine. The SBAR indicated that Licensed Nurse H had notified Resident 5's doctor, Physician J, of his change in condition, and Licensed Nurse H was awaiting a reply. Review of Resident 5 ' s physician order, dated 7/14/24, indicated, Obtain UA and C&S STAT. Review of Resident 5 ' s nurse progress note dated 7/14/24 at 11:54 p.m., indicated Licensed Nurse G had collected the urine specimen for a STAT UA and C&S and she notified the lab that the specimen was ready for pickup. Review of Resident 5 ' s nurse progress notes dated 7/15/24 at 4:40 a.m., 7/15/24 at 9:31 p.m., and 7/16/24 at 1:14 p.m. all indicated Resident 5 was being monitored for continued confusion and blood in urine, but there was no documentation that the nurses followed up with the lab for the results of the stat UA and C&S. Review of Resident 5 ' s lab results for the stat UA and C&S, dated 7/15/24 at 2:10 p.m., indicated, Specimen Requires Recollection and a New Order Placed if Results are Needed. The lab results also indicated the reason the test was not performed was, Specimen Mislabeled - Missing Info. During an interview on 7/24/24 at 2:39 p.m., when queried, Infection Preventionist (IP) stated she did not track Resident 5 ' s urine sample because she was busy doing Covid response testing. IP stated the stat order for the UA was put in on Sunday (7/14/24) and the lab picked up the urine sample on Monday morning (7/15/24). IP stated the UA was not performed due to missing information and the lab did not call her. She did not know if the lab called Resident 5's nurse (Licensed Nurse K). IP stated usually the lab would call for critical values or if a test needed to be redone. IP stated that before nurses come to shift, they should always check results and there should be endorsement (report of information for continuity of care) from nurse to nurse to follow up on results. IP stated that if the results do not come back the same day it was collected, the nurse should call the lab that day. IP stated that in Resident 5 ' s case the PM shift (3 p.m. to 11:30 p.m.) nurse (Licensed Nurse L) should have called the lab Monday (7/15/24) before they left and notified the doctor so they could tell us what to do next. During an interview on 7/30/24 at 3:12 p.m., Licensed Nurse G stated she cared for Resident 5 (3 p.m. to 11:30 p.m.) after Licensed Nurse H put in the change in condition note (7/14/24). Licensed Nurse G stated she collected the urine sample on 7/14/24. Licensed Nurse G stated Resident 5 was confused and he definitely had a fair amount of sediment (particles that make the urine cloudy) in his urine, so she encouraged fluids while they waited for the lab results. Licensed Nurse G stated it was the nurses ' responsibility to follow up with the lab. Licensed Nurse G stated that the nurse who was on when the results came in was responsible for following up on the results. Licensed Nurse G stated every nurse after the sample was sent out should follow up with the lab for results. When queried, Licensed Nurse G stated that if a sample was rejected the nurse should notify the doctor and the responsible party, and then get a new sample if they can, then make a new order for it to be picked up again. When asked how Resident 5 was acting when he was confused (on 7/14/24), Licensed Nurse G stated he was alert to self only (he did not know the date, time, where he was or why he was there). During an interview on 7/30/24 at 3:35 p.m., Licensed Nurse H stated that when she worked with Resident 5 on Sunday (7/14/24) he had hematuria (blood in his urine) and increased confusion. She stated she informed the doctor right away. Licensed Nurse H stated she endorsed to the oncoming shift, Licensed Nurse G, that she was waiting for a response from Physician J. Licensed Nurse H stated Resident 5 seemed more confused, he had some underlying confusion, just every now and then he would say something that was inappropriate, not lethargic just a marked change in mentation. Licensed Nurse H stated Resident 5 had the condom catheter (a urinary device that fits over the penis and drains urine to a collection bag) at that point to help heal the open skin on his scrotum. Licensed Nurse H stated she collected the urine specimen in a container and put it in the refrigerator, and then Licensed Nurse G put the urine in the tubes for the urine test. Licensed Nurse H stated that if there was a stat lab at change of shift, the oncoming nurse was responsible for following up on the results. Licensed Nurse H stated that with the lab it just depended on how busy they were, if it was a critical result they would call, but usually they would fax the results to them. Licensed Nurse H stated the lab should call if the specimen was rejected but the nurse is also responsible to follow up if results were pending. Licensed Nurse H stated that if the results had not been received by the end of her shift she would go online and see if the results were ready or not. When asked if it would it say online if the specimen was rejected, Licensed Nurse H stated it would say test incomplete and results not available see attachment and at that point she would just call. During an interview on 7/30/24 at 3:51 p.m., when asked how he monitored residents with a change in condition, Director of Nursing (DON) stated they did a daily clinical IDT (interdisciplinary team, typically includes the nursing leadership, social services, and medical records) to review all resident changes in condition. When asked if they reviewed Resident 5 on 7/15/24 and 7/16/24, DON stated he was out that week. When queried, DON stated the MDS (minimum data set, an assessment tool) nurse ran the clinical IDT when he was out or the Director of Staff Development (DSD). DON stated that in Resident 5 ' s case, follow up should have happened every shift with the lab results. When asked when the nurse should have called the lab, DON stated the nurse should have called by PM shift on 7/15/24, the day it was picked up and reported as rejected. During an interview on 8/13/24 at 2:49 p.m., when asked the facility process for clinical IDT meetings, DSD E stated the clinical IDT rounds are done after the daily stand-up meeting in the conference room. DSD E stated the medical records department brings all the documentation, and the IDT looked at anyone who had a change in condition, a fall, medication change, the new admits, hospitalization s. DSD E stated they reviewed everything, such as what happened in the previous 24-hours or over the weekend, then they came up with a care plan. When asked what the IDT would review for a resident with acute confusion and hematuria, DSD E stated they would look for lab results, see what happened, did a UA get done, do we have results, did they start antibiotics, get a culture, what symptoms the resident had. When queried, DSD E stated that if DON was not available it would be herself and the MDS nurse leading the clinical IDT rounds. During an interview on 8/13/24 at 2:54 p.m., when asked the facility process for clinical IDT meetings, MDS Nurse stated they did clinical IDT every day after the stand-up meeting. MDS Nurse stated they talked about resident changes in condition, was it care planned, reported to the doctor, reviewed new orders, was it documented in a progress note or was a SBAR done. MDS Nurse stated that if DON was not available the DSD would do the clinical IDT. MDS Nurse verified the clinical IDT discussed Resident 5 on 7/16/24. When asked if the IDT talked about the UA that was ordered for Resident 5 on 7/16/24, MDS Nurse responded, When they were waiting for the results, that was the time he was sent out (to the hospital). When reminded that Resident 5 was sent to the hospital in the evening of 7/16/24 and clinical IDT met in the morning, MDS Nurse stated there was an assistant to the DON that was supposed to follow up on these things like lab results. After multiple queries, MDS Nurse did not respond to what was discussed regarding Resident 5 ' s change in condition or lab results at clinical IDT on 7/16/24. During a phone interview on 8/20/24 at 11 a.m., Medical Director stated there were a lot of reasons a UA would be ordered if a resident had confusion and hematuria, such as blood clots in the bladder or urethra, infection, or a fistula (an abnormal connection between the urethra and another hollow organ). Medical Director stated the UA was usually ordered stat because it was the fastest way to get information and they typically got results in 24 hours or less. Review of Resident 5's nurse progress note dated 7/16/24 at 7:20 p.m., indicated, Pt's (patient's) grandson requested pt's LN (licensed nurse) to call pt's daughter immediately, he did not elaborate further. Three LN's assessed pt. Nurse progress note described outcome of head-to-toe assessment and vital signs (blood pressure, temperature, pulse, respirations, and oxygen saturation [a measurement of how much oxygen is being carried by red blood cells]). Vital signs were normal except oxygen saturation was 81% on room air (normal oxygen saturation is 90 to 100%), oxygen was applied. Further review of nurse progress note indicated, Lungs with diminished breath sounds . Condom catheter in place, gross hematuria noted . This nurse (Licensed Nurse L) called pt's daughter, [FM2 named], to report assessment. Pt's daughter stated she wanted pt to be transferred to the ER (emergency room ). This nurse (Licensed Nurse L) phoned and messaged MD (medical doctor) and then called 911. Review of the ambulance crew documentation on 7/16/24 indicated the 911 call came in at 6:36 p.m., the crew arrived at the facility at 6:41 p.m., and arrived at the hospital emergency department with Resident 5 at 7:03 p.m. The ambulance crew documented that they were responding to a call that Resident 5 had an altered mental status and crackles in his lungs (sounds heard through a stethoscope [a medical instrument for listening to the action of someone's heart or breathing], can be a sign of fluid in the lungs). The ambulance crew further documented that upon arriving to Resident 5 ' s room, Resident 5 was alert and sitting up in bed, he had shallow, labored breathing, rapid pulse, and his skin was hot and dry to the touch. Review of the hospital emergency department (ED) documentation dated 7/16/24, revealed Resident 5 ' s temperature at 7:16 p.m. (40 minutes after 911 was called) was 101.7 degrees Fahrenheit axillary (arm pit) and his pulse was 120 beats per minute (normal pulse is 60 to 100 beats per minute). Review of the ED document History of Present Illness, dated 7/16/24 at 7:12 p.m., indicated a Code Sepsis was called and Resident 5 was diagnosed with sepsis, hypoxia (low oxygen levels), and acute cystitis with hematuria. Resident 5 ' s respiratory rate was elevated in the ED, with a rate as high has 43 breaths per minute at 8:23 p.m. (normal respiratory rate is 12 to 20 breaths per minute). While in the ED, Resident 5 ' s blood pressure was dropping, by 8:50 p.m. (approximately 2 hours and 15 minutes after 911 was called) his blood pressure was 63/47, and he was started on a Levophed drip (an intravenous [directly into the vein] medication that treats low blood pressure) and sent to the intensive care unit (ICU). Review of the hospitalist ' s (a physician who only sees patients in the hospital) note dated 7/16/24 at 9:19 p.m., indicated one of Resident 5 ' s diagnoses was Severe sepsis with septic shock. Review of Resident 5 ' s hospital lab work, dated 7/16/24, indicated Resident 5 ' s white blood cell count was 20 K/uL (a unit of measure) (elevated white blood cells can indicate the body is fighting an infection, normal level is 3.5 to 11 K/uL), his arterial blood gas (measures the amount of oxygen and carbon dioxide in your blood) results showed an oxygen level of 42 mmHg (a unit of measure) (normal oxygen level in the arteries is 83 to 100 mmHg), and his UA indicated his urine had many bacteria (normally urine is sterile [has no bacteria]). Review of facility policy Request for Diagnostic Services, last revised 4/2007, indicated, Orders for diagnostic services will be promptly carried out as instructed by the physician ' s order. Review of facility job description Charge Nurse, dated 3/2019, indicated under Essential Duties section, Performs nursing assessments regarding the health status of the resident / patient.

