Every finding on record at River City Nursing and Rehab Center

Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility, by failing to label and date mark an open beverage found in the 400 hallways nourishment room. Additionally observed were open bundles of bread in the cook area storage bin. Food handling and sanitation are important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure.The findings include:During an observation of the 400 hallways nourishment room on 2/25/26 at 12:53 PM, an open 1.18-liter bottle of Starbucks Vanilla Latte with no date marking was observed. Licensed Practical Nurse (LPN) L was immediately notified and instructed to remove or properly label the item. (Photographic evidence obtained)On 2/26/26 at 1:02 PM, a re-inspection of the 400 hallways nourishment room revealed the same open, undated 1.18-liter bottle of Starbucks Vanilla Latte in the refrigerator. The item was discarded. (Photographic evidence obtained)During a follow-up observation in the kitchen on 2/26/26 at 2:42 PM< ten (10) open bundles of bread were observed in the cook area storage bin with no dates or labels. One (1) of 10 bundles contained visible mold. All 10 items were discarded. (Photographic evidence obtained)On 2/26/26 at 1:21 PM, Dietary Assistant Supervisor (DAS) M reported that kitchen staff were assigned daily to job #6 fill, check labeled items, and clean nourishment rooms, with DAS M responsible for ensuring task completion.On 2/26/26 at 2:42 PM, [NAME] I was asked what happened when bread was opened, used, and placed back on the shelf to store. [NAME] I replied, Tie the bag and store it for the next shift. On 2/26/26 at 2:50 PM, Certified Dietary Manager (CDM) K was asked what happened when staff opened bread, used it, and placed it back on the shelf. CDM K replied, Seal the bread and store it. Food opened and not used from dry storage should be sealed, labeled and dated. A review of the facility's policy and procedure titled Food Safety and Sanitation (dated 2019), revealed:Policy: All local, state and federal standards and regulations will be followed in order to assure a safe and sanitary food and nutrition services department. Procedure: 4 .all time and temperature control for safety (TCS) foods (including leftovers) should be labeled, covered, and dated when stored. When a food package is opened, the food item should be marked to indicate the open date. This date is used to determine when to discard the food. (Copy obtained)Reference: FDA Food Code 2022. https://www.fda.gov/media/184685/download?attachment; (Accessed on 3/9/2026)Annex 5 - C. Intervention Strategies for Achieving Long-term Compliance. 4. Establish First-In-First-Out (FIFO) Procedures. Page 555. Product rotation is important for both quality and safety reasons. First-In-First Out (FIFO) means that the first batch of product prepared and placed in storage should be the first one sold or used. Date marking foods as required by the Food Code facilitates the use of a FIFO procedure in refrigerated, ready-to-eat, TCS foods. The FIFO concept limits the potential for pathogen growth, encourages product rotation, and documents compliance with time/temperature requirements.

Based on observations, record reviews and interviews, the facility failed to implement interventions identified in the comprehensive care plan for two (Residents #31 and #3) of 32 residents in the total survey sample. Resident #31 had no floor mat at bedside as per the physician's order and her care plan. Resident #3 had no pillow supporting her left elbow as per the physician's order and her care plan. Failing to follow these residents' care plans could result in falls with injuries, worsening of pressure areas, increased pain, and overall functional decline. The findings include:1.A review of Resident #31's medical record revealed that she was admitted to the facility on [DATE]. Her diagnoses included spinal stenosis (narrowing of the spinal column spaces placing pressure on the nerves that travel through it), hemiplegia (paralysis of one vertical side of the body often causing trunk muscle control loss, including limpness or spasticity), polyneuropathy (widespread, simultaneous dysfunction of multiple peripheral nerves, often causing numbness, burning pain and muscle weakness, especially in the hands and feet), seizures, dementia and bipolar disorder.A review of the most recent Quarterly Minimum Data Set (MDS) assessment, dated 2/9/26, revealed a Brief Interview for Mental Status (BIMS) score of 4 out of 15 possible points, indicating severe cognitive impairment. Resident #31 was documented with a functional impairment of both upper and lower extremities on her right side.A review of the February 2026 Medication Administration Record (MAR) revealed an active physician's order, dated 4/10/2025, for Floor mats to right side of bedside. Check placement every shift.A review of the active comprehensive care plan (initiated 10/2/20) revealed a Focus Area indicating that the resident was identified as being at risk for falls related to impaired mobility, deconditioning, balance problems, muscle weakness, seizure disorder/epilepsy, medication side effects, and a history of CVA (stroke) with right-sided weakness. Interventions included: I will have a floor mat at right bedside per daughter's request. (initiated on 9/27/24, revised on 4/2/25).On 2/24/26 at 10:02 AM, the resident was observed lying in bed with the head of the bed (HOB) elevated. No floor mat was observed. (Photographic evidence obtained)On 2/24/26 at 2:01 PM, another observation revealed that the resident was in bed with her eyes closed. No floor mat was observed. (Photographic evidence obtained)On 2/25/26 at 9:54 AM, the resident was observed sitting in a wheelchair at the entrance of her room. No fall mats were observed in the room. (Photographic evidence obtained)On 2/26/26 at 2:20 PM, during an interview with Resident #31's assigned certified nursing assistant (CNA), CNA E, she stated she had been employed by the facility for five months. She confirmed that she provided care for the resident, but stated she was not aware that the resident was at risk for falls. She stated information about a resident's risk for falls could be found in the Kardex, but Resident #31 had not had a fall since she had been caring for her. CNA E stated she had never seen fall mats placed at the resident's bedside.On 2/26/26 at 1:03 PM during an interview with the Risk Manager, she confirmed, after reading aloud from Resident #31's Kardex, that Resident #31 should have fall mats on the right side of her bed. Upon entering the resident's room with the Risk Manager, she confirmed that there was no fall mat on the floor adjacent to the resident's bed. A staff member entered the resident's room with a floor mat at that time. 2.A review of Resident #3's medical record found that she was admitted to the facility on [DATE]. Her diagnoses included contracture (permanent tightening and shortening of muscles, tendons, skin, or joint capsules, usually caused by scarring, immobility or neurological conditions) of the left hand and both knees; osteoarthritis in her left elbow; dementia, pressure ulcer at the left elbow, and transient ischemic attack (TIA - temporary blockage of blood flow to the brain that causes stroke-like symptoms lasting from a few minutes to 24 hours.)A review of Resident #3's most recent Quarterly MDS assessment, dated 1/17/26, revealed that facility staff assessed the resident for mental status and found that short- and long-term memory were impaired, and the resident was unable to recall the season, the location of her room, staff names/faces or that she was in a nursing home. Her cognitive skills for daily decision making were documented as severely impaired. She was noted as dependent for all care needs with impairment to her upper and lower extremities on both sides.A review of the active comprehensive care plan revealed that the resident was identified as at risk for skin breakdown. The plan included an intervention for placement of an off-loading pillow under the resident's left elbow.On 2/23/26 at 11:34 AM, Resident #3 was observed in bed with her eyes closed. No pillow was observed under her left elbow.On 2/24/26 at 10:27 AM, the resident was observed in bed with her eyes closed. No pillow supporting the resident's left elbow was observed. The resident's left elbow had a bandage that was loose and was not adhering to her elbow wound. (Photographic evidence obtained)On 2/25/26 at 10:47 AM, Resident #3 was observed in bed with her eyes closed. A towel was observed under her left elbow, but no supportive pillow was observed. (Photographic evidence obtained)On 2/25/26 at 2:49 PM, during an interview with Licensed Practical Nurse (LPN) D, she stated she had been working at the facility for three to four years and had been a nurse for 30 years. She further stated a resident's functional status could be found in the Kardex. She conducted rounds every two hours. She reported that pressure injury interventions often involved turning and repositioning residents, conducting skin sweeps, off-loading and providing proper peri-care. She stated Resident #3 was not on her assignment. A review of the resident's February 2026 Treatment Administration Record (TAR) revealed that LPN D documented having performed the task of checking placement of the off-loading pillow under the resident's left elbow on 2/24/26. LPN D was made aware that her documentation on Resident #3's TAR had been reviewed. She stated she was helping another nurse yesterday. She further stated she did not know whether she documented on Resident #3 or not. She was asked if she was aware that the resident had a pressure ulcer; she confirmed that she was aware. LPN D was asked to check the resident's care plan as it related to the care and treatment of pressure injuries. She verbalized the interventions as she read them from the care plan. She was asked how often the off-loading pillow was supposed to be checked and she replied, every time you go into the room. She was accompanied to Resident #3's room to observe the resident. LPN D asked if this could be done the following day. She was informed that the observation should occur at this time. LPN D asked that she be given a few minutes and she walked away. She returned with the Risk Manager, and they were accompanied to Resident #3's room. In the room, LPN D checked the resident's left elbow and removed a towel that was rolled up underneath it. LPN D stated the towel was not supposed to be there and instead, a pillow was supposed to be supporting the resident's left elbow. The Risk Manager removed a yellow off-loading pillow from a chair in the corner of the resident's room and laid it on the resident's bed. The survey team then exited the room.On 2/25/26 at 3:07 PM during an interview with the Director of Nursing (DON), she stated when a staff member was assisting another staff member with residents, whoever was performing the task was responsible for documenting completion of the task; staff members should not sign off on tasks that were not done by them.

