Every finding on record at Riverside Landing Nursing and Rehabilitation

Based on observation and interview the facility failed to ensure a staff members utilized appropriate personal protective equipment when entering a resident's contact isolation room. This had the potential to affect the remaining 13 residents (#11, #12, #13, #16,#18, #19, #22, #23, #26, #29, #30, #34, and #40) on the hall. The facility census was 39. Findings include:Review of Resident #10's medical records revealed an admission date of 07/15/26 and diagnoses including malignant neoplasm of frontal lobe, unspecified psychosis not due to a substance or known physiological condition, type one diabetes, hypothyroidism, epilepsy, cutaneous abscess of right axilla, and unspecified staphylococcus as the cause of diseases classified elsewhere.Review of Resident #10's annual Minimum Data Set (MDS) dated [DATE] revealed a brief interview for mental status score of 15 indicating that the resident was cognitively intact. Further review of the MDS revealed the resident required supervision with her activities of daily living, was occasionally incontinent of bladder and bowel and had no skin issues at the time the annual assessment was completed.Review of Resident #10's physician orders revealed an order dated 07/16/26 for amoxicillin-pot clavulanate oral tablet 875-125 MG, give 1 (one) tablet by mouth two times a day for cellulitis, staph bacteremia until 07/23/26, an order dated 07/16/26 for left thigh- cleanse with wound cleanser, apply mupirocin ointment and apply bordered gauze dressing every shift apply warm compress for 10-15 minutes prior to dressing change and as needed if the dressing becomes soiled or dislodged, an order dated 07/16/26 for right axilla- cleanse with wound cleanser and leave open to the air every shift and as needed, and an order dated 07/17/26 for contact isolation every shift for staphylococcus to axilla. An observation on 07/20/26 at 12:56 P.M. revealed Resident #10 had a sign on the room door indicating the resident was in contact isolation. A facility staff member was observed in the room asking the resident about menu selections for the next day and was observed to not be wearing personal protective equipment (gown and gloves) as required. An observation on 07/20/26 at 12:57 P.M. revealed the facility staff member continued in the room asking the resident about menu selections for the next day and was observed to not be wearing personal protective equipment (gown and gloves) as required. Licensed Practical Nurse (LPN) #5 observed and verified the facility staff member was in the room in room asking the resident about menu selections for the next day and was not wearing personal protective equipment (gown and gloves) as required. Review of the policy titled Isolation Precautions, undated, revealed that only authorized personnel would be allowed to enter isolation areas and they would be required to follow all instructions issued.

Based on observation, record review, staff interview, and policy review, the facility failed to ensure their medication error rate was less than five percent. The facility had two errors out of 25 opportunities for a medication error rate of 8 percent. This affected two residents (#22 and #35) of three residents reviewed for medication administration. Findings include:1 a.) On 07/22/26 at 8:18 A.M., a medication administration observation was completed for Resident #22. The resident's morning medications were administered by registered nurse (RN) #22. The resident was given Multivitamin (MVI) with Minerals, as part of the 14 medications that she was given. Review of Resident #22's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included history of a cerebral vascular accident (CVA) with hemiplegia (paralysis) and hemiparesis (weakness) affecting her left non-dominant side. Review of Resident #22's active physician's orders revealed the resident was to receive a Multivitamin tablet by mouth every morning related to her diagnosis of CVA. The order originated on 02/03/24. She did not have an order to receive a Multivitamin with Minerals, as was observed to be given to the resident during her morning medication pass. On 07/21/26 at 9:02 A.M., an interview with RN #22 confirmed he administered MVI with Minerals to Resident #22 that morning, when the resident had an order to receive a Multivitamin tablet. He acknowledged a Multivitamin tablet was not the same as a Multivitamin with Minerals tablet, which he had previously given to the resident. He checked his medication administration cart and verified they had a bottle of each (Multivitamin and Multivitamin with Minerals) in the top drawer of the medication administration cart that was from their stock supply. He reported he must have pulled the medication from the wrong bottle resulting in the medication error occurring. 1b.) On 07/22/26 8:35 A.M., a medication administration observation was completed for Resident #35. Her morning medications were administered by licensed practical nurse (LPN) #21. The resident was given Amlodipine ( a medication used in the treatment of hypertension) 2.5 milligrams (mg) by mouth, as part of the seven medications she received that morning. Review of Resident #35's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia and essential hypertension (high blood pressure). Review of Resident #35's active physician's orders revealed the resident was to receive Amlodipine 10 mg by mouth every morning for hypertension, not 2.5 mg that she was observed to receive earlier that morning. The order originated on 06/02/26. On 07/21/26 at 8:55 A.M., an interview with LPN #21 confirmed she administered Amlodipine 2.5 mg by mouth to the resident that morning when her physician's orders indicated she was to receive 10 mg. She pulled the blister pack card from the medication administration cart and noted the label from the blister pack she was using did not include the resident's most recent order to give 10 mg every morning. It still included instructions on the label to administer 2.5 mg by mouth every morning. She contacted the pharmacy and determined there was some issue with the resident's insurance, as to why they were still using the previous card that instructed them to give 2.5 mg every morning and not a new blister pack card with the latest instructions for the resident to receive 10 mg every morning. She reported the pharmacy would be sending the new dose of Amlodipine out later that day so the label on the medication packaging matched the physician's order. She further reported she would have to go give the resident three additional tablets of the Amlodipine 2.5 mg tablets to equal the 10 mg she should have been given that morning. Review of the facility's policy on Medication Administration dated January 2025 revealed medications were to be administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices, and only by persons legally authorized to do so. Prior to administration, they were to review and confirm medication orders for each individual resident on the medication administration record (MAR). They were to compare the medication and dosage schedule on the resident's MAR with the medication label. If the label and MAR were different, and the container was not flagged indicating a change in directions, or if there was any other reason to question the dosage or directions, the prescriber's orders were checked for the correct dosage schedule. They were then to apply a direction change sticker to the label if directions had changed from the current label. The nurse administering the medication was to verify the medication was correct three times before administering the medication (when pulling the medication package from the medication cart, when the dose was prepared, and before administering it).