Based on interview and record review, the facility failed to honor the rights of one of two residents (Resident 5) when Resident 5 ' s medical decision-maker, Family Member 2 (FM2) was not asked or notified before starting to give Resident 5 a new pain medication MS (morphine sulphate) Contin (a long-acting pain medication made with morphine, an opiate). This failure resulted in Resident 5 becoming over sedated (state of calmness, relaxation, or sleepiness), requiring naloxone (a medication that reverses the potentially deadly effects of opiate toxicity), when he was administered a new medication before FM2 had been given a chance to consider the risks and benefits or permission for them to give it to him. Finding: During a telephone interview on 7/24/24 at 10 a.m., FM2 stated Resident 5 was riddled with arthritis (joint pain) particularly in his neck and knee. FM2 stated Resident 5 had been prescribed Norco (brand name for a pain medication made with acetaminophen and hydrocodone [an opiate]) scheduled twice daily until about four or six months ago when he was assigned a new doctor (Physician J). At that time the Norco was changed to be given only as needed. FM2 stated Resident 5 was screaming in pain one day, so the nurses called the doctor (Physician J) who ordered morphine 30 mg (milligrams, a unit of measure) instead of going back to the scheduled Norco. FM2 stated Resident 5 was given six doses of the morphine and then on 7/9/24 the nurse (unidentified) called FM2 to tell her Resident 5 was doing well after being given Narcan (brand name for naloxone). FM2 stated she asked the nurse, Why did you need Narcan? and the nurse told her Resident 5 had a bad reaction to morphine. FM2 stated she was angry because she had no idea Resident 5 was taking morphine. FM2 stated she asked the nurse, Where did that (the morphine) come from? You ' re supposed to advise me. When queried, FM2 stated the nurse had given Resident 5 the Narcan because he was not responding (to touch or verbal stimuli). During a record review on 7/24/24 at 10:45 a.m., Resident 5 ' s face sheet revealed an admitted [DATE] with multiple medical diagnoses including schizoaffective disorder (a mental health condition with symptoms that include delusions [false beliefs], hallucinations, depressed episodes, and manic periods of high energy), osteoarthritis (joint pain) of the knee, spondylitis of the cervical spine (stiff, painful neck), and cognitive (relating to or involving the processes of thinking and reasoning) communication disorder, among others. Resident 5 ' s face sheet further indicated FM2 was his responsible party and his Health Care Decision Maker. Review of Resident 5 ' s physician order, dated 3/7/24, indicated that a new physician, Physician J, was taking over Resident 5 ' s care. Review of Resident 5 ' s medication administration record (MAR) for May 2024 indicated his order for Norco 10/325 mg three time per day was discontinued on 5/8/24, and oxycodone (an opiate pain medication) 10 mg every six hours as needed was started on 5/8/24. Review of Resident 5 ' s July 2024 MAR revealed a physician order with a start date of 7/6/24 for MS Contin Oral Tablet Extended Release 30 mg (Morphine Sulphate) Give one table by mouth two times a day for pain management. Resident 5 ' s July 2024 MAR indicated Resident 5 received a dose of the MS Contin on 7/7/24 at 9 a.m. and 5 p.m., 7/8/24 at 9 a.m. and 5 p.m., and 7/9/24 at 9 a.m. Review of Resident 5 ' s count sheet (a log where the nurses write the date and time each pill is removed in order to keep track of how many pills are left of the medication), not dated, for his oxycodone 10 mg indicated Resident 5 received doses on 7/7/24 at 1 p.m., 7/8/24 at 1:57 p.m. and 8 p.m., and 7/9/24 9:57 a.m. Further review of Resident 5 ' s July 2024 MAR indicated naloxone 0.4 mg was given on 7/9/24 at 4:11 p.m. On 7/9/24 at 5:10 p.m., a MAR note indicated the naloxone was effective. Review of Resident 5 ' s physician progress notes for May 2024 and July 2024 (the months during which Resident 5's pain medications were changed) revealed no documentation of the rationale for the change of medications or any discussion with FM2 regarding the changes to Resident 5 ' s pain medication regimen. Resident 5 ' s physician progress note dated 7/11/24 indicated, Chief complaint: Opioid overdose, AMS (altered mental status). Assessment: . Pt (patient) noted to be [more] lethargic (feeling a lack of energy or interest in doing things) after dose of opioid. Review of Resident 5 ' s nurse progress notes for the month of May 2024 and July 2024 (the months during which Resident 5's pain medications were changed) also revealed no documentation that FM2 was notified of the changes to Resident 5 ' s pain medication regimen. During an interview on 7/24/24 at 3:51 p.m., Licensed Nurse F stated she recalled that on 7/9/24 Resident 5 was seemingly out of it, so I gave Narcan to him. Shortly thereafter Resident 5 turned back into his crying person that he is when he ' s in pain. Licensed Nurse F stated she called Resident 5 ' s doctor (Physician J) and informed him Resident 5 was seemingly out of it and she had given Narcan to him. Licensed Nurse F stated the only thing she noticed that was new for Resident 5 was the morphine. Licensed Nurse F stated the doctor responded to cut the morphine dose in half from 30 mg to 15 mg. Licensed Nurse F stated she called FM2, and she was very angry. Licensed Nurse F stated FM2 told her, I ' m supposed to be notified whenever there ' s a change in medication. When queried, Licensed Nurse F stated Resident 5 was usually sitting up at that time of day when her shift began and she thought it was unusual that he was in bed. Licensed Nurse F stated Resident 5 was awake but not acknowledging her. When asked how Resident 5 communicated at baseline, Licensed Nurse F stated Resident 5 could verbalize that he needed pain meds (medications), and when she brought him his medications, he asked, Do you have pain meds in there (the pill cup)? Licensed Nurse F verified she reassessed Resident 5 throughout the rest of her shift (3 p.m. to 11:30 p.m.) and the naloxone had been effective. When queried, Licensed Nurse F stated she thought the dose of the MS Contin was too high. She thought that to start Resident 5 at 30 mg was too much and it had caused Resident 5 to become over sedated. During an interview on 7/30/24 at 3:12 p.m., Licensed Nurse G verified she entered the order for the MS Contin on 7/5/24. She stated Resident 5 was showing signs the pain medication he was taking (oxycodone 10 mg every six hours as needed) was not working and gave the example that he was refusing turning and calling out in pain. Licensed Nurse G stated he also was not eating because of the neck pain he was having. Licensed Nurse G stated Resident 5 ' s pain medication was ordered PRN (as needed), but she thought something routine (scheduled) would help. Licensed Nurse G stated she contacted Resident 5 ' s doctor (Physician J) and he responded with the order for the MS Contin. When queried, Licensed Nurse G stated she did not recall informing FM2, Resident 5 ' s responsible party (RP), that the doctor (Physician J) ordered the MS Contin. When asked who was responsible for informing the RP of medication changes, Licensed Nurse G stated it would be the nurse ' s responsibility. During an interview on 7/30/24 at 3:51 p.m., Director of Nursing (DON) stated he could not remember why Resident 5 ' s pain medication was changed in May 2024. DON verified it was changed again at beginning of July 2024. DON stated they usually informed the resident ' s RP of a pain regimen change or medication that needed informed consent and they usually specified (documented) in the record that the RP agreed the medication was what they wanted. DON stated that in this case it was not specified in the record. DON stated it was the responsibility of the nurse who took the medication order from the doctor to tell the RP of any changes. DON verified FM2 should have been notified of the changes in treatment for Resident 5 ' s pain. During a phone interview on 8/20/24 at 11 a.m., Medical Director verified the resident or the resident's decision maker or responsible party should be involved in the decision to change a resident's pain medication regimen. When asked who was responsible for having that discussion with the resident or the decision maker, Medical Director stated it could be the resident's doctor, the LVN (licensed vocational nurse), the RN (registered nurse), the DON. When queried, Medical Director stated the rationale for involving the resident or decision maker or responsible party in medication changes was to make sure they were aware of the plan. Review of the package insert information for MS Contin Extended Release on website dailymed.nlm.nih.gov, accessed on 8/15/24, revealed under Warnings section, Morphine may be expected to have additive effects when used in conjunction with . other opioids . that cause central nervous system depression because respiratory depression (slow, shallow breathing), hypotension (low blood pressure), and profound sedation or coma may result. Section titled Dosage and Administration revealed, During periods of changing analgesic (pain medication) requirements including initial titration (changing the dose according to patient response), frequent contact is recommended between physician, other members of the healthcare team, the patient, and the caregiver/family. Review of facility job description Charge Nurse, dated 3/2019, indicated under Essential Duties section, Encourage the resident and his/her family to participate in the development and review of the resident ' s plan of care. Review of facility policy Resident Rights, last revised 2/2021, revealed, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to: . be informed of, and participate in, his or her care planning and treatment .