Based on observations and record review, the facility failed to ensure dignity while dining for two (Residents #94 and 54) of two residents reviewed for dignity. The findings include: 1. On 04/24/24 at 8:18 AM, an observation was made of Resident #94 during her breakfast meal. She was lying in bed with her plate uncovered and the plate cloche cover lying on her bed. She was unable to eat her meal without staff assistance. Further observation revealed Certified Nursing Assistant (CNA) D entering the resident's room at 8:43 AM to assist her with eating. CNA D was observed standing over Resident #94 while assisting her with her meal. Resident #94's tray sat uncovered for 25 minutes before she was assisted by staff. A review of Resident #94's medical record revealed an admitted [DATE] and a medical history significant for stroke, right-sided paralysis, difficulty swallowing, and weakness. A review of the Quarterly Minimum Data Set (MDS) assessment, completed on 01/16/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of one out of 15 possible points, indicating severe cognitive impairment. This MDS documented that Resident #94 was ordered to receive a mechanically altered diet. On 04/25/24 at 8:45 AM, an additional observation was made of Resident #94's breakfast tray. The resident was observed lying in her bed with CNA E present and assisting her with her meal. CNA E was observed standing over Resident #94 while assisting her with her meal. 2. On 04/25/24 at 8:44 AM, an observation was made of Resident #54 during her breakfast meal. She was lying in bed wearing a cloth clothing protector. Her meal tray was uncovered and she was attempting to eat her pureed food. A Mighty Shake nutritional supplement was observed on the tray unopened. Resident #54 struggled with her Mighty Shake carton, unable to open it without assistance. Further observation revealed that no staff entered Resident #54's room during the meal to assist her. A review of Resident #54's medical record revealed an admitted [DATE] and a medical history significant for stroke, right-sided paralysis, Parkinson's disease, difficulty swallowing, and weakness. An Admission Minimum Data Set (MDS) assessment, completed on 01/24/24, revealed that Resident #54 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 possible points, indicating moderately impaired cognition. This MDS documented that Resident #54 was ordered to receive a mechanically altered diet. A review of the facility's policy titled Assistance with Meals (revised July 2017), revealed the following: Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example, not standing over residents while assisting them with meals. The staff will prepare residents for eating.

Based on observations, interviews, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as body weight, by failing to provide nutritional interventions in a timely manner for two (Residents #54 and #94) of two residents reviewed for nutritional status, resulting in significant weight loss. The findings include: 1. During a tour of the facility on 04/23/24 at 8:59 AM, Resident #54 was observed eating her breakfast while lying in bed. She had difficulty holding her spoon while eating her pureed food. A moderate amount of food was present on the cloth clothing protector which was worn over her shirt. She also had a Mighty Shake nutritional supplement on her tray which was untouched. Resident #54 consumed approximately 15% of her meal tray. A review of Resident #54's medical record revealed an admission on 01/18/24 and a medical history significant for stroke, right-sided paralysis, Parkinson's disease, difficulty swallowing, and weakness. An Admission Minimum Data Set (MDS) assessment, completed on 01/24/24, documented that Resident #54 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 possible points, indicating moderate cognitive impairment. This MDS also documented that Resident #54 held food in her mouth and had coughing/choking during meals. Her weight was documented as 188 pounds. This MDS also noted that Resident #54 was ordered to receive a mechanically altered diet when she was admitted to the facility. This MDS noted that Resident #54 was at risk for but had no skin breakdown or pressure ulcers upon admission. A review of Resident #54's recorded weights revealed that on 04/19/24, she weighed 160.6 pounds, indicating that she lost 14.76 percent of her weight since her initial weight taken at the facility on 01/23/24, approximately three months earlier. A review of Resident #54's progress notes revealed there were no Nutrition Progress Notes written since her admission. There was a Comprehensive Nutritional Evaluation documented by a dietitian on 01/23/24, which indicated that Resident #54 was at nutritional risk due to her difficulty swallowing. This evaluation recommended adding Boost nutritional supplement and for staff to assist her with eating. Further review of Resident #54's progress notes revealed there was a Skin and Wound Evaluation written on 04/14/24, which documented a stage 2 pressure ulcer located on Resident #54's medial sacral area. This note documented the wound as in-house acquired with the following measurements: 1.1 centimeter (cm) x 2.1 cm x 0.6 cm. A second Skin and Wound Evaluation written on 04/21/24 documented the following measurements of the same wound: 1.6 cm x 3.2 cm x 0.7 cm, indicating that the wound worsened during this review period. A review of Resident #54's physician's orders revealed an order written on 01/18/24 for: Liberalize diet, pureed texture, nectar consistency. An order was written on 03/19/24 for: Magic Cup nutritional supplement to be given two times a day (with lunch and dinner) for weight management. An order was written on 04/11/24 for: Mighty Shake nutritional supplement to be given three times a day, and an order was written on 04/14/24 for: ProHeal Critical Care nutritional supplement to be given two times a day for 30 days for the new sacral pressure ulcer. An observation was made on 04/24/24 at 8:20 AM of Resident #54 during the breakfast meal. She was observed lying in bed wearing a cloth clothing protector. Her tray was uncovered, and she was attempting to eat her pureed food. The Mighty Shake nutritional supplement had been poured into a cup and Resident #54 was observed drinking the shake from the cup with minimal difficulty. When her tray was removed at 8:56 AM, she had consumed approximately 50% of the mighty shake and 5% of the meal tray. Certified Nursing Assistant (CNA) D was overheard telling CNA E that Resident #54 hardly ate her food and drank about half of her shake. An observation was made on 04/24/24 at 12:10 PM of Resident #54 during the lunch meal. She was sitting in her wheelchair wearing a cloth clothing protector. Her tray was uncovered and she was attempting to eat her pureed food. There was a Magic Cup nutritional supplement observed on her tray that she was attempting to eat. Resident #54 consumed about 50% of her meal tray and 100% of her Magic Cup. On 04/24/24 at 12:10 PM, an interview was conducted with Resident #54's husband. He stated he had concerns about the weight his wife had lost and the new wound that had formed on her sacrum. He stated he was concerned about her ability to properly feed herself and that he tried to come to the facility each day to assist her with her lunch. When asked if he had spoken to a dietitian at the facility about his concerns, he stated he had spoken to a dietitian shortly after Resident #54 was admitted , but that he had not seen the dietitian since then. On 04/25/24 at 8:44 AM, an observation was made of Resident #54 during the breakfast meal. She was lying in bed wearing a cloth clothing protector. Her tray was uncovered and she was attempting to eat her pureed food. The Mighty Shake nutritional supplement was present on the tray but was unopened. Resident #54 struggled with her Mighty