Based on record review, review of residents' code status maintained in files at the nurses' station, staff interview, and policy review, the facility failed to ensure residents' code status were consistent between what was documented in the electronic medical record (EMR) and what was kept on file at the nurses' station. This affected two residents (#2 and #12) of two residents reviewed for advanced directives. Findings include: 1.) Review of Resident #2's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included malignant neoplasm of the endometrium (lining of the inside of the uterus), acquired absence of bilateral ovaries, adult-onset diabetes mellitus, chronic obstructive pulmonary disease, and hypertension. Review of Resident #2's active physician's orders revealed the resident was a full code. The order originated on [DATE]. Review of Resident #2's active care plans revealed the resident had a care plan in place for being a full code status per her wishes. The care plan originated on [DATE] and was last revised on [DATE]. The goal was for the resident to remain a full code and receive artificial resuscitation (CPR) through the review date. The interventions included placing the resident's advanced directives on the resident's chart, call 911 for emergency help if needed, review her code status at least quarterly, annually and as needed (prn) with resident/family/responsible party, staff would initiate CPR until EMS arrived, and staff to notify the physician of the resident's wishes and to carry out any orders. On [DATE] at 4:50 P.M., review of Resident #2's file maintained at the nurses' station that included a copy of her face sheet and advanced directives revealed the resident was identified as being a Do Not Resuscitate Comfort Care Arrest (DNRCC-A), which was an order that allowed life-saving treatments, up until your heart or breathing stops, and then no life saving treatments such as CPR to be attempted from that point on. The DNRCC-A form was dated [DATE]. On [DATE] at 1:50 P.M., an interview with Licensed Practical Nurse (LPN) #21 revealed, if a resident became unresponsive, they would have to determine a resident's code status to see if CPR should be performed. They could go to the file at the nurses' station or pull the resident's information up on the computer. If she was down the hall, when a resident was found unresponsive, she would have an aide or another nurse to check the resident's code status in the file kept at the nurses' station. The face sheet and advanced directives maintained in the file at the nurses' station was also used to make copies when a resident was being transferred to the hospital or out for a medical appointment. She reported the code status should match between what is in the resident's electronic medical record (EMR) and what was kept in the file at the nurses' station. She thought they were being updated frequently by the MDS nurse. She then stated they had a transportation aide/ medical record employee that had been keeping them updated, but they haven't had anyone in that position for about a month now. She confirmed Resident #2's EMR reflected the resident was a full code and the resident's code status identified on the advanced directive they had on file at the nurses' station had her as a DNRCC-A. Review of the facility's policy on Advanced Directives (not dated) revealed the facility would maintain written standards and practice guidelines regarding advanced directives to assure that the resident's wishes were honored. The facility staff would document in the clinical record whether or not the resident had executed advanced directives. They would also review and revise the advance directive if requested by the resident/ responsible party. The physician would write an appropriate order for the resident relating to their advance directive. All pertinent information related to advanced directives was to be documented in the resident's clinical record. 2. Review of Resident #12's medical record revealed an admission date of [DATE] and diagnoses including Alzheimer's disease, diabetes, hypothyroidism, heart failure and dementia. Review of Resident #12's annual Minimum Data Set, dated [DATE] revealed a brief interview for mental status score of three indicating the resident had severe cognitive impairment and was receiving hospice services. Review of Resident #12's paper file at the nurse's station revealed a form dated [DATE] indicating the resident had chosen a DNRCC (do not resuscitate comfort care) indicating that no life saving medical treatments will be provided and care will focus on pain relief and symptom control. Review of Resident #12's physician's orders revealed an order dated for [DATE] for advanced directive of DNRCC/Arrest (do not resuscitate comfort care/arrest) indicating that all life saving medical treatments will be provided until the resident's heart stops beating or they stop breathing. In an interview on [DATE] at 1:48 P.M. Licensed Practical Nurse (LPN) #21 stated the paper files were for the Certified Nursing Assistant or nurse to be able to pull the file and check code status of a resident quickly. LPN #21 was not sure who was responsible to keep the file updated. In an interview on [DATE] at 1:52 P.M. LPN #21 verified the form in paper file states DNRCC and the order in the computer states DNRCC/Arrest for Resident #12.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of a facility investigation file, interview, and policy review, the facility failed to ensure medications were properly secured to prevent a resident with cognitive impairment and wandering behavior from accessing the medication and ingesting an unknown quantity of the medication. This affected one resident (#6) of three residents reviewed for accidents/ supervision. Findings include:Review of Resident #6's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included Schizophreniform disorder (a short-term mental health condition featuring psychotic symptoms like delusions, hallucinations, and disorganized speech) paranoid schizophrenia, depression, anxiety, and selective mutism. Review of Resident #6's nurses' progress notes revealed a nurse's note dated 04/15/26 at 12:45 P.M. by Licensed Practical Nurse (LPN) #21 that indicated the resident was noted with medication in her mouth. Her mouth was rinsed and two tablets were pulled from her mouth. The on-call physician service was immediately called and a new order was received to check the resident's vital signs and send her to the emergency room (ER) for further evaluation. She was transferred to the hospital via squad for a possible medication ingestion. She returned to the facility on [DATE] at 9:05 P.M., after she was evaluated at the hospital. Further review of Resident #6's nurses' progress notes revealed an interdisciplinary team (IDT) note dated 04/28/26 at 8:14 A.M. indicating the IDT met to review the incident that occurred on 04/15/26 at 12:45 P.M. Education was provided to all nursing staff regarding safe medication practices, storage, and medication administration cart safety. Resident #6 was indicated to have been evaluated and released from ER with safe levels of Acetaminophen in her system via lab testing completed at the hospital. Review of Resident #6's active physician's orders revealed the resident had an order to receive Acetaminophen (Tylenol) 500 milligrams (mg) by mouth every six hours as needed (prn) for pain. The order originated on 07/01/25. Review of Resident #6's medication administration record (MAR) for April 2026 revealed the resident's order for Acetaminophen 500 mg every six hours prn for pain was included on the MAR. Her last documented use of the prn Acetaminophen order was on 04/10/26 at 8:16 P.M. She did not receive any prn doses of Acetaminophen on 04/15/26. Review of Resident #6's hospital records for her transfer to the hospital on [DATE] revealed an emergency department (ED) Provider Note dated 04/15/26 at 2:00 P.M. that indicated the resident presented to the ED for concerns of ingestion of Tylenol. Per the resident's sister, who provided a history, she noted the resident seemed to be drooling or foaming at the mouth, after she finished her lunch meal. The sister tried to clear the resident's mouth. There was concern that there was a bottle of medication out at the nurses' station and possibly another empty bottle of medication. The sister believed the