Based on observation, interviews and record reviews, the facility failed to monitor skin changes and develop a plan to prevent the development of pressure ulcer or injury (bed sore) or worsening of the pressure ulcer of one (1) of four (4) resident (Resident 1). This failure resulted to Resident 1 developing a pressure injury on his left heel and worsening of the pressure sore on his coccyx (tailbone or lower back). Findings: A review of Resident 1's face sheet indicated he was recently readmitted to the facility on [DATE] for osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time)of the right hip, bladder (hollow spherical organ that holds urine) obstruction, acute respiratory and heart failures, diabetes (disease when blood sugar is too high) and complications of a supra-pubic urinary catheter (a hollow flexible tube that is used to drain urine from the bladder. It is inserted into the bladder through a cut in the tummy, a few inches below the navel (tummy button), among other conditions. During a review of the Resident 1's medical records, the Nursing Admission/Readmission evaluation dated 1/25/24 indicated, Resident 1 had a non-blanchable redness on his lower back. The summary note indicated, Resident 1 was at risk for pressure injuries due to thinning skin and limited mobility. A review of a Nurses Progress Notes documented on 2/3/24, at 7:29 AM indicated, Resident 1 had an open skin on the tailbone measuring 7 cm (centimeters, is a unit of measure for lengths) by 2 cm. A review of Resident 1's care plans indicated two preventative plans of care to maintain skin integrity, namely: 1) at risk for pressure ulcer development or skin impairment related to (r/t) incontinence (inability to control elimination of urine or stool) dated 8/29/22; and 2) risk for alteration in skin r/t anticoagulation (medication that help prevent blood clots) use dated 12/23/22. Interventions for the first plan were pressure reducing mattress to protect the skin and cushion on wheelchair; and for #2, monitor for skin tears, bruising, discoloration daily and notify charge nurse, and use care during transfers, toileting, dressing, and mobility. The care plans were not updated to add interventions to prevent worsening of the non-blanchable redness to the lower back after it was discovered on 1/25/24. During further review of Resident 1's medical record, an SBAR (stands for Situation, Background, Assessment, Recommendation, is a structured communication tool used to share information about the condition of a patient) report dated 2/5/24 indicated Resident 1 had a new open area to the left heel that measured 5.79 cm by 2.82 cm. During an interview on 3/15/24, at 2:49 PM, Licensed Nurse A, stated Resident 1's deep tissue pressure injury (DTPI - purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or sheer) on the left heel developed in the facility. During a concurrent observation at Resident 1's room and interview on 3/15/24, at 4:07 PM, wound nurses, Licensed Nurse A and Licensed Nurse B changed the dressing on Resident 1's lower back. The pressure ulcer on the lower back was covered by slough (dead tissue). The DTPI on Resident 1's left heel was noted to be black and approximate the size of a ping-pong or golf ball. Licensed Nurse A stated, Resident 1's coccyx or lower back was with minimal slough before he was hospitalized but became worse when he came back. During a review of the electronic mail dated 4/19/24 received from the facility indicated, Resident 1 was at the acute hospital from 1/7/24 to 1/24/24 and 2/25/24 to 3/3/24. A review of the Hospice note, dated 2/3/24, indicated Resident 1's pressure ulcer on the lower back had opened and measured 7 cm by 2 cm. During an interview on 3/15/24, at 4:53 PM, Certified Nursing Assistant C (CNA C) stated she did skin inspection for redness when residents' clothing and inform the nurse of skin changes. During an interview on 4/18/24, at 2:45 PM, the Wound Consultant stated she could not speak how skin care was before the residents were referred to her. The Wound Consultant stated it is difficult to say whether Resident 1's pressure injuries were avoidable, but given the co-morbidities, health condition and non-cooperative behavior of the resident, wound healing would be difficult. During an interview on 4/19/24, at 2:14 PM, CNA D stated he could not assess the resident's skin when the resident refuses care. During an interview on 4/19/24, at 3:10 PM, CNA E stated Resident 1 was not fully alert, was sent to the acute hospital for a couple of weeks and was more confused and yelling all the time when he came back. CNA E stated Resident 1 was totally dependent, unable to turn in bed. A review of the Treatment Administration Record for the months of 1/24 and 2/24, and Shower Sheets for the same period, indicated Resident 1 was given baths on 1/26/24, 2/5/24, 2/12/24, 2/14/24, 2/16/24, 2/21/24, and 2/23/24. Of the dates Resident 1 was given a bath, only 2/5/24, had a Shower Sheet with notations. The Shower Sheet, dated 2/5/24, indicated boxes for bruises, red areas, and open areas were checked. There were no other comments or details as to the locations of the affected skin. During an interview on 5/2/24, at 4:38 PM, the Director of Nursing (DON) stated when it was pointed out that a care plan to prevent worsening of a pressure ulcer on Resident 1's lower back was not found, he will check if they have more care plans on file that was not provided. The DON did not have a response when asked, how could staff miss identifying skin changes on the heel of Resident 1 if they were supposed to be checking or monitoring skin changes during cleaning and changing or providing showers to residents. A review of the facility policy, titled: Prevention of Pressure injuries revised 4/20 indicated, the purpose of the policy was to identify pressure injury risk factors and interventions for specific risk factors. Inspect the skin daily when performing or assisting with personal care or activities of daily living (ADLs) .inspect pressure points (lower back, heels, buttocks, elbows, etc). Evaluate, report and document potential changes in the skin, and review the interventions and strategies for effectiveness on an ongoing basis. There was no mention of preventing pressure ulcers or injuries worsening, in the policy.

Based on interview and record review, the facility failed to protect one resident (Resident 1) from sexual abuse when CNA (certified nursing assistant) B grabbed her vaginal area forcefully through her brief. This failure caused Resident 1 to cry and experience sadness when she felt physically and emotionally violated. Findings: A Review of Resident 1's medical record and MDS report (an assessment the facility does upon admission and change of condition) indicated that the resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had no loss of memory, problem solving, or language skills. During an interview with the Administrator on 7/12/2021 at 9:00 am, he stated that CNA A came to him the morning of 4/27/2021 and reported that when she was showering Resident 1 that morning, Resident 1 asked CNA A Can I talk to you? I can't talk to anyone. Resident 1 then began to cry and stated that she had been abused by CNA B the night before. Resident 1 stated that when CNA B came into her room, CNA B was laughing in a mocking way, came to her bed and loudly said What language do you speak? CNA B then very gruffly told Resident 1 to let her check Resident 1's brief to see if she was wet. CNA B was pushing Resident 1 over to change her, and then grabbed the resident's vaginal area through the brief. Resident 1 told CNA B not to touch her, and then CNA B left the room laughing. The Administrator stated that he believed the victim, as she was honest and does not confabulate stories. During the same interview, the Administrator stated he had started his investigation of the incident, and interviewed CNA B regarding the incident. He stated that CNA B changed her statement regarding the incident several times. The Administrator suspended CNA B, and when his investigation was completed, he terminated CNA B from her employment. During an observation and concurrent interview on 7/12/21 at 1:45 pm, Resident 1 was alert and oriented, well spoken, and became visibly upset and crying when talking about the incident. Resident 1 stated that on the night of the incident, she was not sleeping well. Resident 1 stated she was awake when CNA B entered her room for rounds check. Resident 1 further stated that CNA B behaved as if she was high on drugs or alcohol, and She was really out there. Resident 1 stated that CNA B was laughing as if she was mocking the resident, and used rough language and handling while changing the Resident 1's brief. Resident 1 stated that CNA B was saying weird things like What language do you speak? Resident 1 stated that she had only been in the facility for one month, so she had never received care from CNA B prior to this incident. During an interview with CNA A on 7/15/2021 at 2:30 pm, she reiterated the same information she had given the Administrator regarding the incident. She also stated that the night of the incident, when she had been signing off of her shift, she saw CNA B. CNA B gruffly said that she was in a bad mood. CNA A stated she did not pursue any further conversation about CNA B's state of mind at that time. CNA A stated she had only worked at the facility for a few months, and did not know CNA B other than to see her at the facility. Record Review of CNA B's statement written on 4/27/21, indicated that she went to Resident 1's room to answer a call light at 11:35 pm on 4/26/2021, and Resident 1 was harsh with her and seemed like she was mad. It further indicated that CNA B went to get a brief for Resident 1, and that Resident 1 was asking her what language she spoke. The statement further indicated that while changing the brief, she could not finish, and left the brief unhooked because Resident 1 told her not to touch her anymore. Record Review on 7/12/2021 of CNA B's personnel file, revealed that she had worked at the facility since 2018. She received a Corrective Action Verbal Notice on 8/24/18 for telling a resident that she was not going to get her pain medicine when the resident had requested CNA B to ask the nurse for her med. On 1/10/2019 she received another Corrective Action Written Notice and a Performance Improvement Plan for unprofessional and disrespectful communication with residents, as well as not accepting and taking directive from supervisory/management , lack of teamwork, and speaking in a threatening manner. On 2/15/2019 she again received a Corrective Action for breaking a rule by working off the clock. Document Review on 7/12/2021 of the facility's Abuse Prohibition and Prevention Policy and Procedure, dated 3/2018 indicated that each resident has the right to be free from abandonment, mental/emotional, isolation, involuntary seclusion, verbal, physical, financial, sexual, neglect, and misappropriation of property.