Shake carton. When her tray was removed at 9:01 AM, she had consumed approximately 5% of her meal. A telephone interview was conducted with Registered Dietitian (RD) C on 04/25/24 at 10:01 AM. RD C stated she started working at the facility in May 2023 and came to the facility every other Tuesday to see residents. She further stated she was a part-time dietitian for this facility and worked at numerous facilities. There was a dietary manager at the facility with whom she communicated. She said the dietary manager watched the residents' weights and would tell her about changes and which residents she should see each time she came to the facility. When asked when she had last seen or assessed Resident #54, she stated she had not seen Resident #54 since her initial evaluation in January. She said she was not aware that Resident #54 had suffered weight loss. She was also not aware that Resident #54 had a new wound and stated she was upset by this information. She said she was scheduled to come to the facility on [DATE], would assess Resident #54, and planned to order Boost nutritional supplement related to the weight loss that was suffered, because it was more concentrated in calories and protein which gives it more bang for the buck. An interview was conducted with the facility's Dietary Manager on 04/25/24 at 10:33 AM. The Dietary Manager stated she started working full-time at the facility in September 2023. She said she often did not see RD C when she came to the facility, because she was in Care Plan Meetings on Tuesdays. She further stated she would leave notes containing resident information and weights for RD C to review when conducting her resident rounds. The Dietary Manager stated she was aware that Resident #54 had lost weight and that she had spoken with the resident's husband about starting nutritional supplements with her meal trays. When asked what other interventions could be implemented, she stated they could try double protein with meals or another supplement such as Boost, but that she could not write orders, only the dietitian could write orders. 2. During a tour of the facility on 04/22/24 at 11:40 AM, Resident #94's family stated they had concerns about the resident's weight loss. The family member stated they came to the facility almost every day to assist Resident #94 with her lunch meal, and that the facility staff assisted her with her other meals. A review of Resident #94's medical record revealed and admitted [DATE] and a medical history significant for stroke, right-sided paralysis, difficulty swallowing, and weakness. A Quarterly MDS assessment, completed on 01/16/24, revealed that Resident #94 had a BIMS score of 1 out of 15 possible points, indicating severe cognitive impairment. This MDS documented that Resident #94 was ordered to receive a mechanically altered diet. It also documented that she had suffered weight loss. A review of the last six months of recorded weights revealed that on 10/02/23, Resident #94 weighed 172.6 pounds, and on 04/08/24 she weighed 149.8 pounds. This indicated that Resident #94 lost 13.21 percent of her weight within six months. A review of Resident #94's progress notes revealed a Nutritional Progress Note written on 08/29/23 at 2:22 PM by a dietitian. It noted that Resident #94 had been receiving tube feedings but that it had been stopped and she was having fair to good oral intake of meals. A review of the resident's nutrition evaluations revealed a Quarterly Nutritional Evaluation, documented by the facility's Dietary Manager on 10/11/23, revealing that Resident #94's weight was stable. Further review revealed the next Quarterly Nutritional Evaluation documented by the facility's Dietary Manager on 01/11/24 indicated that Resident #94 had suffered a 6.52 percent weight loss in one month. Weight Change Notes were written by the facility's Dietary Manager on 01/15/24, 01/29/24, 02/05/24, and 03/07/24, which all documented weight loss being suffered by Resident #94. Additionally, a Quarterly Nutritional Evaluation was done on 04/11/24 by the facility's Dietary Manager, which documented the 13.21 percent weight loss in six months: however, there were no notes written by the dietitian addressing this weight loss. A review of Resident #94's physician's orders revealed an order dated 07/11/23: Liberalize diet, pureed texture, nectar consistency. An order was written on 01/18/24 for: Magic Cup nutritional supplement to be given two times a day for weight maintenance, and an order was written from 01/31/24 to 03/29/24 for Mighty Shake to be given three times a day. An observation was made on 04/23/24 at 8:57 AM of Resident #94 during the breakfast meal. She was lying in bed with a staff member assisting her with her meal. She had consumed about 15% of her meal with the staff member's assistance. An observation was made on 04/23/24 at 12:23 PM of Resident #94 during the lunch meal. She was lying in bed with a family member assisting her with her meal. She had consumed about 25% of her meal with the family member's assistance. An observation was made on 04/24/24 at 8:18 AM of Resident #94 during the breakfast meal. She was lying in bed with her plate uncovered and the cloche cover lying on her bed. No staff member was assisting her with her meal. Further observation revealed Certified Nursing Assistant D entering Resident #94's room at 8:43 AM to assist the resident with eating. CNA D stood over Resident #94 while assisting her with the meal. When her tray was removed at 8:54 AM, she had consumed about 15% of her meal with CNA D's assistance. An observation was made on 04/24/24 at 12:09 PM of Resident #94 during the lunch meal. She was lying in bed with a staff member assisting her with her meal. She consumed approximately 25% of her meal tray and 100% of her Magic Cup nutritional supplement with the staff member's assistance. An observation was made on 04/25/24 at 8:45 AM of Resident #94 during the breakfast meal. She was lying in bed and CNA E was assisting her with her meal. CNA E stood over Resident #94 while assisting her with her meal. When her tray was removed at 8:51 AM, she had consumed approximately 15% of her meal with CNA E's assistance. A telephone interview was conducted with Registered Dietitian C on 04/25/24 at 9:49 AM. When asked when she had last seen or assessed Resident #94, she stated she had last assessed Resident #94 in October 2023. She said she was not aware that Resident #94 had suffered weight loss. When asked why the Mighty Shake supplement was stopped in March despite the weight loss, The dietitian stated she did not know. She said she was scheduled to come to the facility on [DATE] and would assess Resident #94 at that time. She planned to order Boost nutritional supplement related to the weight loss that was suffered. An interview was conducted with the facility's Dietary Manager on 04/25/24 at 10:25 AM. She stated she was aware that Resident #94 had suffered weight loss, but that she had not talked to the dietitian about the weight loss. When asked why the Mighty Shake supplement was stopped in March, she stated a staff member told her the family wanted it stopped. She further stated she did not remember who the staff member was that told her and she had not followed up with the family or the dietitian regarding that change. When asked what other interventions could be implemented, she stated they could try double protein with meals or another supplement such as Boost, but that she could not write orders, only the dietitian could write orders. A review of the facility's policy titled Medical Nutrition Therapy Documentation (dated 2019) revealed the following: The Certified Dietary Manager's role is to collect the factual data for documentation, communicate pertinent information to the Registered Dietitian and the interdisciplinary team, and implement the physician's diet and supplement orders as applicable.