resident may have ingested Tylenol. The sister first noted symptoms about a hour ago, but was not clear when the exact time of possible ingestion occurred. She was also unsure how many pills the resident might have ingested. The hospital records did indicate that the facility's nursing staff did speak with poison control, who recommended a four hour Tylenol level to be checked. A four hour Tylenol level was checked at the hospital, as part of the resident's workup, and her Tylenol level came back at 16 micrograms/ milliliter (ug/ml). There was no evidence of any significant Tylenol ingestion occurring, based on the lab test performed. Review of Resident #6's laboratory testing results for labs completed at the hospital revealed the resident had Acetaminophen levels collected on 04/15/26 at 2:07 P.M. and again on 04/15/26 at 5:01 P.M. The Acetaminophen level at 2:07 P.M. was 38.0 ug/ml and at 5:01 P.M. it was 16.0 ug/ml. The lab results indicated Acetaminophen toxic ranges were greater than 200 ug/ml four hours post ingestion or greater than 50 ug/ml 12 hours post ingestion. Review of Resident #6's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no speech and rarely/ never was able to make herself understood. Her cognitive status was unable to be assessed due to her mutism (no speech). She was noted to display wandering behavior that occurred daily. On 07/21/26 at 8:49 A.M., an interview with Resident #6's representative, who worked at the facility as a housekeeper, revealed she was the one that found Resident #6 with something in her mouth on 04/15/26 at 12:45 P.M. She stated she was able to clear two white tablets from the resident's mouth, but looked like some had been chewed or dissolved in the resident's mouth. She was unsure how much the resident may have ingested before she found her. She was concerned that the facility's nurses had left a bottle of Tylenol sitting on top of the medication administration cart for the resident to gain access to. She reported the resident was known to wander about the facility and was also known to put things in her mouth. Review of the facility's investigation file revealed they completed a Root Cause Analysis of the incident occurring on 04/15/26 at 12:45 P.M. The root cause analysis was completed on 04/15/26 and indicated Resident #6 found an open bottle of Acetaminophen and allegedly ingested an unknown amount. The resident was near the medication administration cart with a bottle of Acetaminophen in her hand and tablets in her mouth. Two tablets were removed from the resident's oral cavity, four tablets were found on a table and white residue from chewed up tablets were noted in and around the resident's mouth. The resident was assessed and the physician was notified with new order received to send resident to ER for an evaluation. The resident returned from the ER around 9:00 P.M. the same day with no signs or symptoms of distress and no further orders. The root cause of the incident was determined to be a failure to implement proper medication storage. The facility's investigation file included a Notice of Corrective Action dated 04/20/26 that had been issued to LPN #21. The Notice of Corrective Action revealed LPN #21 was given a final written warning for failure to provide quality customer service, standards, and practices. Negligence or carelessness resulting in danger, damage, or losses of company property, fellow employee, residents, or visitors. Improvement required included following policy procedure. The nurse signed receipt of the final written warning on 04/20/26. On 07/22/26 at 2:38 P.M., an interview with LPN #21 revealed they were not sure where the bottle of Tylenol came from that Resident #6 was able to gain access to and put some of the pills in her mouth. The stock bottle of Tylenol was found on her medication cart, so she took the rap for it. She stated she almost lost her job for it and was given a final written warning. She reported there was another bottle of Tylenol found in the front room of an office located on C-hall. The office was the first room on the left at the proximal end of C-hall. The front room used to have staff lockers in it and the back room was the office space used by the Assistant Director of Nursing/ Unit Manager. They had since removed the lockers so they did not have to worry about staff storing things in their lockers that residents may have access to. She confirmed she had passed out Tylenol to residents during the noon medication pass, so it was possible she left the bottle on top of her medication administration cart. There was a lot going on that day and more staff than just her were passing medications, but she was the only one passing medications from that particular medication administration cart, where the Tylenol bottle had been found. She denied she had administered any Tylenol to Resident #6 that day. She confirmed the resident's sister was the one that found the resident with the pills in her mouth. Her sister was trying to get her to swallow what was in her mouth by giving her drinks of water, while the nurse was wanting her to rinse and spit. The physician was notified and the resident was sent to the ER to be evaluated. They did a blood test to check her for Tylenol toxicity but it came back at normal levels. Since that incident occurred, the facility provided the nursing staff with education about medication storage. They also have been completing audits and were all the time checking their medication carts to ensure they were locked and medications were not being left out on top of the medication administration carts. Review of the facility's policy on Medication Storage and the Storage of Medications dated January 2025 revealed medications and biologicals were to be stored properly, following manufacturer's or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. The medication supply should be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medications were to stored in a controlled environment, which may include containers such as medication carts, medication rooms, or medication cabinets. The deficient practice was corrected on 04/15/26 when the facility implemented the following corrective actions: On 04/15/26 at 12:45 P.M., Resident #6's representative was notified of the incident, while the representative was working in the facility at the time of the incident. Resident #6 was immediately assessed by the nurse and no negative findings were noted. On 04/15/26 at 12:46 P.M., Resident #6's physician was notified of the incident and new orders were received to send the resident to the ER for an evaluation. On 04/15/26 at 12:55 P.M., the facility's Administrator conducted an environmental check to ensure there were no other medications improperly stored in the facility. On 04/15/26 at 3:00 P.M., Ad Hoc QAPI meeting was conducted with the QAPI members and the medical director via phone to discuss the incident. On 04/15/26 at 3:30 P.M., the facility's Administrator educated the facility's interdisciplinary team on proper medication storage and identifying when the policy for Medication Storage was not being followed. As a systematic change, the IDT would identify any improper medication storage and notify the Administrator or the DON. On 04/15/26 by 3:30 P.M., all like residents were interviewed by staff to ensure no other residents had encountered medications improperly stored. On 04/16/26 by 12:00 P.M., the facility's Director of Nursing (DON) and Unit Manager completed education with the involved nurse (immediately after the incident occurred) and all nursing staff regarding medication storage. The DON/ designee would complete audits of proper medication storage three times a week for four weeks and then as needed thereafter. Results of the audits to be reviewed in Ad Hoc QAPI meetings. At the time of the annual survey completed 07/23/26, surveyors verified education was provided to staff, audits were being completed, as per the facility corrective action plan. In addition, review of the employee file of LPN #21 verified she received a final written warning for the Tylenol being found on her medication cart. In addition, interview with facility nursing staff confirmed the staff had been educated, and the management staff were always checking their medication carts to ensure they were properly secured and no medications were being left out on top of the medication cart.