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistance, and implement the care plan for three of 15 sampled residents (Resident 2, 3, and 8) when: 1. Resident 2 had 32 falls in a 11-month period from 2/15/16 to 1/30/17. Resident 2 sustained a forehead laceration, periorbital hematoma (bruising around the eye, commonly due to an injury to the face), subdural hematoma (a mass of accumulated blood inside the head caused by bleeding, usually results from a serious head injury and can be life threatening), and jaw dislocation from an unwitnessed fall in the resident's room on 3/9/16 and required hospitalization . Resident 2 also sustained redness to his elbow with mild pain from an unwitnessed fall in the resident's room on 3/28/16, a bump with bleeding and being non-responsive after hit his head from an unwitnessed fall in the resident's bathroom on 5/16/16 and was sent to the acute care hospital for evaluation, and a laceration to the right upper eyebrow from an unwitnessed fall in the resident's room on 9/9/16. 2. Resident 3 had eight falls in a 11-month period from 3/26/16 to 2/6/17, and 3. Resident 8 fell on [DATE] while attempting to reach an object on the floor. These failures also had the potential to cause further falls for residents, potentially cause serious injuries or death to the residents. Findings: 1. Resident 2's admission record indicated Resident 2 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with multiple [DIAGNOSES REDACTED]. Resident 2's MDS (minimum data set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems) dated 6/25/16 and 12/26/16 indicated Resident 2's BIMS (brief interview for mental status) score were 5 to 3, which indicated Resident 2's cognition was severely impaired. The MDS indicated Resident 2 required extensive assistance with one person (staff) assist for ADLs (activities of daily living) including transfer, dressing, toileting, and hygiene. Resident 2's 13 fall risk assessments dated from 2/16/16 to 1/30/17 indicated Resident 2 was at moderate to high risk for falls due to multiple problems including history of falls, memory problems, decrease in muscle coordination, and balance problems. Resident 2's fall risk care plan initiated on 7/7/14 and last revised on 11/9/16, indicated Resident 2 was at high risk for fall related to multiple problems including unaware of safety needs, confusion, history of falls, and memory impairment. The care plan indicated interventions including anti roll back device on w/c (wheelchair) when available .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed .Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c .eye to eye supervision . The facility's Fall Scene Investigation Report and IDT (interdisciplinary team) notes dated from 2/15/16 to 1/30/17, indicated Resident 2 had 32 falls from 2/15/16 to 1/30/17. The facility's Fall Scene Investigation Report and IDT notes indicated 21 of these 32 falls were unwitnessed falls in Resident 2's room, bathroom, or patio. Six of the 32 falls were witnessed by Resident 2's roommates. Fall #1 The facility's Fall Scene Investigation Report and IDT note dated 2/15/16, indicated at around 5:45 p.m., Resident 2 had an unwitnessed fall in his room and was found on the floor. The IDT note indicated new interventions including Educate staff to ensure Resident wears proper footwear at all times. IDT anticipates further falls related to decline of his cognitive function. Resident is unable to remember to don proper footwear and to keep walker by his side to prevent further falls from self transferring. Therapy to screen resident. Resident 2's fall risk care plan initiated on 7/7/14 and last revised on 11/9/16. Fall #2 The facility's Fall Scene Investigation Report and IDT note dated 2/24/16, indicated at around 4:30 a.m. Resident ambulating in the hallway using FWW (front wheel walker) and maneuvering his FWW and lost his balance while maneuvering .LN (licensed nurse) was standing on cart while resident is at the other end of the hall. The IDT note indicated a new intervention Monitoring for safety to prevent recurrence. Resident 2's fall risk care plan initiated on 7/7/14 and last revised on 11/9/16. Fall #3 The facility's Fall Scene Investigation Report and IDT note dated 3/3/16 at 2:16 p.m., indicated Resident 2 had an unwitnessed fall and was found on the floor in the patio outside building on premises. The IDT note indicated a new intervention NOT TO GO OUTSIDE W/OUT (WITHOUT) ASSISTANCE. Resident 2's fall risk care plan initiated on 7/7/14 and was last revised on 11/9/16. Fall #4 The facility's Fall Scene Investigation Report and IDT note dated 3/9/16 at 12:38 a.m., indicated Resident 2 had an unwitnessed fall in Resident 2's room and was found on the floor. The IDT note indicated Resident 2 hit his head and knocked over his roommate's wheelchair. Resident 2 sustained a laceration on his right thumb and on the right side of his forehead over his eye with a moderate to large amount of bleeding on forehead. Resident 2 was sent to an acute care hospital emergency room for evaluation due to increased swelling to right eye and neck pain and feeling dizzy. The IDT note indicated a new intervention Resident sent out to acute ER (emergency room ) for evaluation. Resident 2's fall risk care plan initiated on 7/7/14 and was last revised on 11/9/16. Fall #5 The facility's Fall Scene Investigation Report and IDT note dated 3/16/16, indicated Resident 2 was readmitted to the facility after hospitalized in an acute care hospital due to forehead laceration, periorbital hematoma, subdural hematoma, and jaw dislocation from the fall on 3/9/16, The IDT notes indicated Resident 2 had an unwitnessed fall in his room and was found on the floor on 3/16/16 at 7:45 p.m. The IDT note indicated new interventions including Wheelchair and FWW will be placed outside the resident's room. Resident will be working with therapy. Bed in lowest position with a landing mat next to it. Resident 2's fall risk care plan initiated on 7/7/14 and last revised on 11/9/16. Fall #6 The facility's Fall Scene Investigation Report and IDT note dated 3/28/16 at 7:32 p.m., indicated Resident 2 had an unwitnessed fall and was found on the floor in his room. Resident 2 sustained redness to his elbow with mild pain. The IDT note indicated new interventions including Eye to eye supervision had been communicated to nursing staff by DON and will also be communicated by therapy. Keep unsteady objects away from resident's bed to prevent resident from leaning on them and falling. Bolster mattress. The IDT note did not specify when and how to provide eye to eye supervision to Resident 2. Resident 2's fall risk care plan initiated on 7/7/14 and last revised on 11/9/16, indicated the eye to eye supervision was initiated on 5/17/16. The care plan did not specify when and how to provide eye to eye supervision to Resident 2. Falls #7-10 The facility's Fall Scene Investigation Report and IDT note dated 4/7/16, 4/13/16, 4/27/16, and 5/8/16, indicated Resident 2 had four unwitnessed falls in his room or bathroom. The IDT notes indicated new interventions including Call light (within) reach .encouraged to use pole for transferring .more vigilant resident monitoring at the evening time .Will continue to provide (patient) teaching not to transfer by self . Resident 2's fall risk care plan initiated on 7/7/14 and last revised on 11/9/16. Fall #11 The facility's Fall Scene Investigation Report and IDT note dated 5/16/16, indicated Resident 2 had an unwitnessed fall and was found on the floor in the bathroom at 12:45 a.m. The IDT note indicated Resident 2 hit his head and acquired a bump that was bleeding a minimal amount . The IDT note also indicated Resident 2 was non-responsive and was sent to an acute care hospital. The IDT note indicated new intervention Sent resident out to acute. Resident 2's fall risk care plan initiated on 7/7/14 and last revised on 11/9/16. Falls #12-13 The facility's Fall Scene Investigation Report and IDT note dated 5/17/16 at 10:47 a.m. and 12:27 a.m. indicated Resident 2 had 2 falls in front of the nurse station or in the resident's room on 5/17/16. One of these two falls was witnessed by a family member of his roommate in the resident's room. The IDT notes indicated new interventions including .Will remain on eye to eye supervision while up in his w/c .Will place in afternoon sensory group .Will have staff toilet the resident (every two hours) . The IDT note did not specify when and how to provide eye to eye supervision to Resident 2 when Resident 2 also fell in front of the nurse station. The IDT note did not specify providing supervision to Resident 2 in the resident's room when Resident 2 had multiple unwitnessed falls in his room. Resident 2's fall risk care plan initiated on 7/7/14 and last revised on 11/9/16, did not specify when and how to provide eye to eye supervision to Resident 2 when Resident 2 also fell in front of the nurse station. Falls #14-32 The facility's Fall Scene Investigation Report and IDT notes dated 5/31/16, 6/5/16, 6/28/16, 7/14/16, 7/16/16, 7/19/16, 8/16/16, 9/8/16, 9/9/16, 9/16/16, 9/16/16 (second fall of the same day), 10/17/16, 11/8/16, 11/13/16, 12/17/16, 1/12/17, 1/20/17, 1/22/17, and 1/30/17, indicated Resident 2 had 19 falls in different locations and different times of the day. 11 of these 19 falls were unwitnessed in the Resident 2's room or bathroom. Four of the 19 falls were witnessed by Resident 2's roommate. Resident 2 sustained a laceration to his right upper eyebrow from an unwitnessed fall on 9/9/16. The IDT notes indicated new intervention including occupational therapy, self-release seat belt, IDT anticipated further falls related to his cognition and poor self-awareness, reminder sign for resident to stop first and ask for help, re-education of using call light for assistance, and transfer pole. The IDT notes did not specify how to provide supervision to Resident 2 when Resident 2 had 19 falls after 5/17/16 with the eye to eye supervision. Resident 2's fall risk care plan initiated on 7/7/14 and last revised on 11/9/16, did not specify how to provide supervision to Resident 2 to prevent further falls when Resident 2 had 19 falls after 5/17/16 with the eye to eye supervision. During a concurrent observation and interview on 2/14/17, at 9 a.m., Resident 2 was sitting in a wheelchair in the hallway alone. Resident 2 stated it was OK to talk but he did not remember what had happened to him. During a concurrent interview and record review on 2/16/17, at 11 a.m., Licensed Staff D stated Resident 2 had dementia and was occasionally confused. Licensed Staff D stated Resident 2 did not remember to use the call light for assistance. When asked about the eye to eye supervision in the care plan, Licensed Staff D stated when Resident 2 was up, keep him near the nurse station or in the hallway near the medication cart so that she could keep an eye on Resident 2. Licensed Staff D stated if she did not see Resident 2, she would look for him. Licensed Staff D stated she also asked the CNA (certified nursing assistant) to keep an eye on Resident 2. Licensed Staff D stated there was no eye to eye supervision when Resident 2 was in his room. Licensed Staff D stated when Resident 2 was in his room, Licensed Staff D or the CNA checked on Resident 2 every 15 to 30 minutes but no set time. Licensed Staff D reviewed the fall risk care plan and stated the care plan did not indicate a set time for supervision. During an interview on 2/16/17, at 3:20 p.m., Unlicensed Staff J stated Resident 2 was a fall risk and had frequent falls. Unlicensed Staff J stated he also reviewed the care plan for resident care. Unlicensed Staff J stated eye to eye supervision meant to check on resident with his eyes when he made rounds to Resident 2's room or when Resident 2 was in the hallway. Unlicensed Staff J stated he did not check Resident 2 constantly because Resident 2 was not on one to one (1:1). Unlicensed Staff J stated he checked Resident 2 at least every 