Based on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals were stored in locked compartments with access granted only to authorized personnel for one (Resident #45) of one resident reviewed for medication storage. The findings include: During a tour of the facility on 04/22/24 at 1:00 PM, Resident #45's room was entered and a medication cup containing seven (7) medication tablets was observed sitting unattended on the bedside table. (Photographic evidence obtained) Further observation revealed an individual entering Resident #45's room. An interview was conducted with this individual on 04/22/24 at 1:37 PM. She stated she was Resident #45's private duty aide. She further stated the nurse brought the observed medications into Resident #45's room around breakfast time, and that this was not the first time the nursing staff had left medications for her to administer to Resident #45. When asked, the private duty aide stated she was not a certified medication technician, she was a certified nursing assistant. When asked to clarify whether she worked at the facility or was hired by Resident #45's family, she stated she was hired by Resident #45's family. A review of Resident #45's record revealed that Licensed Practical Nurse (LPN) A documented that she administered the following medications to Resident #45 on 04/22/24 at 9:36 AM: Acetaminophen (a medication used for pain) 650 milligrams (mg) (2 tablets), Cetirizine (an allergy medication) 10 mg, Clopidogrel (a blood thinning medication) 75 mg, Rosuvastatin (a cholesterol lowering medication) 10 mg, Sertraline (an antidepressant medication) 25 mg (1/2 tablet), and Vitamin D (an oral supplement medication) 2000 units. A review of Resident #45's Minimum Data Set (MDS) assessments revealed she had a Brief Interview for Mental Status score of one out of 15 possible points, indicating severe cognitive impairment. Further review of the medical record revealed there was no documentation verifying that Resident #45 was safe to self-administer medications or that her private duty aide was safe to administer her medications to her. An interview was conducted with LPN A on 04/25/24 at 8:20 AM. She stated she had no recollection of leaving the above medications at Resident #45's bedside. A review of the facility's policy titled Medication Administration (revised 01/01/23), revealed: Medications are administered by licensed nurses or other staff who are legally authorized to do so as ordered by the physician and in accordance with professional standards of practice.

Based on record review and interviews, the facility failed to ensure it maintained an environment free of accident hazards for one (Resident #1) of four residents sampled for transfers. The facility failed to use a of mechanical lift to transfer a dependent resident and failed to educate staff on transferring residents. Failure to properly transfer residents could result in adverse outcomes including injury, fractures, and death. The findings include: A medical record review for Resident #1 revealed she was admitted to the facility on [DATE] with a re-entry on 06/18/2022. Her diagnoses included weakness, lack of coordination, [CONDITION(S)] and [CONDITION(S)], dementia, and displaced spiral fracture of shaft of left femur. A review of the quarterly minimum data set (MDS) assessment, dated 03/22/2022, revealed the resident had a brief interview of mental status (BIMS) score of 00, indicating impaired cognition. Resident was unable to complete the assessment. Resident was dependent on staff with two-persons assist with mobility. During an interview with Employee B, CNA on 06/22/2022 at 1:09 PM, she reported while transferring Resident #1 without using the Hoyer lift on April 11, 2022, the resident slid to the floor. Resident #1's daughter was in the room and held resident in the front while she held the resident in the back. Employee B, CNA stated that she had asked Employee A, CNA how to transfer Resident #1 and was told to just pivot the resident. She said, she was new at the time and did not know how to properly move Resident #1. Employee B, CNA stated she discovered later that she had incorrectly transferred Resident #1. She was supposed to use a Hoyer lift but did not know how to access the Kardex properly to review Resident #1's care plan related to mobility. A review of facility provided documentation of falls indicated Resident #1 experienced a staff related misadventure which included Employee B, CNA attempting to move Resident #1 from one location to another. On 04/11/2022, while being assisted by her daughter and Employee B, CNA, the resident slid down to the floor. A review of the care plan for Resident #1 revealed she had limited physical mobility, was a risk for falls and had an Activity of Daily Living (ADL) deficit. Interventions included the use of a mechanical lift for transfers. On 05/21/2022, Resident #1 was noted to have swelling and bruise to her left lower leg. Upon assessment, resident was observed in pain during range of motion. Doctor was notified and daughter was present during assessment. Cold packs applied to left lower leg and x-rays taken. A review of a radiology procedure performed at the facility on 05/22/2022 at 11:31 AM, indicated the following results for Resident #1: Spiral displaced fracture the mid and distal diaphysis the femur is identified. There is no evidence of healing. There is mild osteopenia. Impression: Nonhealed/incompletely healed displaced fracture of the femur. A review of progress notes for Resident #1 dated 5/31/2022 at 00:00 hours indicated Resident #1 was readmitted to the facility after hospitalization for a left leg fracture. The resident had a Femoral Distal fracture that was documented as not new they are healing as expected. Resident #1 was transferred to hospital for left leg pain and bruising. In the Emergency Department the patient was found a bruise to the left knee and pain. X-ray of the left femur showed partial healing displaced oblique femur fracture. X-ray of left tib-fib showed a subacute to chronic medial tibial plateau fracture age indeterminate. A posterior malleolus fracture. Ortho consulted and no surgical intervention was necessary signed by Provider #1. On 06/22/2022 at 1:28 PM a list of staff was provided that included staff who did not sign off on the in-service related to transferring residents following the documented incident on 4/11/2022 that involved Resident #1. Those staff members were Employee F, CNA, Employee G, CNA, Employee H, CNA, Employee I, CNA, Employee J, CNA & Employee K, CNA. The DON explained, she found out that Employee B, CNA did not know how to access the Kardex. The in-services were held to be sure everyone knew how to access the Kardex/care plan for each resident. The DON stated she thought Resident #1's fracture may have occurred when she slid to the floor on 04/11/2022. During a follow up interview with the DON on 06/22/2022 at 3:00 PM, she provided additional medical records, and confirmed that she had not completed 100% of training/in-service for Transferring and Kardex access for resident care. She explained that the Clinical Nurse educator was in transition at the time. An interview was conducted with the daughter of Resident #1 on 06/22/2022 at 5:24 PM. She confirmed, she was present when her mother slid to the floor. The first thing that happened was that the nurse aid was not using the lift to move Resident #1. The daughter stated that her mother (Resident #1) was too close to the edge, she slid to the floor, and everyone came in. She stated then on 05/22/2022 when she visited Resident #1, she pushed the resident in her wheelchair and she said, ouch and complained about leg pain. The aid in the room (she did not know the name of the staff member) lifted her pant leg and the leg was blue. She went right out to the nurse station and said what happened and no one knew anything. They still said they do not know what happened. On 06/24/2022 at 10:41 AM, the administrator emailed confirmation that Employee F, CNA, Employee G, CNA, Employee H, CNA, Employee I, CNA, Employee J, CNA, & Employee K, CNA did not sign off on the in-service related to transferring residents following the documented incident on 04/11/2022 that involved Resident #1.