Based on record review and interview the facility failed to follow ordered drug parameters for a resident's diuretic medication and failed to follow a medication hold order for a resident prior to surgery. This affected two residents (#8 and #34) of six residents reviewed for unnecessary medications. The facility census was 39. Findings include:1. Review of Resident #8's medical record revealed an admission date of 08/01/25 and diagnoses including but not limited to acute on chronic diastolic (congestive) heart failure, diabetes, acute respiratory failure with hypoxia, unspecified convulsions, dementia, acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure, chronic kidney disease stage 4, anemia, secondary hyperparathyroidism of renal origin, and paroxysmal atrial fibrillation.Review of Resident #8's physicians orders revealed an order dated 03/19/26 for torsemide oral tablet 10 milligrams (MG) give 10 mg by mouth in the morning related to acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure, for weight <172lbs (pounds), hold torsemide; for weight 172-176lbs, give torsemide 10 mg; for weight >176lbs, give torsemide 20 mg. Review of Resident #8's quarterly Minimum Data Set (MDS) dated [DATE] revealed a brief interview for mental status score of 11 indicating the resident had moderate cognitive impairment. Further review of the MDS revealed the resident was occasionally incontinent of bladder and was receiving diuretic medication.Review of Resident #8's May 2026, June 2026, and July 2026 medication administration records (MAR) revealed, for the torsemide order, a space to enter the resident's weight and a place for the nurse giving the medication to mark the order was completed.Further review of the May 2026 MAR revealed that on the following dates the torsemide medication was marked as given when Resident #8's weight was less than 172 pounds 05/01/26 - 171.8, 05/03/26 - 170.5, 05/04/26 - 171.2, 05/06/26 - 171.4, 05/07/26 - 171.6, 05/08/26 - 171.6, 05/09/26 - 164.7, 05/10/26 - 164.7 05/11/26 - 168.2, 05/12/26 - 169.4, 05/13/26 - 171.6, 05/14/26 - 170.2, 05/17/26 - 171.4, 05/18/26 - 171.6, 05/21/26 - 171.4, 05/22/26 - 171, 05/23/26 - 170.4, 05/24/26 169.4, 05/25/26 - 169.8, 05/26/26 - 170.2, 05/27/26 - 170.2, 05/28/26 - 171.6 and 05/31/26 - 171.6. Review of the June 2026 MAR revealed that on the following dates the torsemide medication was marked as given when Resident #8's weight was less than 172 pounds 06/03/26 - 169.6, and 06/08/26 - 170. Review of the June and July 2026 MARs also revealed the following dates with weights greater than 176 pounds and no indication that the higher dose of torsemide (20 mg instead of 10 mg) was given 06/19/26 - 177.4, 06/20/26 - 177.2, 06/23/26 - 179. 2, 06/24/26 - 179.2, 06/25/26 - 179.2, 06/26/26 - 178.8, 06/27/26 - 179, 06/28/26 - 179.4, 06/29/26 - 178.2, 06/30/26 - 178, 07/01/26 07/02/26 - 179.2, - 178.4, 07/02/26 - 179.2, 07/03/26 - 178.2, 07/04/26 - 177.8, 07/05/26 - 177.8, 07/06/26 - 177.8, 07/07/26 - 176.8, 07/08/26 - 177.4, 07/09/26 - 177.4, 07/10/26 - 176.8, 07/11/26 - 177.4, 07/17/26 - 178.4, 07/18/26 - 178, 07/21/26 - 178, and 07/22/26 - 180. Interview on 07/22/26 at 4:30 P.M. Registered Nurse (RN) #22 stated that when the torsemide order comes up on the electronic MAR it prompts the nurse to put in the weight but does not have a place to mark the amount of medication that was given, the nurse has to follow the guidelines at the end of the order to determine what to give the resident. Interview on 07/22/26 at 5:38 P.M. the Director of Nursing (DON) verified that the torsemide was not held as per the parameters of the order on 05/01/26 - 171.8, 05/03/26 - 170.5, 05/04/26 - 171.2, 05/06/26 - 171.4, 05/07/26 - 171.6, 05/08/26 - 171.6, 05/09/26 - 164.7, 05/10/26 - 164.7 05/11/26 - 168.2, 05/12/26 - 169.4, 05/13/26 - 171.6, 05/14/26 - 170.2, 05/17/26 - 171.4, 05/18/26 - 171.6, 05/21/26 - 171.4, 05/22/26 - 171, 05/23/26 - 170.4, 05/24/26 169.4, 05/25/26 - 169.8, 05/26/26 - 170.2, 05/27/26 - 170.2, 05/28/26 - 171.6, 05/31/26 - 171.6, 06/03/26 - 169.6, and 06/08/26 - 170. The DON further verified there was no way to tell if Resident #8 received 10mg or 20 mg on the days the resident's weight was greater than 176 pounds 06/19/26 - 177.4, 06/20/26 - 177.2, 06/23/26 - 179. 2, 06/24/26 - 179.2, 06/25/26 - 179.2, 06/26/26 - 178.8, 06/27/26 - 179, 06/28/26 - 179.4, 06/29/26 - 178.2, 06/30/26 - 178, 07/01/26 07/02/26 - 179.2, - 178.4, 07/02/26 - 179.2, 07/03/26 - 178.2, 07/04/26 - 177.8, 07/05/26 - 177.8, 07/06/26 - 177.8, 07/07/26 - 176.8, 07/08/26 - 177.4, 07/09/26 - 177.4, 07/10/26 - 176.8, 07/11/26 - 177.4, 07/17/26 - 178.4, 07/18/26 - 178, 07/21/26 - 178, and 07/22/26 - 180. 2. Review of Resident #34's medical record revealed an ad mission date of 04/23/26, a re-entry date of 05/19/26 and diagnoses including hypo-osmolality and hyponatremia, metabolic encephalopathy, cerebral infarction, hypertension, nontoxic multinodular goiter, anemia, and cerebral infarction due to unspecified occlusion or stenosis of right cerebral artery. Review of Resident #34's physician's orders revealed an order dated 04/23/26 for aspirin 81 mg give one tablet via gastrostomy tube in the mornings for anticoagulant. Review of Resident #34's admission Minimum Data Set (MDS) dated [DATE] revealed a brief interview for mental status score of 11 indicating the resident had moderate cognitive impairment. Further review of the MDS revealed the resident was dependent on facility staff for all activities of daily living, always incontinent of bladder and bowel and was receiving antiplatelet medications. Review of Resident #34's preoperative instructions dated 06/30/26 revealed the resident was scheduled for surgery 07/22/26 and had instructions to hold non-steroidal anti-inflammatory drugs and any aspirin containing products for five days prior to the residents surgery. Review of Resident #34's July 2026 MAR revealed the resident received the aspirin 81 mg on 07/17/26, 07/18/26, 07/19/26, 07/20/26, and 07/21/26. Interview on 07/21/26 at 5:15 P.M. Licensed Practical Nurse (LPN) #43 verified the aspirin 81 mg has been given and not held as per pre-op instructions. LPN #43 stated that she would contact the surgeon to see if the resident could have her surgery. Interview on 07/22/26 at 7:29 A.M. LPN #43 stated the on call physician from the surgeon's office returned her call last night and stated to send resident that they would proceed with the surgery and to hold this mornings dose of aspirin.