30 minutes when Resident 2 was in bed. Unlicensed Staff J stated he asked his coworker to check on Resident 2 when Unlicensed Staff J was busy. During a concurrent interview and record review on 2/16/17, at 4 p.m., the Director of Nursing (DON) stated Resident 2 had short term memory deficit and had no safety awareness. The DON stated they started new interventions after each fall because the previous interventions were not working. The DON stated the new interventions included: bed in low position, pad on the floor, alarm device (a device attached to the resident that triggers an alarm when the resident attempts to get up from the wheelchair or bed), self-release seat belt, and eye to eye supervision but not 1:1. The DON stated eye to eye supervision meant staff saw resident in a distance to monitor or supervise by giving verbal commands and close enough to react if Resident 2 was falling. The DON stated when Resident 2 was in the room, staff checked on Resident 2 frequently but no set time. The DON stated the physical therapist screened Resident 2 many times and tried out using a pole for transfers and wearing nonskid socks. The DON stated Resident 2 was not able to use the call light for assistance because Resident 2 had dementia and memory impairment. The DON stated they included .call light . in the care plan and told Resident 2 to use the call light because Resident 2 might have clarity episode but not happened yet. The DON stated they had asked the family to provide 1:1 but the family was not able to provide 1:1. The DON stated they had not come to the conclusion for staff providing 1:1. When asked Resident 2 had 32 falls but had not come to the conclusion for 1:1, the DON stated they did not know Resident 2 had 32 falls because they did not count the falls until yesterday (2/15/17) when they provided the copies of Resident 2's Fall Scene Investigation Report and IDT notes. The DON stated they did not increase supervision to Resident 2 after they initiated eye to eye supervision on 5/17/16. The DON acknowledged that Resident 2 had multiple falls after 5/17/16. 2. Resident 3's admission record indicated Resident 3 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident 3's MDS dated [DATE] and 12/23/16 indicated Resident 3's cognitive skills for daily decision making was severely impaired - never/rarely made decisions The MDS indicated Resident 3 required extensive assistance with one to two persons assist for ADLs including transfer, ambulation, dressing, eating, and toilet use. Resident 3's Fall Risk assessment dated [DATE], 11/24/16, and 12/16/16 indicated Resident 3 was at moderate to high risk for falls due to multiple problems including history of falls, memory problems, balance problems and decrease in muscle coordination. Resident 3's fall risk care plan initiated on 1/6/16 and last revised on 1/9/17, indicated Resident 3 was at high risk for falls related to multiple issues including history of falls sustaining fracture of left hip, confusion, poor safety awareness, unsafe behavior, and bow legged gait. The interventions included .Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c .reduce occurrences of resident in the dining room when staff not present (initiated on 2/6/17) .weighted vest and blanket when available . The facility's Fall Scene Investigation Report and IDT notes dated from 3/26/16 to 2/5/17, indicated Resident 3 had eight falls with no injuries as following: 1. 3/26/16 at 12: 45 a.m., Resident 3 fell in the hallway witnessed by a social worker. 2. 8/8/16 at 3:15 p.m., Resident 3 fell in the dining room 3. 8/24/16 at 9:30 a.m., Resident 3 had an unwitnessed fall in the hallway 4. 10/26/16 at 11:30 a.m., Resident 3 had a fall in the dining room 5. 11/17/16 at 4 p.m., Resident 3 had an unwitnessed fall in the dining room 6. 12/8/16 at 4:10 p.m., Resident 3 had a fall in the dining room 7. 1/31/17 at 8:15 a.m., Resident 3 had a fall when ambulating from her room to the hallway 8. 2/5/17 at 4:15 p.m., Resident 3 had an unwitnessed fall in the dining room. Resident 3's fall risk care plan did not indicate how the facility would provide supervision to Resident 3 to prevent further falls. During an interview on 2/16/17, at 9:50 a.m., Licensed Staff A stated Resident 3 was at high risk for falls. Licensed Staff A stated they kept Resident 3 in front of the nurse station and everybody kept an eye on her. Licensed Staff A stated her assigned nurse would be responsible when resident fell . Licensed Staff A reviewed Resident 3's fall risk care plan and stated the care plan did not specify the level of supervision to Resident 3. Licensed Staff A stated when Resident 3 was in her room, no direct supervision and no documented supervision or checking resident. Licensed Staff A stated they kept Resident 3 out of her room when she was awake. During an interview on 2/16/17, at 2:45 p.m., Unlicensed Staff K stated when Resident 3 was up, take her to the activity room and tell activity staff or other staff to keep an eye on her. During a concurrent interview and record review on 2/16/17, at 4 p.m., the DON stated Resident 3 had short term memory impairment, dementia and Resident 3 was very mobile. The DON stated any staff could see Resident 3 and intervene to prevent fall. The DON stated the care plan did not specify providing supervision to Resident 3. 3. Resident 8's Admission Record sheet, dated 2/2/17, indicated she was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident 8's Medical Administration Record for January 2017 indicated she was receiving multiple psychotropic medications (drugs that affect brain activities), including Trazodone, Duloxetine, Ativan, Buspirone, and Desipramine. Resident 8 was also regularly receiving the pain killers Morphine and Dilaudid. These medications have the potential to cause sedation and lightheadness. Review of Resident 8's medical records indicated she fell on [DATE]. A nurses note dated 1/26/17 10:53 p.m. documented that On 1/26/17 at 10pm the resident was found sitting on the floor by her bed by her w/c. Per the resident, she was getting up to go to the bathroom and slid to the floor. During an interview on 2/15/17 at 4:25 p.m. Resident 8 stated that on 1/26/17 she was sitting on her wheelchair between her bed and the bathroom and fell when attempting to grab an object on the floor. It hurt when I fell she said. She stated she had to crawl to the bathroom to press the call light for help. When asked why she did not press the call light so staff could assist her in reaching the object on the floor, Resident 8 stated that she wanted to press her call light for help but could not reach it. Resident 8's care plan, initiated 12/21/16, stated as focus: The resident is high risk for falls and as intervention: Be sure the resident's call light in within reach and encourage the resident to use it. The facility's policy and procedure titled FALLS MANAGEMENT, revised November 2012, indicated It is the policy of this facility that our physical environment remains as free of accident hazards as possible. Residents will be assessed for fall risk and interventions will be implemented to reduce the risk for falls .

Based on observation, interview and facility record review, the facility failed to protect 1 resident (Random Resident 16) from verbal abuse by Administrative Staff O. Administrative Staff O yelled at Random Resident 16 while she was slapping her hands together in a threatening manner. This abuse occurred in the dining room and was witnessed by other residents who were playing bingo. This failure resulted in Random Resident 16 becoming upset; Confidential Resident 23 feeling uncomfortable and bad for Random Resident 16, and Confidential Resident 22 feeling fearful of Administrative Staff O. IMMEDIATE JEOPARDY (IJ) was identified on 12/5/13 at 10:12 a.m. under 483.13 Resident Behavior & Facility Practice for: F223 IMMEDIATE JEOPARDY was abated on 12/6/13 at 4:56 p.m. . Findings: During a confidential interview on 12/3/13 at 11:55 a.m., Confidential Resident 23 (CR 23) stated she witnessed Administrative Staff O yelling at Random Resident 16 (RR 16) during a Bingo game in the facility dining room. She reported the incident occurred approximately two weeks prior. She stated that she was playing Bingo with a group of residents and RR 16 was off to the side of the room reading. She said Administrative Staff O approached RR 16 and yelled at him about withdrawing his money from the front desk staff (a facility may hold money for a resident in a trust fund). CR 23 reported Administrative Staff O then yelled, "We are not your bank. We are not your wallet." While she was yelling, CR 23 reported that Administrative Staff O was slapping her hands together in a threatening manner (CR 23 imitated the motion by slapping the back of one hand into the palm of the other). CR 23 stated she felt badly for the way RR 16 was treated. She further stated she felt uncomfortable witnessing the incident and felt it was wrong. CR 23 stated she immediately reported the incident to Administrative Staff A because, "I knew he (RR 16) wouldn't remember, so I spoke up." During an interview on 12/4/13 at 4:15 p.m., Administrative Staff A stated that CR 23 had reported the incident between Administrative Staff O and RR 16 to him on the day of the incident (11/21/13). He stated CR 23 had informed him the verbal altercation took place during a Bingo game in the dining room. Administrative Staff A stated he spoke with RR 16 and Administrative Staff O about the incident but did not document either of the interviews. He stated he did not interview any witnesses and did not complete any facility incident report forms. He stated he suggested to Administrative Staff O that in the future, she should not to speak to residents alone but should bring someone with her when she needed to speak with residents. He said he also instructed Administrative Staff O to post a sign at the front desk stating the facility requested a $5 minimum for cash withdrawals. During an interview on 12/4/13 at 4:30 p.m., Administrative Staff O stated that she reviewed RR 16's money withdrawal receipts on a monthly basis. She further stated that RR 16 often withdrew his money in $1 or $2 dollar increments. She said the facility requests that residents withdraw a minimum of $5 dollars because the girls up front are busy and it cuts down on traffic. She stated RR 16 "insisted" on withdrawing his money $1 or $2 dollars at a time. Administrative Staff O stated she had an interaction with RR 16 in the dining room during a Bingo game regarding his money. She further stated that on the day of the incident, she had reviewed RR 16's monthly account and become aware he continued to make frequent withdrawals of his money. She said she approached RR 16 in the dining room while an activity was in progress. She stated she then had a conversation with RR 16 telling him that as a courtesy, the facility requested a $5 dollar minimum for cash withdrawals. She reported she said to RR 16, "don't you remember we talked about this before?" She stated RR 16 then became upset and responded, "I heard you." When queried if she thought RR 16 was capable of remembering facility rules, she responded she was not sure if he could remember and added, "I'm not a clinician." During an observation and concurrent interview on 12/3/13 at 11:35 a.m., Random Resident 16 was sitting in his wheelchair at his bedside listening to music. He stated he gets his spending money from the receptionist at the front