Based on observations, staff interview, and facility policy review, the facility failed to ensure safe and secure storage (including limited access and mechanisms to minimize loss or diversion) of all medications, with the potential of affecting all residents, related to staff not ensuring one (St. [NAME] nursing unit (rooms 300/400) of two treatment carts containing medications was locked when not in use and unattended. The findings include: On 4/10/22 at 12:10 p.m., an observation was made of an unlocked and unattended treatment cart on the St. [NAME] nursing unit (rooms 300/400). The same cart was observed unlocked and unattended at 1:53 p.m. The second drawer was opened, and multiple bags of medications with resident labels were observed. There was no staff observed in the area. (Photographic evidence obtained) On 4/11/22 at 11:15 a.m. and at 4:38 p.m., this same treatment cart on the St. [NAME] nursing unit (rooms 300/400) was observed unlocked and unattended. (Photographic evidence obtained at 4:38 p.m.) On 04/12/22 at 8:45 a.m., this same treatment cart on the St. [NAME] nursing unit (rooms 300/400) was observed unattended and unlocked. The drawers were opened and accessed. (Photographic evidence obtained) In an interview on 4/13/22 at 9:15 a.m., Licensed Practical Nurse (LPN) C was asked how many treatment carts were in the facility. She stated, There are two, one for the 100/200 hallway and one for the 300/400 hallway. She was asked where the treatment carts were stored. She stated, One is on each unit by the nurses' station. She was asked if the carts were secured behind a locked door. She stated, No, they are out by the nurses' station. She was asked if the carts were expected to be locked when they were not in use and were unattended. She stated, Yes, we don't want residents with memory issues to open the carts and get into them. She was asked if there were medications on the treatment carts that could be harmful to a resident if they removed it and ingested it. She replied, Yes, there's creams and ointments that we wouldn't want any resident to ingest. She was asked who held the keys for the treatment carts. She stated, I have one key for each cart, and then the 100 hall nurse has a key for that hall, and the 400 nurse has a key for that hall, so there are two keys for each cart. On 4/14/22 at 8:50 a.m., the treatment cart on the St. [NAME] nursing unit (300/400 hallway) was observed to be unlocked and unattended. (Photographic evidence of lock and items in second drawer was obtained) A review of the facility policy titled Storage of Medications revealed: Policy statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

Based on interviews and record review, the facility failed to ensure that each resident had the right to participate in the development and implementation of his or her person-centered plan of care for one (Resident #23) of 42 residents sampled. The findings include: A review of Resident #23's record revealed he was initially admitted on [DATE]. After being transferred to the hospital on 4/6/2022, he was last readmitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Progress Notes in the electronic medical record (EMR) revealed that Resident #23 was alert and oriented with some confusion but was able to make his needs known. A review of the Minimum Data Set (MDS) assessment completed on 1/26/2022, Resident #23 scored 9 out of a possible 15 points on the Brief Interview for Mental Status (BIMS), indicating moderately impaired congition. His activities of daily living (ADL) functional status was listed as: total dependence with transfers, extensive assistance with toilet use and bed mobility, and limited assistance with dressing, eating, and personal hygiene. A review of the resident's active care plan revealed it was initiated on 12/3/2021. During an interview with Resident #23 on 4/10/2022 at 12:18 p.m., he stated he was kept in the dark about his care. He denied having been notified of or attending any care plan meetings. During an interview on 4/12/2022 at 2:25 p.m., Resident #23 stated things had gotten a little better in the facility. He again addressed concerns about not knowing what was going on with his care. He stated his niece was his next of kin, was involved in his care and could provide additional information. He requested that she be contacted for additional information. During a telephone interview with Resident #23's niece on 4/12/2022 at 3:11 p.m., she confirmed that she was the resident's next of kin and she was heavily involved in his care. She stated she received a letter regarding a care plan meeting last year but had not received anything since that time. She stated she could call the nurses' station for information, but that no one had called her to schedule a meeting or to discuss the resident's plan of care. During an interview on 4/13/2022 at 3:13 p.m. with the Social Services Director (SSD), she stated care plan meetings were held quarterly. Families were contacted by phone and a notice was also mailed out to advise them of care plan meetings. She stated the meetings could be held in person or via telephone or Zoom if the families were unable to come to the facility. When asked about Resident #23, the SSD stated she was familiar with the resident. She confirmed that his niece was involved in his care. When asked about care plan meetings for Resident #23, she provided written correspondence for a care plan meeting for Resident #23 dated 2/25/2021. She confirmed that this was the last meeting held for the resident. She stated she had made several unsuccessful attempts to contact the resident's niece regarding his care, but when asked could not provide evidence of this. During an interview with the Director of Nursing (DON) on 4/13/2022 at 4:02 p.m., she stated the SSD was solely responsible for scheduling the residents' care plan meetings. She stated the Administrator would be responsible for identifying whether or not this was being done. During an interview with the Administrator on 4/13/2022 at 4:20 p.m., she confirmed that she had identified concerns with residents not having scheduled care plan meetings. She stated the concerns had been discussed during Quality Assessment and Assurance (QAA) meetings, however, no performance improvement plan had been put in place to date. She stated the SSD was solely responsible for care plan meetings (scheduling, reviewing , and ensuring they were done). On 4/14/2022 at 11:31 a.m., the Administrator advised the survey team that a facility-wide audit was done to identify residents who had missed care plan meetings. She stated Resident #23 was identified in the audit and again confirmed that the resident had not had a care plan meeting since 2/25/2021. A review of the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered (Revised December 2016), revealed that the Interdisciplinary Team (IDT), in conjuction with the resident and his/her family or legal representative, develop and implement a comprehensive, person-centered care plan for each resident. Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to partciapiate in the development and implementation of his or her plan of care, including the right to partcipate in the planning process.