Based on observation and interview, the facility failed to store and prepare foods in a safe and sanitary manner. This had the potential to affect all 35 residents residing in the facility. The facility census was 35.Findings include: Observations made during a tour of the kitchen on 04/27/26 from 9:00 A.M. to 9:20 A.M. revealed splattered dried food on the outside of the free-standing oven next to the stove. The food splatters had dripped down the side of the oven in several places and were white to tan, yellow, and/or clear in color. The outside of the free-standing oven beside the stove appeared greasy and sticky and was greasy to the touch. The floor between the free-standing oven and the stove was observed to be crumb-covered and had a plastic cap and a dried food spill next to the wall. The food spill was a pale yellow to tan in color about four inches in diameter, about a quarter of an inch thick and dried with the top of the spill cracked open in the center along the surface.Further observations made during a tour of the kitchen on 04/27/26 from 9:00 A.M. to 9:20 A.M. revealed the black plastic cover of the ice machine filter to be sticky to the touch and covered in dust. On the food preparation counter to the left of the ice machine, there were eight bowls pre-filled with dry cereal that were undated and unlabeled, a rectangular four-by-six inch lidded container half full of a yellow greasy substance with no label or date. In the room that connected the kitchen and the dining room was a reach in freezer/refrigerator combination, with the freezer on top, that the facility used to store open multi-use condiments, resident food brought in by friends and family, perishable snacks, and beverages. The outside of the doors of the reach in freezer/refrigerator were observed to have dried food drips on the outside that were white, pink, and green in color. The bottom shelf and opening of the inside of the reach in freezer were observed to have dried green, pink, and white food drips. The shelves inside of the reach in refrigerator were smeared with a white liquid that had been spilled and partially cleaned up then dried. A gallon container of whole milk with a use by date of 04/14/26 was in the back of the refrigerator on the second shelf and had about eight ounces of yellow fluid with white clumps remaining in the container. On the bottom shelf of the refrigerator were 10, four-ounce dessert bowls of fruit with no labels or dates. On the second shelf of the refrigerator door was an open undated 14-ounce bottle of ketchup that was unable to be closed because the plastic lid was broken off and missing.Further observations made during a tour of the kitchen on 04/27/26 from 9:00 A.M. to 9:20 A.M. revealed in the dry storage a case of 12, 50-ounce cans of tomato juice sitting on the floor. In the walk-in refrigerator an undated, unlabeled gallon-zip style bag of white lunch meat was observed on the shelf to the right of the door. On the same shelf was observed an unlabeled, undated eight quart container with the bottom covered with fruit. An undated, unlabeled eight-quart container was observed on the shelf to the left of the door with three quarts of fruit remaining in the container. An unlabeled, 10-quart bowl of red gelatin with fruit dated 04/20/26 was observed on the bottom shelf of the walk-in refrigerator to the left of the door. Four unlabeled and undated eight-ounce glasses of red liquid were observed on an upper shelf to the left of the door and on shelf to the left of the door, 13 undated and unlabeled small bowls of coleslaw were observed. In the walk-in freezer an unopened case of 180 hotdogs was observed to be sitting on the floor of the freezer.In an interview on 04/27/26 at 9:20 A.M. Dietary [NAME] #159 verified the above findings at the time of observation. This deficiency represents non-compliance investigated under Complaint Number #2967642.

Based on review of the facility's cycle menu/ spreadsheet, observation, and staff interview, the facility failed to ensure residents were served meals in a form that met their needs. This had the potential to affect seven residents (Resident #1, #10, #16, #19, #23, #41, and #95) of seven residents who the facility identified as being on a mechanical soft diet. Findings include: Review of the cycle menu for the Summer of 2025 revealed the residents were to receive chicken parmesan, spaghetti noodles, Italian blend mixed vegetables, choice of a roll, and cake. The spread sheet that went along with the cycle menu revealed the residents on a mechanical soft diet were to receive four ounces of chopped Italian blend mixed vegetables as part of their meal. On 06/04/25 at 12:10 P.M., an observation of the tray line for the lunch meal served revealed the facility had three different diets that were being provided to the residents. Of the three different diets, seven residents were ordered to receive mechanical soft diets. Each type of diet was observed to be served. The first mechanical soft diet was dipped from the steam table to be served to Resident #41, who was eating her meal in the dining room. Dietary [NAME] #204 was noted to dip the tray from the steam table and placed the Italian blend mixed vegetables on a plate for Resident #41. She did not chop the Italian blend mixed vegetables, as was indicated to be required on the cycle menu's spreadsheet. The tray was placed on an open cart and another dietary aide was in the process of taking it out to the dining room to be served. Dietary Manager #188 was asked to verify if the Italian blend mixed vegetables that were being served to Resident #41 were supposed to be chopped. She verified the spreadsheet for the cycle menu did indicate the vegetables were to be chopped. She contacted the facility's dietitian and confirmed the vegetables needed to be chopped for those residents requiring a mechanical soft diet.

Based on record review, staff interview, and policy review, the facility failed to ensure residents did not have psychotropic medications ordered on an as needed basis (prn) limited to an initial 14 day order and only extended with a face to face evaluation of the resident with a clinical rationale as to why the prn psychotropic medication should be extended. They also failed to ensure non-pharmacological interventions (NPI's) were attempted prior to the use of an anti-psychotic medication intramuscularly (IM) ordered on a prn basis. This affected two (Resident #13 and #37) of five residents reviewed for unnecessary medications. Findings include: 1. Review of Resident #37's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included schizo-affective disorder (a mental health condition including schizophrenia and mood disorder symptoms), bipolar disorder, anxiety disorder, depression, and insomnia. Review of Resident #37's physician's orders revealed the resident had an order in place for the use of Zyprexa (an anti-psychotic medication used in the treatment of schizophrenia, bipolar disorder, and depression) 10 milligrams (mg) with directions to inject IM every 24 hours prn for agitation related to schizo-affective disorder x 180 days. The order was last updated on 04/17/25 and was not to end until 10/14/25. Review of Resident #37's pharmacy recommendations revealed the facility's consulting pharmacist recommended the physician review the resident's order for the use of Zyprexa to be given on a prn basis. The pharmacy recommendations were made as a result of a medication regimen review on 09/05/24 and 04/06/25. The pharmacist included a copy of the regulation under 483.45(e)(4) that indicated prn orders for psychotropic medications were limited to 14 days and requested that the physician note the new regulations which went into effect on 11/28/17. The pharmacist further indicated the new guidelines required a progress note from the prescriber for continued use that included how the medication was being used, a clinical rationale, and a time frame for when the prn medication would be reviewed again (suggesting a review again in 90 days). The pharmacy recommendation did not communicate to the physician that the use of anti-psychotics on an as needed basis was limited to a 14 day period and could not be renewed without an evaluation by the prescriber. The prescriber (psychiatrist) responded to the recommendation and only provided direction to order the prn IM Zyprexa x 180 days. The last recommendation was addressed by the prescriber on 04/16/25, which was why the current order was to be extended through 10/14/25. Review of Resident #37's medication administration records (MAR's) for December 2024 through April 2025 revealed the resident was given her Zyprexa IM on a prn basis 12 times during that five month period. 