desk. When asked about the incident in the dining room during Bingo, he said he didn't play Bingo. Review of RR 16 medical record on 12/3/13 at 12:20 p.m. revealed he had multiple medical [DIAGNOSES REDACTED]. A physician history and physical note indicated RR 16 had severe, "crippling" mental and physical health issues. Review of RR 16 MDS (a resident assessment tool) dated 9/9/13 indicated he had disorganized thinking, decreased ability to make himself understood, and exhibited forgetfulness, confusion and disorientation. Review of RR 16's medical record revealed a social service note dated 12/9/13 at 6:37 a.m. that indicated Facility Staff Q had talked with RR 16 regarding verbal abuse by an employee and the resident, "does not recall incident." Review of facility document titled, "Windsor Healthcare Self Performance Review" (no date) indicated Administrative Staff O gets, "frustrated with interruptions and inadvertently take(s) it out on residents..." The document further indicated Administrative Staff O will continue to work on, "dealing with my frustrations in a positive and respectful manner." The bottom of the document was signed by Administrative Staff O on 12/13/12. Review of facility document titled, "Windsor Healthcare Employee Performance Review" (no date) indicated Administrative Staff O's goals included working on positive and respectful relationships with residents. The document was signed by Former Employee P and Administrative Staff O on 12/26/12. Review of facility document titled, "Corrective Action Memo" (dated 3/1/12) indicated Administrative Staff O received a verbal warning for insubordination and she, "needs to monitor her tone and impatience." The document was signed by Former Employee P on 3/1/12. During a record review on 12/4/13, approximately one year after Administrative Staff O's self evaluation indicated she took her frustrations out on residents, a facility plan to monitor and evaluate Administrative Staff O's behavior toward residents was not located in her employee file. During an interview on 12/4/13 at 4:15 p.m., Administrative Staff A confirmed that a facility plan to monitor and evaluate Administrative Staff O's behavior toward residents was not present in her employee file. Immediate Jeopardy (IJ) was called on 12/5/13 at 10:12 a.m. Administrative Staff A and Administrative Staff B were present when the IJ was identified. During a confidential interview on 12/5/13 at 1:25 p.m., Confidential Resident 22 (CR 22) stated she had witnessed the incident between Administrative Staff O and RR 16 in the dining room. She stated that she was playing Bingo with other residents in the dining room and RR 16 was sitting one table over. She reported that Administrative Staff O was, "kind of screaming" when she told RR 16 that withdrawing $1 to $2 dollars of his spending money, "is not going to work." She then told RR 16 there was a $5 limit to cash withdrawals. CR 22 stated Administrative Staff O then screamed, "We're not your wallet." CR 22 stated that while Administrative Staff O was screaming at RR 16, RR 16 was sitting in his wheelchair and leaning away from her (she gestured a recoiling and cowering posture). CR 22 stated, "I'm afraid of her" (referring to Admin. Staff O). The facility corrective actions that abated the Immediate Jeopardy included, 1. Administrative Staff O was suspended pending facility investigation, 2. Facility managers, supervisors and line staff were notified that Administrative Staff O was not allowed into the facility or on facility property until the investigation was complete, 3. An SOC 341 (adult/elder abuse report form) was completed and submitted, 4. Administrative Staff A initiated an investigation of the incident per facility policy and procedure, 5. All residents were interviewed/assessed for evidence of verbal abuse, 6. All employees were re-educated regarding verbal abuse and abuse reporting/investigating requirements. These actions were validated through observations and interviews on 12/6/13. The Immediate Jeopardy was abated on 12/6/13 at 4:56 p.m. Administrative Staff A, Consultant R and Consultant S were present when the IJ was abated. Based on subsequent interviews with Confidential Resident's 22, 23 and 24, and Family Member 25, the facility had a pattern of failing to protect and prevent verbal abuse by Administrative Staff 0. This resulted in Confidential Resident's 22 and 23 becoming fearful of Administrative Staff O, Confidential Resident 24 requesting her executor deal with Administrative Staff O due to continuous rude and demeaning behaviors, and Family Member 25 using a third party to deal with financial matters due to rude behaviors and failures to return telephone calls about financial concerns by Administrative Staff O. During a confidential interview on 12/3/13 at 11:55 a.m., Confidential Resident 23 (CR 23) stated in the past, she had spoken with Administrative Staff O about her finances. CR 23 further stated that on one occasion in Administrative Staff O's office, Administrative Staff O became upset and slammed her hand on the desk in a threatening way. CR 23 stated she was fearful during the encounter. She further stated Admin. Staff O, "scares people." During a confidential interview on 12/5/13 at 1:25 p.m., Confidential Resident 22 (CR 22) stated when she had gone to Administrative Staff O's office to withdraw some of her money in the past, Administrative Staff O had gotten "angry" and "huffy." CR 22 stated, "I'm afraid of her" and added, "I don't feel like that about anybody else." When queried as to why she felt afraid of Administrative Staff O, she stated it was because of, "the way she approaches people." During an interview, on 12/10/13 at 10:30 a.m., Confidential Resident 24 (CR 24) stopped this writer in the hallway and asked to be able to discuss the problems with Admin Staff O. CR 24 provided the telephone number of her executor and asked that this writer speak to the executor about the problems with Admin Staff O and that even the executor was having a very difficult time with this staff person. Confidential Resident 24 (CR 24) stated that she had been interviewed by administration the prior week about Admin Staff O and provided an overview of that interview. CR 24 stated that administration was told that she had requested her executor to handle all financial affairs due to being so upset and could not deal with that person for financial affairs due to her continuous rude and demeaning behavior. CR 24 stated that it was very embarrassing and inappropriate for the billing manager to stand at the nursing station and holler and belittle residents and staff in front of everyone. CR 24 could not understand why this staff person did not ask residents or staff to go to a private location for discussions. CR 24 stated that the Admin Staff O had an attitude problem and even her body language was threatening. During a confidential interview on 12/10/13 at 11:00 a.m., Family Member 25 stated she is responsible for her family member's billing and financial issues. Family Member 25 further stated she had worked with Administrative Staff O regarding her family member's finances. She stated Administrative Staff O had been rude to her, hung up the telephone on her, and failed to return her calls. She said, "I can't call her anymore" and stated she now goes through a third party to deal with financial matters. Review of facility Resident Council Minutes dated 2/19/13 revealed some residents felt they were bothering the business office when they inquired about their money. The Minutes further indicate former Employee P would be notified right away. Review of facility Resident Council Minutes dated 4/16/13 revealed residents could now request their money from staff at the front reception desk. The Minutes further indicated the residents reported the front desk staff have a, "great attitude." Review of facility document titled, "Subject: Abuse Prevention, Investigation and Reporting" subtitled, "Policy" (revised 3/13) revealed that verbal abuse would not be tolerated in the facility at any time. The document further revealed that if the suspected perpetrator was an employee, the facility would remove or suspend the employee during the abuse investigation. Review of facility document titled, "Abuse Investigations" (December 2006) indicated that all reports of resident abuse shall be promptly and thoroughly investigated by facility management. Review of facility policy titled, "Preventing Resident Abuse" (December 2006) indicated the facility would monitor staff to, "identify inappropriate behaviors toward residents."

Based on observation, resident and staff interview, record review, the facility failed to ensure that 1 of 15 sampled residents (Resident 10) and 3 of 6 random residents (Random Resident 20, 21, and 23), received [MEDICATION NAME]? insulin (([MEDICATION NAME] (rDNA)) - A rapid acting insulin) within five to 10 minutes of their meals, as recommended by the insulin manufacture and the attending physician. Insulin is a medication used for the management of Diabetes. This failure had the potential for harm to the resident's health, including [DIAGNOSES REDACTED] (low blood sugar) which can lead to unconsciousness, [MEDICAL CONDITION], and even death. The most common cause of [DIAGNOSES REDACTED] (low blood sugar) is taking insulin or diabetes medicine at the wrong time. The following symptoms to watch for include the following: hunger, nervousness or shakiness, sweating, dizziness or light-headedness, sleepiness, confusion, trouble speaking, feeling anxious or weak. If left untreated can result in loss of consciousness, [MEDICAL CONDITION], coma and even death. (www.diabetes.com/blood-sugar-control-matters <http://www.diabetes.com/blood-sugar-control-matters>). Sometimes blood sugar may be too low even if there are no symptoms. If blood sugars get too low, the following can occur; faint, have a [MEDICAL CONDITION], or go into a coma (<http://www.healthdesk.com/health>). The Institute of Safe Medication Practice (ISMP), a nationally recognized organization that promotes the safe use of medication in healthcare facilities, includes [MEDICATION NAME]? insulin among its list of drugs which have a heightened risk of causing significant patient harm when used in error. An Immediate Jeopardy (IJ) was called on 12/8/10 at 5:30 p.m. The Administrator, Director of Nurses, Quality Improvement Nurse and Corporate Compliance Officer were present. The IJ was called based on the facility ' s failure to have a system in place to ensure that the administration of [MEDICATION NAME]? insulin, for the residents on rapid acting insulin, was within the timeframe recommended by the manufacturer ' s guidelines and the attending physician ' s written order. This was evidenced when insulin dependent residents did not receive their meals within 5 - 10 minutes after administration of the rapid acting insulin. This failure placed the residents at risk for hypoglycemic reactions which includes [MEDICAL CONDITION], loss of consciousness, coma, and possibly death. Findings: During a dining observation on 12/7/10 at 12:35 p.m., Random Resident 20 was observed to be sitting in a wheelchair beside the bed rocking back and forth. Random Resident 20 kept repeating "I'm so hungry, I'm so hungry, and then stated "they take too long to give me my food and I already had my insulin. I'm so hungry..." At 12:40 p.m. Random Resident 20's food tray was delivered. Review of Random Resident 20's Medication Administration