Based on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for one (Resident #86) of a sample of 42 residents. The findings include: On 04/10/22 at 12:56 p.m., two bottles of [MEDICATION(S)] eye drops were observed on Resident #86's bedside table. The resident was asked if she administered the eye drops herself. She stated yes. She stated, I have my family buy them for me because it's a larger bottle and I am able to use it, even with my arthritis. She was asked when she used the eye drops. She stated, I use them when my eyes are itchy and scratchy, and then I don't have to wait for the nurse. She was asked if staff were aware that she had the eye drops on her bedside table. She stated yes. She was asked how long she had kept the eye drops at her bedside. She stated, As long as I've been here. She was asked again whether she kept the eye drops on her bedside table and she stated yes. On 04/11/22 at 9:20 a.m., two bottles of [MEDICATION(S)] eye drops were on Resident #86's bedside table. The resident was asked how often she used the eye drops. She stated, My ophthalmologist said I could use them whenever my eyes feel dry or scratchy. I'd say three or four times a day. On 04/12/22 at 8:45 a.m., two bottles of [MEDICATION(S)] eye drops were observed on Resident #86's bedside table. On 04/12/22 at 9:25 a.m., during an interview with Licensed Practical Nurse (LPN) B, she was asked if any of the residents on her assignment today had an order to keep medications at the bedside. She replied, No, I don't think so; not that I know of. She was asked if any of her residents had eye drops kept in their rooms. She replied, I think she (referring to the room behind her) did, but I don't think she has them in her room anymore. She was asked what the protocol was for residents who wanted to self-administer medications. She stated, The provider can give permission for that. If a resident wanted to self-administer medications or keep them in their room, the provider would need to give permission first, to make sure the resident is appropriate to self administer. She was asked if she was caring for Resident #86 today. She replied yes. She was asked if the resident kept any medications in her room. LPN B replied, I'm not sure. I don't think so. She was asked if this resident kept any eye drops in her room. She replied, I'm not sure. She was asked if this resident had a physician's order to keep eye drops in her room. She stated, No, I don't think so. During a medical record review for Resident #86 on 04/12/22 at 10:15 am, the following order was viewed: 3/21/22: [MEDICATION(S)] Hydration PF solution 0.4-0.3%: instill one drop in both eyes two times a day for dry eyes. A review of the Electronic Medication Administration Record (eMAR) for Resident #86 showed this medication was being signed off as having been administered each day in April 2022 (up to April 11, 2022) at 9:00 a.m., at 9:00 p.m., and at 9:00 a.m. on April 12, 2022. On 04/12/22 at 11:30 a.m., the Assistant Director of Nursing (ADON) and the St. [NAME] Unit Nurse Manager were observed performing wound care for Resident #86. While setting up an area on resident's bedside table, the ADON was asked if Resident #86 required a physician's order to keep the [MEDICATION(S)] eye drops at her bedside, as two bottles were observed on the bedside table. The ADON stated, Yes, she should have an order to keep them in the room. She was asked if the resident had an order to keep them at bedside. She stated, I don't know, I'll have to look. On 04/12/22 at 1:15 p.m., the ADON stated [Resident #86's] eye drops are care planned and the order to self-administer was clarified. She was asked when the resident was care planned and when the order was clarified. She stated, We just called the doctor and he's okay with the resident self-administering the eye drops. We care planned that and the resident demonstrated she was able to self-administer the eye drops. The ADON was asked for a copy of the facility's policy for Self-Administration of Medications. She was also asked if any other residents had eye drops or other medications at the bedside. She replied No. Further review of Resident #86's medical record revealed an evaluation titled Self Medication Evaluation form dated 4/12/22 and locked at 12:38 p.m. The record review did not reveal any other Self Medication Evaluations performed for Resident #86. A review of the resident's active care plan on 04/12/22 at 1:02 p.m., revealed no focus areas/goals/interventions for self-administration of medications. On 04/13/22 at 9:15 a.m. during a wound care treatment observation with Resident #86 and the wound care nurse, a bottle of [MEDICATION(S)] eye drops was observed on the resident's bedside table inside of a red plastic cup. On 04/14/22 at 12:00 p.m. during a wound care treatment observation with Resident #86 and the wound care nurse, a bottle of [MEDICATION(S)] eye drops was observed on the resident's bedside table inside of a red plastic cup. Information from www.[MEDICATION(S)].Myalcon.com (accessed on 04/14/22 at 12:20 p.m.) revealed the following warnings: Safety: for external use only. Stop use and ask a doctor if you experience any of the following: eye pain changes in vision continued redness or irritation of the eye conditions worsens or persists longer than 72 hours Keep out of reach of children. If swallowed, get medical help or contact a Poison Control Center right away.

Based on observations, interviews and record review, the facility failed to ensure that one (Resident #251) of three residents with an indwelling catheter, from a total of 42 sampled residents, received appropriate care and services to prevent urinary tract infections ([CONDITION(S)]). The findings include: On 4/10/22 at 2:35 PM, cloudy urine in a urinary catheter bag dated 1/18/22 was observed. Resident #251 could not recall when it was last changed. During another observation of Resident #251 on 4/12/22 at 12:30 PM, cloudy urine was observed in his urinary catheter bag dated 1/18/22. A review of the clinical record revealed that Resident #251 was admitted to the facility on [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Other diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Suprapubic catheter care: Cleanse stoma with soap and water, dry, and apply clean dressing every night shift. A review of a skin/wound note, dated 3/15/22, revealed: Suprapubic site with brown drainage - cleansed with normal saline (NS) and drainage sponge applied with paper tape. A review of the active care plan revealed the resident had a suprapubic urinary catheter with interventions to change per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Social Services Progress Note dated 1/4/22, revealed the resident was admitted on [DATE] with a urinary tract infection. A review of the Admission Minimum Data Set (MDS) assessment, dated 1/3/22, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15 points, indicating moderately impaired cognitive. The resident required extensive assistance for bed mobility, transfers, toilet use, and limited assistance for eating. He had an indwelling urinary catheter, and had a urinary tract infection within the last 30 days from the assessment reference date. On 4/14/22 ay 9:44 AM, Registered Nurse (RN) F confirmed that the resident's suprapubic dressing was not dated. When asked how often the urine bag needed to be changed, she looked at the bag and said, Oh wow, it's way past due. She added that it should be changed every 30 days and as needed. She confirmed that the tubing contained sediment and discolored urine. She also confirmed that the catheter insertion gauze was not dated, therefore, one was unable to tell whether it had been cleaned as ordered. In an interview on 4/14/22 at 12:40 PM, the Director of Nursing (DON) stated the facility did not have a timeline for urinary catheter bag changes. She stated if there were any signs of occlusion or infection, then the whole system should be changed. She confirmed that Resident #251's bag contained sediment and the urine had an unusual appearance. She stated the whole system will be changed and the physician will be notified for orders of urinalysis to rule out infection. A review of the facility's policy and procedure titled Catheter Care, Urinary (Revised September 2014), revealed that the purpose of the procedure was to prevent catheter - associated urinary tract infection. Changing indwelling catheters or the drainage bags at routine, fixed intervals is not recommended. Rather, it suggested to change catheters and drainage bags based on clinical indication such as infection, obstruction, or when the closed system is compromised. Observe the resident for complications associated with urinary catheters by checking the urine for unusual appearance (i.e., color, blood, etc). The policy also revealed that catheter care documentation should include: 3. All assessment data obtained when giving the catheter care. 4. Character of the urine such as color (straw- colored, dark, or red) clarity (cloudy, solid particles or blood) and odor.