10 out of the 12 times the prn Zyprexa was administered IM, there was no evidence of any NPI's being attempted prior to the administration of the IM Zyprexa. Doses given without evidence of NPI's being attempted prior to it's administration included 12/12/24 at 8:07 A.M., 01/10/25 at 5:39 P.M., 01/18/25 at 9:04 A.M., 01/20/25 at 7:05 P.M., 01/27/25 at 9:21 A.M., 01/29/25 at 2:50 P.M., 02/03/25 at 11:00 A.M., 02/04/25 at 7:25 A.M., 03/03/25 at 9:39 A.M., and 04/05/25 at 10:18 P.M. On 06/05/25 at 2:30 P.M., an interview with the Director of Nursing (DON) confirmed Resident #37 had an order to receive Zyprexa 10 mg IM ordered every 24 hours prn for agitation related to schizo-affective disorder. She confirmed the resident has had the prn Zyprexa IM ordered on a couple of different occasions that exceeded 14 days. She further confirmed Resident #37's psychiatrist had been ordering the prn anti-psychotic for 180 days at a time. She stated she attempted to discuss the extended orders for prn psychotropic medications with the psychiatrist and had been told by the psychiatrist that he knew the regulations. It was told to her that the initial order was required to be for 14 days. If it was needed to be extended then the physician/ prescriber would have to see the resident and could order for an additional 14 days. At that time, if the prn psychotropic medication was to be extended again, the physician/ prescriber would have to re-evaluate the resident and then could order the medication for up to 180 days. She was informed the regulations addressed prn orders for anti-psychotics separate from prn psychotropics. The regulations for prn anti-psychotics specified a limitation of a 14 day order for use of anti-psychotics used on a prn basis with no exception. She acknowledged if the physician/ prescriber wanted to continue the use beyond 14 days, they would have to evaluate the resident at the end of the 14 days and re-order the medication for an additional 14 days. She was then informed of the 10 doses of the prn Zyprexa IM that had been given to Resident #37 between 12/12/24 and 04/05/25 that had no evidence of any NPI's being attempted prior to the use of the use of the prn IM Zyprexa. She stated she would reach out to see if she had any additional guidance from her physician/ psychiatrist or pharmacist regarding the use of the prn Zyprexa greater than 14 days. She would also look to see if they could find any evidence of NPI's being attempted prior to the use of the prn Zyprexa that was administered IM. However, no additional information was provided. Review of the facility's policy on Psychotropic Drug and Unnecessary Drug Use undated revealed the facility would use psychotropic drug therapy only when appropriate to enhance the resident's quality of life, while maximizing functional potential and well being of the resident. Qualified staff would assess the resident for the use of psychotropic medications quarterly and develop a comprehensive care plan that addressed behavioral and medication management with NPI's and pharmacological interventions. PRN orders for anti-psychotic medications were limited to 14 days and would not be renewed unless the attending physician or prescribing practitioner evaluated the resident in person, for the appropriateness of that medication. 2. Review of Resident #13's medical record revealed an admission date of 03/25/25, a re-entry date of 04/12/25 and diagnoses including an unspecified fracture of the sacrum, stomach cancer, neuropathy, anemia, hypertension, and anxiety. Resident #13 was a hospice client. Review of Resident #13's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental status score of 13 indicating Resident #13 had intact cognition and had received antianxiety medication in the MDS assessment time frame. Review of Resident #13's physician orders revealed an order dated 05/19/25 for Xanax 0.5 milligrams by mouth every eight hours as needed for anxiety. The Xanax order had no end date to indicate the length of time the medication could be used for. Further review of Resident #13's physician orders revealed an order dated 06/03/25 for lorazepam 0.5 milligrams by mouth every eight hours as needed for anxiety. The lorazepam order had no end date to indicate the length of time the medication could be used for. In an interview on 06/05/25 at 11:14 A.M. the Director of Nursing (DON) verified the orders for the as needed medications Xanax and lorazepam did not have an end date to indicate the duration of use for the medications.

Based on record review, staff interview, and policy review, the facility failed to ensure a resident's pressure ulcer was assessed weekly for measurements and evidence of healing. This affected one (Resident #28) of three residents reviewed for pressure ulcers. Findings include: Review of Resident #28's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included a motor vehicle accident with a fracture of the pelvis, adult onset diabetes mellitus with diabetic neuropathy and a foot ulcer, protein-calorie malnutrition, anemia, and peripheral vascular disease. Review of Resident #28's progress notes revealed a note dated 04/25/25 at 10:41 A.M. by the wound nurse practitioner that indicated the resident had a deep tissue pressure injury (DTPI) to the left heel that was present upon his admission. A DTPI was a localized area of discolored, intact skin, or a blood filled blister due to underlying soft tissue damage from pressure and/ or shear. The discolored area was typically purple or maroon in color. Review of Resident #28's active care plans revealed the resident had a care plan in place for having an actual impaired skin integrity/ pressure ulcer related to a DTPI on his left heel. The care plan was initiated on 04/18/25. The interventions included the need to complete a skin assessment and documentation per the facility's policy. Review of Resident #28's weekly wound assessments of the DTPI to the left heel revealed the pressure ulcer was assessed on 04/25/25, 05/08/25, 05/22/25, 05/29/25, and 06/05/25. The subsequent assessments continued to classify the pressure ulcer as a DTPI and showed evidence of healing. There was no evidence of any weekly assessment of the DTPI being completed on 05/02/25 or on 05/15/25. Review of Resident #28's progress notes revealed no explanation as to why weekly wound assessments of the DTPI on the left heel was not assessed on 05/02/25 or on 05/15/25. The resident was not noted to be out of the facility on those days or known to have refused any assessment of the left heel pressure ulcer. On 06/09/25 at 1:30 P.M., an interview with Licensed Practical Nurse (LPN) #191 revealed she was the employee that rounded with the wound nurse practitioner weekly. The weekly wound assessments were completed on Thursdays. She obtained measurements on that day when the wound nurse practitioner assessed the wound. Wounds were to be assessed every seven days for measurement purposes and to monitor for healing. She denied she was working when Resident #28 did not have his DTPI to the left heel assessed on 05/02/25 or on 05/15/25. She was off work during those times due to an excused work absence. She reported the facility's prior Minimum Data Set (MDS) nurse and acting interim Director of Nursing (DON) at the time should have assessed the resident's wound. Neither employee she mentioned was still working in the facility. On 06/09/25 at 3:10 P.M., an interview with the facility's current interim DON confirmed Resident #28 was admitted with the DTPI to the left heel. She acknowledged there was no documented evidence of the facility's nursing staff assessing the resident's pressure ulcer on 05/02/25 or on 05/15/25. She was not able to provide any additional documentation for evidence of the facility assessing the resident's wound to the left heel on those days. She stated that was during the time LPN #191 was off of work and no one else documented the wound as having been assessed. Review of the facility's policy on Pressure Ulcers revised April 2016 revealed the purpose of the policy was for the facility to assess each resident with skin conditions and measure the skin areas as was indicated in the regulatory guidelines and NPUAP (National Pressure Ulcer Advisory Panel) guidelines. The information was taken from the revised version of the Quick Reference Guide by NPUAP. Review of the facility's policy on Pressure Ulcer Prevention and Risk Identification undated revealed, if a new skin area was identified on an assessment or during any other type of care or service, the licensed nurse would initiate a skin grid/ measurement flow record. The skin grid would then be updated every seven days until the area was resolved.