Record (MAR) on 12/7/10 at 12:50 p.m., indicated that Random Resident 20 was on [MEDICATION NAME]? insulin with sliding scale coverage based upon blood sugar levels four (4) times a day at the following times: 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9 p.m. The MAR included documentation on 12/7/10 at 11:30 a.m. that the patient ' s blood sugar was 158 milligrams per deciliter (mg/dl - which is the standard for recording blood sugar levels) and 5 units (the standard measurement for insulin preparations) of [MEDICATION NAME]? was given, approximately 70 minutes before the food tray arrived. (Normal blood sugar ranges are 70 to 110 mg/dl). During an interview on 12/7/10 at 1 p.m., Licensed Nurse H stated that the insulin had been given at 12:05 p.m., because it was supposed to be given within 15 minutes of delivery of food. Licensed Nurse H corroborated that the insulin was documented on the MAR as being given at 11:30 a.m. Licensed Nurse H did not explain the discrepancy. The MAR and the nurses notes did not include documentation of Random Resident 20's complaint of hunger after the insulin injection. During the entrance conference with the Administrator, on 12/7/10 at 9 a.m., she provided the meal times, which indicated that the meal trays would start to be delivered to the residents at: 7:10 a.m., 12:10 p.m., and 5:10 p.m. During a medication pass observation, on 12/8/10 at 6:30 a.m., Licensed Staff AA (night shift) provided a list of 9 residents who received insulin injections; included on the list was the following residents: Sampled Resident 1, 6, and 10 and Random Resident 17, 18, 20, 21, 22 and 23. Licensed Staff AA stated that all the blood sugars for the above residents had been tested at 6 a.m. Licensed Staff AA, on 12/8/10 at 7:05 a.m., was observed giving 5 units of [MEDICATION NAME]? insulin to Random Resident 20. Licensed Staff AA stated during an interview that the blood sugar level at 6 a.m. was 169 mg/dl. Random Resident 20's breakfast tray was delivered to him at approximately 7:42 a.m., while he was talking on the telephone. Observation revealed that Random Resident 20 began eating his breakfast at 7:50 a.m. This was approximately 45 minutes after Random Resident 20 received the 5 units of [MEDICATION NAME]?. Licensed Staff AA documented on the MAR that the insulin was given at 6:30 a.m. Review of Random Resident 20's record, on 12/8/10 at 11 a.m., revealed a physician's orders [REDACTED].? 10 minutes before meals per sliding scale. Observations on 12/8/10 between 11:30 a.m. and 1:25 p.m., revealed the following regarding the administration of [MEDICATION NAME]? insulin to insulin-dependent diabetic residents and the delivery of their meals as: Lunch trays were delivered by staff in this order: 1. To the Rehabilitation Room for residents receiving assisted dining, 2. To the other two dining rooms, and 3. To the residents that were eating in their rooms. 1. Random Resident 23 received 10 units of [MEDICATION NAME]? insulin at 12:05 p.m., per sliding scale and received the lunch tray at 1:02 p.m. in the resident room (Approximately 57 minutes after the administration of the rapid acting insulin). 2. Random Resident 21 received 3 units of [MEDICATION NAME]? insulin ordered for lunchtime everyday and 7 units of [MEDICATION NAME]? per sliding scale at 12:24 p.m. for a total of 10 units of [MEDICATION NAME]? insulin. 3. Random Resident 20 received 5 units of [MEDICATION NAME]? insulin at 12:05 p.m., per sliding scale and received the lunch tray at 12:30 p.m. in the resident room. (Approximately 25 minutes after the administration of the rapid acting insulin). 4. Resident 10 received 12 units of [MEDICATION NAME]? insulin at noon, per sliding scale and received the lunch tray at 12:20 p.m. in the dining room (Approximately 20 minutes after the administration of the rapid acting insulin). Observation revealed Random Resident 21's lunch tray was on his bedside table at approximately 1:05 p.m. and Random Resident 21 had his eyes closed and was snoring. At approximately 1:10 p.m., Random Resident 21 still had his eyes closed and was snoring. At approximately 1:14 p.m., staff were observed entering Random Resident 21's room. Staff were observed telling Random Resident 21 to wake up and asked him to eat his lunch (This was approximately 50 minutes after the administration of the rapid acting insulin). During an interview on 12/8/10 at 1:20 p.m., Random Resident 21 stated that during the last few days he had fallen asleep while waiting for his lunch tray and the staff do not wake him up, which he said happens a lot. During an interview on 12/8/10 at 2:45 p.m., Licensed Staff W stated that the policy and procedure for the administration of rapid acting insulin was to administer the insulin within 10 minutes of eating. During an interview on 12/8/10 at 3 p.m., the Director of Staff Development (DSD) was asked how the licensed staff was trained regarding rapid acting insulin. She stated that during in-services, she instructed the licensed staff to read and follow a handout about of [MEDICATION NAME]? insulin, which included the instruction to administer the insulin within 5 to 10 minutes of food intake. Review of the in-service meeting minutes, indicated the following about the rapid acting insulin. The insulin must be given 5 - 10 minutes before meals. DSD corroborated that even with the in-services, errors related to insulin administration still had occurred. Review of the [MEDICATION NAME]? manufacture's guidelines on 12/8/10 at 4:15 p.m., indicated the following: 1. Take [MEDICATION NAME]? exactly as prescribed. [MEDICATION NAME]? is fast acting insulin. 2. Eat a meal within 5 to 10 minutes of taking [MEDICATION NAME]? to avoid low blood sugar. 3. [MEDICATION NAME]? starts working within 10 to 20 minutes after the administration. 4. Do not inject [MEDICATION NAME]? if there isn't a plan to eat right after the administration. 5. Side effects of [MEDICATION NAME] include the following: low blood sugar ([DIAGNOSES REDACTED]). Severe low blood sugar can cause unconsciousness, [MEDICAL CONDITION], and death. During an interview with the corporate nurse consultant on 12/8/10 at 3:05 p.m., when asked for the policy and procedure for insulin administration or sliding scale insulin, corporate nurse consultant stated that there was no written policy and procedure for the administration of insulin. During an interview with the Director of Nurses (DON) on 12/8/10 at 3:35 p.m., when asked for specific information for [MEDICATION NAME]? insulin, the DON provided the manufacturer's insert, which are guidelines. The DON stated that the material from the manufacturer's guidelines was not included during the in-service sessions for the licensed staff. During a telephone interview with the Medical Director; Physician E, on 12/8/10 at 3:45 p.m., when asked if there are parameters for licensed staff to follow for [MEDICATION NAME]? insulin, he asked for clarification of the question. Physician E stated that he was not sure of all the names of insulin ' s, and asked if the question related to "super fast acting," "regular," or "long acting insulin." When told that [MEDICATION NAME]? was the "super fast acting insulin" (Also known as "rapid acting" insulin) he stated that he only used "regular" or "long" acting insulin in skilled nursing facilities and that none of his residents were on the "super fast acting" insulins. When asked if there was a timeframe for eating after the administration of the "super fast acting" insulin ([MEDICATION NAME]?), Physician E stated that it should not be given until the food tray was in front of the resident. When asked if he was the attending physician for Random Resident 20 and Random Resident 21, Physician E stated yes. Physician E stated that the skilled nursing facility should have contacted him when the residents were admitted to let him know that they were on "super fast acting" insulin and he would have changed the order to "regular" and "long" acting insulin. Review of the admission facesheets for the 9 residents, who had orders for insulin, indicated that 8 of 9 residents that were receiving [MEDICATION NAME]? insulin, listed Physician E as their attending physician. On 12/8/10 at 7:40 p.m., the Administrator presented an action plan. The action plan was accepted on 12/10/10 and consisted of the following elements: 1. The facility will identify all residents receiving [MEDICATION NAME]? insulin. 2. The residents will be assessed by the Licensed Nurse for any possible signs and symptoms of [DIAGNOSES REDACTED]. 3. The DON, Nurse Resource Consultant and or Quality Assurance (QA) nurse will re-educate licensed nurses on the proper time for [MEDICATION NAME]? insulin administration with skills competency review post training. This training will begin with the current shift (evening shift) of licensed nurses on duty and will extend to other licensed nurses on other shifts prior to the start of their shifts until all licensed nurses are retrained. 4. The training will be included in the licensed nurse's new orientation and reviewed annually. 5. The licensed nurses during their observation round will monitor the residents for any signs and symptoms of [DIAGNOSES REDACTED]. 6. The DON or designee will check on licensed nurse daily for four (4) weeks on the administration of the rapid acting insulin (skills competency). 7. During their monthly scheduled facility visit, the Pharmacy Nurse Consultant will observe randomly selected licensed nurses on the administration of the rapid acting insulin skills. Findings will be reported to the administrator and the DON for appropriate corrective measures. 8. The DON will provide a summary analysis of the findings to the Continuous Quality Improvement (CQI) Steering Committee for further recommendations. 9. At the present time and all following months, the license nurses will document on the Medication Administration Record (MAR) the time finger stick blood sugar was taken, amount of insulin being administered, the time of insulin administration, time the resident begins to eat their food, and the amount of diet consumed. During the lunch meal on 12/10/10 between 11:30 a.m. to 1:15 p.m., the 6 residents who were present in the facility and receiving rapid acting insulin [MEDICATION NAME]? were observed. Insulin injections were administered to the residents when the lunch tray was served and they began to eat. During concurrent interviews, the licensed staff that was giving the rapid acting insulin indicated that they had attended the in-service and were knowledgeable regarding the administration of rapid acting insulin in conjunction with the resident's meals. Review of the MAR for the 6 residents, indicated that the time the finger stick blood sugar was taken, the amount of insulin being administered, the time of insulin administration, the time the resident began to eat, and the amount of diet consumed. Review of the educational plan and the sign-in sheets, indicated that all licensed staff had received the in-service training except for 1 nurse, who was notified that her to return to work was contingent upon taking the class prior to start of duty. Review of the Skills Competency check-lists for licensed staff, indicated that the skill competencies had been checked by the Nurse Recourse Consultant and/or QA nurse. Based on the implementation of the action plan, the Immediate Jeopardy was abated on 12/10/10 at 2:50 p.m. The Administrator and the Corporate Compliance Officer were present.