Based on observations, interviews, and record reviews, the facility failed to ensure that two (Resident #72 and Resident #43) of 16 residents receiving respiratory care, for a total sample of 42 residents, received oxygen as ordered. The findings include: 1. On 4/10/22 at 1:20 PM, Resident #72's oxygen flow rate was set at 3 Liters per minute (L/min). (Photographic evidence obtained) On 4/12/22 at 9:26 AM, an observation of Resident #72 revealed her oxygen canula was dated 4/11/22 and her oxygen flow rate was set at 3 Liters per minute (L/min). (Photographic evidence obtained) On 4/13/22 at 9:03 AM, Resident #72's oxygen flow rate was set at 3 Liters per minute (L/min). (Photographic evidence obtained) A review of the medical record revealed that Resident #72 was admitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Active physician's orders included: Oxygen via nasal cannula continuous at 2 L/min to keep saturation greater than 92%, Oxygen tubing change every shift every Sunday, [NAME] Cap ([NAME] ([NAME] methysticum) 1 mg (milligram) every morning and bedtime for generalized anxiety disorder, take 1 capsule every morning and at bedtime for shortness of breath, and Chloroxygen Concentrate 50mg/18 drops orally every morning and at bedtime for shortness of breath. A review of the resident's Quarterly Minimum Data Set (MDS) assessment, dated 3/4/2022, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 points, indicating intact cognition. She required extensive assistance for bed mobility and toilet use, supervision with setup help only with eating, and she was on oxygen therapy. A review of the active care plan indicated the resident had a focus area of [CONDITION(S)]/[CONDITION(S)] with a risk for respiratory distress and may use oxygen. Interventions included oxygen therapy as ordered by the physician. Monitor difficulty breathing (Dyspnea) on exertion, remind resident not to push beyond endurance, and monitor for signs or symptoms of acute respiratory insufficiency: anxiety, confusion, restlessness, shortness of breath at rest, cyanosis, and somnolence. A medication administration note dated 3/20/2022 at 8:07 AM read, Oxygen via nasal cannula continuous at 2 liters to keep saturation greater than 92% every shift. An Encounter Note dated 3/16/2022 at 11:00 PM read, No rales, rhonchi, or wheezing; oxygen saturation within normal levels .496/j44.9: [CONDITION(S)] ([CONDITION(S)]) Continue with supplemental oxygen and monitor symptoms. A medication administration note dated 3/12/2022 at 5:00 PM read, Oxygen via nasal cannula continuous at 2 liters to keep saturation greater than 92% every shift. A medication administration note dated 3/6/2022 at 8:26 AM read, Oxygen via nasal cannula continuous at 2 liters to keep saturation greater than 92% every shift. A medication administration note dated 2/28/2022 at 5:17 AM read, Oxygen tubing change every night shift every Sunday. Patient refused to let me change tubing. Educated her it is supposed to be changed every week to keep clean but she refused. A medication administration note dated 2/7/2022 at 3:12 AM read, Oxygen via nasal cannula continuous at 2 liters to keep saturation greater than 92% every shift. On 4/14/22 at 11:40 AM, Licensed Practical Nurse (LPN) E confirmed that Resident #72's current oxygen setting was at 3 L/min. She walked to the nurses' station and verified that the April 2022 TAR (Treatment Administration Record) contained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She also verified the resident's physician's order indicated oxygen to be set at 2 L/min. She continued to state Resident #72 was complaining that when lying flat, she does not feel it. When asked who monitored the resident's oxygen flow rate, LPN E confirmed that nursing and the unit managers did a level check. When asked how often Resident #72's flow rate was monitored, LPN E confirmed it was monitored daily by reviewing the TAR & MAR (Medication Administration Record). She stated she reviewed Resident #72's medications during morning medication administration and would complete a second review during her afternoon medication administration pass. In an interview with the Director of Nursing (DON) on 4/14/22 at 12:35 PM, she confirmed that nursing reviewed oxygen flow rates every shift, based on orders. She continued to state that for residents receiving oxygen, nursing must follow physicians' orders every shift or depending on what the order read. A review of the facility policy and procedure titled, Oxygen Administration (Revised 01/2022), revealed: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Policy explanation and compliance guidelines included: 1) Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practical when the situation is under control. 2) Personnel authorized to initiate oxygen therapy include physicians, RNs, LPNs, and respiratory therapists. 2. On 4/10/22 at 3:16 p.m., Resident #43 was observed lying in bed with the head of the bed elevated. Her oxygen concentrator's flow rate was set at 3 L min and she was receiving oxygen through a nasal cannula. She was asked if she was aware of what her oxygen flow rate was set at. She stated, I'm not sure, I think maybe 3 L/min? She was asked if she ever changed the oxygen flow rate on her concentrator. She stated, No, I don't that. I can't even reach it, see? The nurses take care of that. A review of her medical record revealed and active order for oxygen with a flow rate to be set at 2 L/min via nasal cannula continuously. On 4/11/22 at 9:10 a.m., Resident #43 was observed lying in bed with the head of her bed elevated. Her oxygen concentrator flow rate was set at 3 L/min. (Photographic evidence obtained) On 4/11/22 at 12:25 p.m., Resident #43 was observed lying in bed with her eyes closed. Her respirations were observed at 18 per minute. Her oxygen concentrator flow rate was set at 3 L/min. On 4/12/22 at 9:20 a.m., Resident #43 was observed lying in bed, watching TV with the head of her bed elevated. Her oxygen concentrator flow rate was set at 3 L/min. (Photographic evidence obtained) On 4/12/22 at 4:20 p.m., Resident #43 was observed lying in bed with the head of her bed elevated. Her daughter was visiting and her oxygen concentrator flow rate was set at 3 L/min. LPN A was observed in the hallway by the resident's room at this time. She was asked if she was caring for Resident #43 today. She stated yes. She was asked what the resident's oxygen flow rate was ordered to be set at, and she stated, She's 3 L/min, I think. I just checked her O2 sat a few minutes ago, and she's 99%. On 4/13/22 at 8:35 a.m., Resident #43 was observed lying in bed with the head of her bed elevated and a nasal cannula in place. Her oxygen concentrator flow rate was set at 2.5 L/min. (Photographic evidence obtained) On 4/13/22 at 12:10 p.m., Resident #43 was observed lying in bed eating lunch, with the head of her bed elevated and a nasal cannula in place. Her oxygen concentrator flow rate was set at 2.5 L/min. On 4/14/22 at 8:20 a.m., Resident #43 was observed lying in bed with the head of her bed elevated and a nasal cannula in place. Her oxygen concentrator flow rate was set at 2.5 L/min. (Photographic evidence obtained) During a medical record review for Resident #43, it was revealed that her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of her current/active physician's orders revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the person-centered care plan, dated 8/3/21 (revised 2/25/22), revealed the following focus areas, goals and interventions: Focus: I may use oxygen therapy and require suctioning r/t hx (related to a history of) [CONDITION(S)] ([CONDITION(S)] accident - stroke), CHF ([CONDITION(S)]), [CONDITION(S)], and increased secretions. Goal: I will have no s/sx (signs or symptoms) of poor oxygen absorption through the next review date. Interventions: Change the resident's position every 2 hours to facilitate lung secretion movement and drainage as tolerated. Give medications as ordered by MD (physician), monitor/document side effects and effectiveness. Monitor for s/sx of respiratory distress and report to MD PRN (as needed): respirations, pulse oximetry, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage, skin color. Oxygen Settings: I may use O2 via nasal cannula/mask per MD orders. Suction as needed. A review of the facility's policy for Oxygen Administration (1/21, revised 1/22) revealed: Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician, except in the event of an emergency. 4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's evaluation and orders, such as but not limited to: c. equipment setting for the prescribed flow rates.