Based on record review and interview, the facility failed to follow protocols for the use of an antibiotic to treat a urinary tract infection. This affected one resident (#6) of one residents reviewed for catheter use. The facility census was 42. Findings include: Review of Resident #6's medical record revealed an admission date of 10/12/24 and diagnoses including malignant neoplasm of endometrium, diabetes, chronic obstructive pulmonary disease, lumbosacral disorder, fibromyalgia, hypertension, anemia, protein-calorie malnutrition, neurogenic bladder, and lumbosacral plexus disorder. Review of Resident #6's annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident also had an indwelling catheter. Review of Resident #6's progress notes revealed on 05/19/25 at 11:06 P.M. an order was obtained to obtain a urine specimen for urinalysis and culture and sensitivity related to the resident having cloudy urine with an abnormal smell. On 05/20/25 at 3:04 A.M. the urine specimen was obtained. Further review of Resident #6's progress notes revealed on 05/22/25 at 3:00 P.M. the urine specimen results were reported to the resident's primary care provider. Review of Resident #6's urine culture revealed two organisms were grown. Klebsiella pneumoniae 70-99,000 CFU/ml (colony-forming units per milliliter) and proteus mirabilis 70-99,000 CFU/ml (colony-forming units per milliliter). Review of Resident #6's physicians orders revealed an order on 05/22/25 for ciprofloxacin 500 milligrams by mouth two times a day for five days for urinary tract infection. Review of the facility's criteria for urinary tract infection (UTI) surveillance revealed Resident #6 did not meet the criteria for a UTI as her culture did not have greater than 100,000 CFU/ml (colony-forming units per milliliter) of any organism. In an interview on 06/09/25 at 2:14 P.M. the Director of Nursing (DON) verified Resident #6 was treated for a urinary tract infection that did not meet the facility's criteria for a UTI as her culture did not have greater than 100,000 CFU/ml (colony-forming units per milliliter) of any organism.

Based on record review, staff interview, and policy review, the facility failed to ensure pharmacy recommendations were appropriately implemented when agreed upon by the physician. This affected one (Resident #37) of five residents reviewed for unnecessary medications/ monthly medication regimen reviews. Findings include: Review of Resident #37's medical record revealed the resident was admitted to the facility 04/27/24. Her diagnoses included hypothyroidism. Review of Resident #37's physician's orders revealed the resident had an order in place to receive Levothyroxine Sodium 75 micrograms (mcg) by mouth (po) every morning for hypothyroidism. The resident also had an order to receive Ferrous Sulfate 325 milligrams (mg) po every morning and Magnesium Oxide 400 mg po every morning as supplements. Review of Resident #37's pharmacy recommendations revealed the facility's contracted pharmacist made recommendations following monthly reviews of the resident's medication regimen. There were two recommendations made by the pharmacist that addressed the administration time for the Levothyroxine Sodium in relation to the administration times of the Ferrous Sulfate and the Magnesium Oxide. A pharmacy recommendation for Resident #37 dated 06/11/24 revealed the pharmacist requested the physician to evaluate and consider modification of the current administration times for Levothyroxine Sodium (Synthroid) one tablet po every day between the hours of 4:00 A.M. and 6:00 A.M., Ferrous Sulfate one tablet po every day between the hours of 7:00 A.M. and 10:30 A.M., and Magnesium Oxide 400 mg po twice a day between the hours of 7:00 A.M. to 10:30 A.M. and again between 8:00 P.M. and 11:30 P.M. The pharmacist explained due to the potential for binding, administration of Synthroid was recommended to be administered first thing in the morning, at least 30 minutes prior to all other medications, and separated by at least four hours from Iron and Magnesium containing products. The nurse practitioner responded to the recommendation on 06/13/24 and agreed with the recommendation. A second pharmacy recommendation for Resident #37 dated 10/03/24 revealed the facility's contracted pharmacist again requested the physician evaluate the resident and consider modification of the current administration times for Synthroid and Ferrous Sulfate. The same explanation, as to the potential for binding with the administration of Synthroid concurrently or within four hours of Iron and Magnesium containing products, was included for the physician's consideration. The physician reviewed the recommendation and agreed to it on 10/09/24. Review of Resident #37's electronic medication administration records (eMAR's) for October and November 2024 revealed the facility continued to administer the resident's Levothyroxine Sodium within four hours of her Ferrous Sulfate and Magnesium Oxide. The resident's Levothyroxine Sodium had an administration time of every 24 hours as did the Ferrous Sulfate. The nurses initialed the eMAR under the day the medications were administered and recorded the time of the administration inside the box where they entered their initials. Out of the 30 days in which the resident received the medications, four times the Levothyroxine and the Ferrous Sulfate were administered at the same time. 24 times the two medications were documented as having been administered within four hours from one another. Only two of the 30 times the resident was given those medications were the administration times separated by four hours as recommended by the pharmacist and agreed upon by the physician and/ or nurse practitioner. The Magnesium Oxide 400 mg was set up for administration in the am. It was not clear what time the Magnesium Oxide was given and if it was separated by at least four hours from the Levothyroxine administration time. One of the 30 times the resident was given Levothyroxine, had the administration time of 8:59 P.M. and was not administered first thing in the morning as recommended by the pharmacist and ordered by the physician. Review of Resident #37's eMAR for June 2025 revealed the resident continued to receive Levothyroxine, Ferrous Sulfate, and Magnesium Oxide. The administration times for all three were set for early and they were being administered at the same time. The facility was not following the pharmacist's previous two recommendations or the physician's orders regarding the separation of administration times of the Levothyroxine from Ferrous Sulfate and Magnesium. Findings were verified by Regional Director of Quality Assurance #210. On 06/03/25 at 3:24 P.M., an interview with Regional Director of Quality Assurance #210 revealed she suspected Resident #37's administration times for the Levothyroxine, Ferrous Sulfate, and the Magnesium got changed during one of the resident's hospitalizations. She acknowledged two separate recommendations had been made by their contracted pharmacist pertaining to the administration times of those medications with the latest being on 10/03/24. She was informed the eMAR for November 2024 showed the medications were being given within four hours of each other prior to the resident going out to the hospital in the middle of the month. She was not able to explain why the times of administration for all three medications were set for early on the June 2025 eMAR. She acknowledged administering the Levothyroxine within four hours of the other two medications could affect the Levothyroxine's absorption. Review of the facility's policy on Consultant Pharmacist Services Provider Requirements dated October 2007 revealed regular and reliable consultant pharmacist services were to be provided to the residents. Medication regimen reviews were to be completed monthly for each resident in the skilled nursing facility. They were to communicate to the responsible prescriber and the director of nursing or actual problems detected and other findings related to medication therapy orders at least monthly. They were also to assist nursing care center staff in outlining medication administration schedules to maximize the effectiveness and to avoid potential interactions. The policy did not address the need for the facility staff to implement the recommendations as made and agreed to by the physician.

Based on record review and interview, the facility failed to provide recommended restorative programs for a resident. This affected one resident (#9) of two residents reviewed for rehabilitative services. The facility census was 42. Findings include: Review of Resident #9's medical record revealed an admission date of 12/12/19, a re-entry/readmission date of 01/18/25 and diagnoses including acute respiratory failure, paraplegia, unspecified psychosis, asthma, and chronic hepatitis. Review of Resident #9's therapy records revealed an occupational therapy evaluation completed on 07/04/24 that indicated the resident did not require occupational therapy and referred/recommended the resident to the restorative nursing program. Review of Resident #9's medical record revealed a quarterly restorative assessment dated [DATE] that indicated the resident had been referred to the restorative nursing program by therapy, and that restorative nursing program was indicated for passive range of motion, active range of motion and bed mobility and would be continued. Further review of Resident #9's medical record failed to reveal any documentation of restorative nursing program minutes being provided for passive range of motion, active range of motion or bed mobility. Review of Resident #9's physicians orders for the past year revealed no orders for a restorative program. Review of Resident #9's annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition and restorative nursing programs were performed for at least 15 minutes a day for five days related to passive range of motion, active range of motion and bed mobility in the past seven days. In an interview on 06/10/25 9:31 A.M. the Director of Nursing (DON) verified there was no documentation of restorative nursing program minutes being provided for passive range of motion, active range of motion or bed mobility found in Resident #9's medical record. The DON further verified the restorative nursing programs for passive range of motion, active range of motion and bed mobility were not being provided.