Based on staff interview, record review and policy and procedure review, the facility failed to ensure: 1. That the licensed staff implemented the physician's written orders for the insulin sliding scale, for blood sugar levels greater then 400 milligrams per deciliter ((mg/dl), the standard for recording blood sugar levels) for 1 of 15 sampled residents (Resident 10) and 1 random resident (Random Resident 20). 2. That all licensed staff knew the range limits of the glucometer (A small, portable machine that's used to measure how much sugar is in blood) so they could implement the physician's orders [REDACTED]. the insulin sliding scale and to notify the attending physician when the results on the meter registered " high" (indicating a blood sugar level of greater then 600 mg/dl) for 1 random resident (Random Resident 20). As a result a physician was not contacted regarding potentially emergent conditions, with [MEDICAL CONDITION] above 400 mg/dl, which could lead to diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic non-ketoti[DIAGNOSES REDACTED] (HHNS). Both of these conditions can be fatal if not treated promptly. 3. That licensed staff followed physician's orders [REDACTED]. bowel medications for 1 of 15 sampled residents (Resident 7), which lead to fecal impaction. Findings: 1. Review of Random Resident 20's record on 12/13/10 at 7:30 a.m., and 10 a.m., indicated that Random Resident 20 had [DIAGNOSES REDACTED]. Random Resident 20 had been recently admitted following a hospital stay for Hyperglycemic hypersomolar non-ketoti[DIAGNOSES REDACTED] ((HHNS)) is a life threatening complication of diabetes. When HHNS occurs, it occurs in a person who has type 2 diabetes. HHNS is also sometimes called hypersomolar coma, which means "coma due to too thick blood). Review of the hospital admission record, indicated a blood glucose level of 505 mg/dl for which IV insulin and IV fluids were provided in the Emergency Department (ED) to reverse the HHNS and severe dehydration. Documentation revealed that the resident had several complications from poorly controlled type 2 diabetes, including, multiple [MEDICAL CONDITION], high blood pressure, retinopathic [MEDICAL CONDITION] (Diabetic retinopathy is the most common diabetic eye disease and a leading cause of [MEDICAL CONDITION] in American adults), and bilateral feet [MEDICAL CONDITION] (damage to the nerves from diabetes), which impacts the ability to walk. The discharge planner documented that returning to a home environment was not advisable due to the multiple admissions for HHNS, which required more services and monitoring then could be provided at home. If the blood sugar level is more than 400 mg/dL, it can be a sign of Diabetic Ketoacidosis (DKA) or HHNS, depending on the type of diabetes. HHNS is a serious condition. HHNS can happen to people with either type 1 or type 2 diabetes, but it occurs more often in people with type 2 diabetes. This condition usually results from extremely high levels of blood sugar (over 600 mg/dl); making the blood thick and syrupy. High blood sugar can be life threatening and demands immediate medical attention. Source: (http://www.emedicinehealth.com/diabetes/page 4_em.htm>, and http://www.healthserve.com/diabetes_complications.htm) Review of the physician's orders [REDACTED].? (rapid acting insulin) and to call the physician. Review of the medication administration records (MAR) and nursing notes indicated the following: a. On 11/23/10 at 5 p.m. the blood sugar (BS) was recorded as "Hi " and 13 units of [MEDICATION NAME]? was administered, the physician was not notified. The next BS was recorded at 8 p.m., with the BS result recorded as "Hi" and 13 units of [MEDICATION NAME]? insulin and 10 units of [MEDICATION NAME]? insulin (a long acting insulin) was administered, the physician was not notified. At 9 p.m. the BS was recorded as "Hi", and the physician was notified at this time. The physician ordered [MEDICATION NAME]? 20 units immediately, which was administered at 9:25 p.m. A change in condition assessment form was completed and indicated that the physician was notified at 9:20 p.m. of a "high BS." b. On 11/24/10 at 4:30 p.m. the BS was recorded as 400 mg/dl and 13 units of [MEDICATION NAME]? was administered, the physician was not notified c. On 11/28/10 at 4:30 p.m. the BS was recorded as 420 mg/dl and 13 units of [MEDICATION NAME]? insulin was administered, the physician was not notified. d. On 11/30/10 at 6:30 a.m. the BS was recorded as 447 mg/dl and 13 units of [MEDICATION NAME]? insulin was administered. At 11:30 a.m. the BS was recorded as 589 mg/dl and 13 units of [MEDICATION NAME]? was administered. At 9 p.m. the BS was recorded as 408 mg/dl and 13 units of [MEDICATION NAME]? was administered. The physician was not notified of any of the above high BS results on 11/30/10. e. On 12/2/10 at 11:30 a.m. the BS was recorded as 408 mg/dl and 13 units of [MEDICATION NAME]? insulin was administered, the physician was not notified. Upon inquiry regarding what does the glucometer reading of "Hi" mean, during an interview on 12/13/10 at 11:15 p.m. Licensed Nurse J stated that the glucometer couldn't figure out the number, so listed " Hi. " In addition, Licensed Nurse J stated that she thought that it meant that the blood sugar was over 400 mg/dl. She stated that she gave the 13 units of [MEDICATION NAME]? ordered for the sliding scale range of 400 mg/dl. When asked if there were other orders to follow she stated that she thought the physician needed to be notified if the blood sugar was above 450 mg/dl. When asked if she reviewed the glucometer manual to determine what the "Hi" reading meant she stated that she had not. In addition, she stated that Random Resident 20 kept "begging" for food and was not thirsty, and that after the reading remained "Hi " at 8 p.m. and 9 p.m. she decided to call the physician. When asked about the blood sugar reading of 400 mg/dl on 11/24/10 at 4:30 p.m., she again stated that she thought she was to notify the physician for blood sugar levels greater then 450 mg/dl. During an interview, on 12/13/10 at 11:00 a.m., Licensed Staff I stated that the BS result of 586 mg/dl on 11/30/10 at 11:30 a.m. was called to the physician and she must have forgotten to document this in the nursing notes and the MAR and corroborated that it should have been documented. When asked what the reading of "Hi" on the glucometer indicated, she stated that the BS must be over 600 mg/dl, as she had the previous reading of 586 mg/dl on that glucometer, but she was not sure. When asked what the parameters were for notifying the physician per sliding scale instructions, she stated that she thought it was a BS over 400 mg/dl. During an interview, on 12/13/10 at 10:50 a.m., Licensed Staff P was asked what process would she follow for a glucometer reading of "Hi"? She stated that "Hi" meant that the BS was greater then 600 mg/dl, she would recheck the BS with another glucometer, and if still was "Hi" she would assess the resident and then immediately call the physician. During an interview, on 12/13/10 at 11:25 a.m. with the DON, when asked what the reading of "Hi" indicated on the glucometer she stated that she thought the BS was either 500 mg/dl or 600 mg/dl. When asked for the manufacturer's guidelines, the glucometer manual was provided. The manual indicated that a reading of "Hi" meant that the BS level was over 600 mg/dl, the test should be repeated with a new test strip, and if still "Hi" the physician should be immediately notified. The DON corroborated that the licensed staff should have notified the physician of the blood sugar readings greater then 400 mg/dl and indicated that Random Resident 20's blood sugars were over 600 mg/dl and documented this on the MAR and the nurse's notes. Review of the policy and procedure titled "Blood Glucose Monitoring," dated 10/1/94 on 12/8/10, lacked a defination for the glucometer readings of "Hi" or "Low." The policy indicated that the staff were to notify the physicians per orders. During a concurrent interview with the corporate nurse consultant on 12/8/10 at 3:05 p.m., when asked for a policy and procedure for insulin administration or sliding scale insulin, she stated that there was none. During an interview, on 12/13/10 at 11:55 a.m., with the Administrator Staff A, she stated that Random Resident 21's blood sugars always ran in the high 500's. During a telephone interview on 12/15/10 at 12:45 p.m. with Physician E, when asked if the blood sugar results over 400 mg/dl had been reported, for Random Resident 20, he stated that he remembered a couple of times that the nurses had called to tell him that the blood sugar levels were over 400 mg/dl, but could not remember the specific dates. When asked if he had been notified regarding Random Resident 20's readings that were too high for the glucometer to read for five hours, he stated that he had not been informed that the reading was too high to measure, or that it had been high for five hours, just that it was high. In addition, he stated that it was very important that all the licensed staff understand what the high and low readings on the glucometer indicated. Review of Resident 10's record on 12/13/10 at 11 a.m., indicated that Resident 10 had [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].? (rapid acting insulin) and to call the physician. Resident 10 also had a physician order [REDACTED].? insulin every 12 hours. Review of the Drug Regimen Review (DRR) for November 2010 for Resident 10, indicated a note to the physician from the pharmacist indicating "Administration Error, Priority High. In reviewing the sliding scale insulin and blood glucose, the correct dose was not always given and two (2) blood glucose were above 400 mg/dl with no documentation that the physician was notified. This could be a serious error and attention paid to dosing. Diabetes mellitus (DM) is not in control at all, still too many high blood sugars with the addition of [MEDICATION NAME]?. Physician E's response was that the sliding scale insulin being monitored. Review of Resident 10's October MAR indicated that on 10/2/10 at 9 p.m., the BS result was documented as 498 mg/dl and 3 units of [MEDICATION NAME]? were administered. On 10/15/10 at 9 p.m., the BS result was documented as 498 mg/dl and 3 units of [MEDICATION NAME]? were administered, the physician was not notified. Review of a fax document sent to the physician, dated 10/22/10, indicated that the resident wants to see him, that the resident is concerned about his high BS. The staff included BS results for the month. Physician E faxed a response indicating that he had seen Resident 10 and adjusted his insulin. When is he leaving? Review of the progress note, dated 10/23/10, indicated that the blood glucoses have stayed up, have increased [MEDICATION NAME]?, will continue to increase [MEDICATION NAME]? and sliding scale insulin. The resident's diet may be contributing to his high blood glucose. The resident may be sneaking. Review of the progress note, dated 11/19, indicated that all issues stable. Review of the record, indicated that the [MEDICATION NAME]? insulin and [MEDICATION NAME]? sliding scale insulin orders had not been changed since 10/23/10. During a telephone interview on 12/15/10 at 12:45 p.m. with Physician E, when asked if he had been notified of the drug regime reviews, conducted during November 2010 for Resident 10, he stated he had probably seen the reports. When asked if he was notified that there were two (2) times that the blood glucose was over 400, without the correct dose of insulin provided, he stated that the sliding scales were being monitored and that he had added long acting insulin for the continued high readings and that he thought that the licensed staff had been re-educated about sliding scale insulin requirements. During an interview when asked about the process for the pharmacy drug regimen review on 12/14/10 at 1:15 p.m., the DON stated that reviewing the reports was delegated to one of the nursing supervisor's. This supervisor brings specific nursing medication issues to the DON's attention which trigger in-service's which are conducted during their monthly staff meeting. Education needs are submitted to the Director of Staff Development (DSD) for in-service. The DON does a root cause analysis of the issues identified and will discuss specific issues with licensed staff. 2. During a review of Resident 7's record on 12/13/10 at 3 p.m., the Activities of Daily Living (ADL) Flowsheets for the month of August 2010, indicated that on 5/4/10, Resident 7 return from the hospital for a fecal impaction. The ADL lacked documented evidence that the resident had a bowel movement (BM) for five (5) consecutive days. Review of Resident 7's MAR dated August 2010, indicated the following bowel regimen that the staff were to implement to prevent conspiration, which included the following medications in the sequential order: 1. Senna 8.6 milligram (mg) by mouth as needed, if no BM for 1 day. 2. Milk of Magnesia (MOM) 30 milliliter (ml) by mouth as needed, if no BM for 2 days. 3. [MEDICATION NAME] (stimulant laxative) suppository per rectum, if no BM for 3 days. 4. Fleet enema per rectum, if no BM for 4 days. Review of Resident 7's Medication Administration Record (MAR) dated August 2010, indicated that no as needed bowel medications were administered.