Based on resident and staff interviews and a review of resident and facility records, the facility failed to maintain sufficient nursing staff to provide services and assistance in order to maintain the highest practicable well-being for three (Resident #2, #4 and #5) of four residents interviewed, and for one (Residents #2) of 3 residents reviewed for grievances, from a total of 6 residents in the sample. This had the potential to negatively impact all 66 residents in the facility at the time of the survey. The findings include: 1. An interview was conducted with Resident #2 on 06/03/21 at 11:15 AM. She stated the call light response times were long and took up to 40 minutes for staff to answer. This has, on occasion, resulted in her going to the bathroom on herself. This past Saturday she put her call light on at 2:30 PM because she needed to use the bathroom. The nurse came into her room and said, Ok, let me get someone. But nobody ever came. Resident #2 further explained she had a preferred schedule and liked to get up at 6:00 AM. However, because of staffing issues she is now being assisted to get up later in the morning. In addition, she was sometimes put to bed later than her scheduled time. A record review of the Quarterly Minimum Data Set (MDS) assessment for Resident #2 dated 03/19/21 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS indicated that Resident #2 required extensive assistance and one-person physical assistance with toileting and personal hygiene, and two person assist for transfers. She was on a urinary toileting program and was frequently incontinent of bladder and occasionally incontinent of bowel. A review of her plan of care dated 03/19/21 revealed an Activities of Daily Living (ADL) self-care performance deficit related to [CONDITION(S)], heart failure and [CONDITION(S)]. The interventions included encouraging participation, call bell use, and a mechanical lift for transfers with 2 persons. She also required a 2-person transfer for toileting. 2. During an interview with Resident #4 on 06/03/21 at 11:36 AM, she stated it sometimes took 30 minutes for her call light to be answered. She explained the facility was short of help. 3. During an interview with Resident #5 on 06/03/21 at 3:05 PM, she stated her call lights took 20 minutes to 2 hours to be answered and there were not enough staff to provide timely care or give medications in a timely manner. Sometimes staff would come in and say, We will tell your nurse. Resident #5 stated she was readmitted yesterday and should have received her pain medications around 5:30 PM but did not get that medication until 10:00 PM. She added, her 4:30 AM medication was not provided until 9:30 AM. A review of the facility staffing calculations from 05/02/21 to 05/29/21, found the facility's licensed staff hours fell below the minimum daily state requirements of 1.0 licensed nurse hours per resident on 3 days: and the 2.5 CNA hours per resident on 14 days. In an interview with the Staff Developer on 06/03/21 at 4:25 PM, she stated the Director of Nursing and Human Resources Director (HRD) reviewed daily staffing levels for sufficiency. The HRD, also present during the interview, confirmed the facility had fallen below the staffing hours on the above-mentioned days. She acknowledged resident concerns. An interview was conducted with the Administrator on 06/03/21 at 4:30 PM. She stated Resident #2's family sent a letter to the facility expressing some concerns. A review of the correspondence found the family expressed dismay over a lack of adequate staffing resulting in delayed morning care, toileting care and call light response times for Resident #2. Further review of the resident and facility grievance records revealed no indication the alleged lack of staffing and care was ever addressed or investigated. The Administrator acknowledged there was a lack of evidence that the allegations were addressed or investigated. (Photocopies were obtained)

Based on resident and staff interviews, a review of facility records and policies and procedures, the Grievance Official failed to oversee the grievance process by failing to investigate concerns and prevent further potential violations of residents' rights, or to follow up with the resident to ensure satisfaction with the resolution for one (Resident #2) of three residents reviewed for grievances, from a total of six sampled residents. The findings include: During an interview with Resident #2 on 06/03/2021 at 11:15 AM, she stated she was the Resident Council President. Since the resident council was no longer meeting in person, the Activities Director came around and asked her questions about her care. She explained her concerns which included the call light response times were long and took up to 40 minutes for staff to answer. Which resulted in her going to the bathroom on herself. Resident #2 explained she was on a toileting schedule and even when her call light was on, it took a long time for staff to respond. This past Saturday she put her call light on at 2:30 PM because she needed to use the bathroom. The nurse came into her room and said, Ok, let me get someone, but nobody ever came. Resident #2 further explained she had a preferred schedule and liked to get up at 6:00 AM. However, because of staffing issues, she is now being assisted to get up later in the morning. In addition, she was sometimes put to bed later than her scheduled time. Resident #2 confirmed that she had told the Activities Director about all her concerns and staff issues. A record review of the Quarterly Minimum Data Set (MDS) assessment for Resident #2 dated 03/19/2021 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS indicated that Resident #2 required extensive assistance and one-person physical assistance with toileting and personal hygiene, and two person assist for transfers. She was on a urinary toileting program and was frequently incontinent of bladder and occasionally incontinent of bowel. A review of her plan of care dated 03/19/21 revealed an Activities of Daily Living (ADL) self-care performance deficit related to [CONDITION(S)], heart failure and [CONDITION(S)]. The interventions included encouraging participation, call bell use, and a mechanical lift for transfers with 2 persons. She also required a 2-person transfer for toileting. A review of the nursing progress notes for Resident #2 revealed an entry by the Social Services Director (SSD) on 05/06/2021. It noted she had placed a call to Resident #2's family member to follow up on some concerns. The entry did not list the family member's concerns. The SSD noted she received no answer and left a voicemail. Further review of the progress notes reflected no further information or follow up on the referenced family concerns. The facility's grievance log was reviewed and revealed no documented concerns for Resident #2 or her family member. An interview was conducted with the SSD on 06/03/2021 at 3:48 PM. She explained the grievance process and said she determined who would be responsible for investigating any concerns. The facility then determined what steps were required to resolve the grievance. Once resolved, resolution was communicated to the resident or family member either in person or by phone. The SSD was asked if she had received any concerns filed on behalf of Resident #2. She said, No. An interview was conducted with the Administrator on 06/03/2021 at 4:30 PM. She stated, she had spoken to Resident #2's family member who had informed her that she sent a letter to the facility not long ago. She was asked about the SSD's progress note and call to this family member, but the Administrator said she did not recall what the issues of concern were. After reviewing her notes. The Administrator produced two email correspondences from Resident #2's family member. The first letter was dated 04/26/2021, and detailed concerns over a lack of adequate staffing, delayed morning care, delayed toileting care, call light response times, lack of hydration and food quality and temperature concerns on behalf of Resident #2. The letter asked what the team would be doing to address the issues. A second letter was received from the family member on 05/04/2021 alleging Resident #2 was left in her bed for 3.5 hours past her customary get-up time, was not provided anything to drink, and waited an hour for staff after activating her call light. The Administrator explained she did not receive the first email but did receive the second one on 05/04/2021. She called the family member and left a message to please call back to discuss the concerns. The Administrator said she even provided her cell phone number. Resident #2's family never returned the call. The Administrator insisted she made a second call but never received a call back. Resident #2 was then visited and asked about the concerns but denied most of the claims. Resident #2 is alert and oriented and expressed satisfaction, saying she did not know what her family member was talking about. The Administrator was advised that Resident #2's current concerns were in concert with the allegations in the letter. She replied, Oh, that is not what she said last time. The Administrator was asked why she did not document and manage this situation as a grievance per her grievance policy. She replied she guessed she should have done that. She acknowledged the grievance policy stated all issues would be documented, investigated and the results of the investigation documented in the chart. The Administrator acknowledged that without following this process, there was no way to determine the issue had been addressed, investigated, or managed per the policy. A review of the Resident Complaint/Grievance Policy and Procedure (not dated) revealed the SSD was the Grievance Official (GO). Any resident, responsible party or other interested party can complete a Record of Complaint Grievance Form, or a staff member can complete the form. The grievance form will be forwarded to the SSD within 24 hours and the Grievance Official will investigate the complaint within 5 days. The findings of the investigation will be documented on the complaint/grievance form. Additionally, the GO will document: A. Thorough investigation. B. Action taken, if any. C. Resident/family notification of outcome. D. Follow-up. E. Summary of disposition. The policy instructs documentation of this information will be placed in the medical record and the plan of care updated, if applicable. The GO will meet with the resident and inform of the results of the investigation and how the issue was or will be resolved. Photocopies were obtained