3. Review of Resident #37's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included hypertension and urinary retention. Review of Resident #37's active care plans revealed the resident had a care plan in place for receiving diuretic therapy related to acute renal failure. The care plan was initiated on 04/28/24. The goal was for the resident to be free from any discomfort or adverse reactions while receiving diuretic therapy through the review date. The target date was 08/13/25. Interventions included the need to administer medications as ordered. Review of Resident #37's active physician's orders revealed the resident did not have an order in place for the use of any diuretics. Review of her discontinued orders revealed the resident had not been on a diuretic medication since 06/26/24, when a diuretic had been discontinued. On 06/04/25 at 10:10 A.M., an interview with the facility's Director of Nursing (DON) confirmed Resident #37's active care plans reflected she had the use of a diuretic related to acute renal failure. She acknowledged the resident had not been on a diuretic for almost a year now. She further acknowledged the resident's active care plans should have been revised to reflect she was no longer receiving diuretic therapy. Based on record review, observation and interview the facility failed to revise comprehensive resident care plans to reflect current care and treatment. This affected one resident (#13) of one sampled for falls and two residents (#37 and #39) of five sampled for unnecessary medications. The facility census was 42. Findings include: 1. Review of Resident #13's medical record revealed an admission date of 03/25/25, a re-entry date of 04/12/25 and diagnoses including an unspecified fracture of the sacrum, stomach cancer, neuropathy, anemia, hypertension, and anxiety. Further review revealed Resident #13 was a hospice client. Review of Resident #13's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating Resident #13 had intact cognition and had not experienced falls. Review of Resident #13's medical record revealed she had fallen on 04/07/25 at 11:15 P.M. while in the bathroom. Resident #13 stated she was turning to dry her hands and lost her balance. Review of Resident #13's fall care plan revealed the following interventions were in place to minimize the potential risk factors related to falls and fall related injuries: facility staff was to offer to help the resident with toileting before bed (implemented on 04/07/25), commonly used items such as the resident's water cup, remote control, and call light were to be kept within easy reach of the resident (implemented on 04/15/25), and a visual cue (sign) was to be placed in the room to remind the resident to use her call light for assistance with transfers and ambulation (implemented on 04/15/25). An observation on 06/03/25 at 5:00 P.M. revealed there was no visual cue (sign) in Resident #13's room to remind the resident to use her call light for assistance with transfers and ambulation. In an interview on 06/03/25 at 5:00 P.M. Certified Nursing Assistant (CNA) #134 stated Resident #13 always rang her call light for assistance and waited for facility staff to help her. CNA #134 further stated that was probably why she did not have a visual cue (sign) in her room. In an interview on 06/03/25 at 5:13 P.M. Social Services Designee (SSD) #181 stated the visual cue (sign) was not in the room because Resident #13 was upset by it and found it demeaning when it was placed in her room. SSD #181 further stated the intervention for the visual cue (sign) was supposed to have been removed from the care plan on 04/15/25. In an interview on 06/03/25 at 5:13 P.M. the Director of Nursing (DON) confirmed the intervention of a visual cue (sign) was to be placed in the room to remind the resident to use her call light for assistance with transfers and ambulation remained on Resident #13's care plan. 2. Review of Resident #39's medical record revealed an initial admission date of 08/03/24, a discharge date of 01/05/25, a re-entry/readmission date of 03/16/25 and diagnoses including chronic respiratory failure, acute respiratory failure, diabetes, depression, heart failure, atrial fibrillation, bradycardia, unspecified protein-calorie malnutrition, end stage renal disease, and an unspecified fracture of the shaft of the left humerus. Further review revealed Resident #39 was a hospice client. Review of Resident #39's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident's cognition is intact. Further review of the MDS revealed Resident #39 was receiving hospice services. Review of a hospice visit note dated 05/21/25 revealed the resident requested a sling for her left arm related to swelling. Review of Resident #39's physician orders revealed an order dated 05/23/25 for a sling to the left arm as needed and as the resident will tolerate for pain or swelling. Review of Resident #39's care plan revealed no mention of the sling to the left arm as needed for pain and swelling. In an interview on 06/05/25 at 4:20 P.M. Director of Nursing (DON) confirmed the sling to the left arm for pain and swelling was not reflected on Resident #39's care plan.

Based on record review and interview, the facility failed to develop a comprehensive care plan for catheter care. This affected one resident (#6) of one sampled for catheter use. The facility census was 42. Findings include: Review of Resident #6's medical record revealed an admission date of 10/12/24 and diagnoses including malignant neoplasm of endometrium, diabetes, chronic obstructive pulmonary disease, lumbosacral disorder, fibromyalgia, hypertension, anemia, protein-calorie malnutrition, neurogenic bladder, and lumbosacral plexus disorder. Review of Resident #6's annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition and reflected the use of an indwelling (urinary) catheter. Review of Resident #6's physician orders revealed the following orders dated 02/10/25: monitor urine for color, consistency and odor every shift, may irrigate catheter with 30 cubic centimeters (cc) of normal saline every 24 hours as needed for blockage; the resident has #16 french (size of catheter) with 10 cc indwelling catheter for the diagnosis of urinary retention, catheter care every shift, ensure privacy bag is in place, and may change catheter and catheter bag every 30 days or as needed for blockage. Review of Resident #6's care plan revealed no care plan in place for catheter care. In an interview on 06/09/25 at 2:14 P.M. the Director of Nursing (DON) verified there was not a care plan in place for catheter care.

Based on record review, staff interview and policy review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Identification Screen submitted to the state Department of Medicaid was completed accurately to reflect all the resident's mental illness diagnoses. This affected one (Resident #17) of one residents reviewed for PASRR. Findings include: Review of Resident #17's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included paranoid schizophrenia, bipolar disorder, anxiety disorder, and other specified depressive disorder. All listed diagnoses were in place at the time of her admission on [DATE]. Review of a PASRR Identification Screen completed for Resident #17 on 04/26/24 revealed the resident review was completed for a significant change in condition that was deemed to be a decline. Section E. ) of the identification screen included indications of serious mental illness. The assessor was to check all the listed diagnoses that applied. The assessor failed to check the box for a mood disorder despite the resident having the diagnoses of Bipolar disease, which was a mood disorder. The identification screen was completed by Social Service Designee #141. Review of the PASRR result notice for the PASRR Identification Screen completed for Resident #17 on 04/26/24 revealed the results of that screen was received on 04/26/24. A referral had been made for a Level II evaluation (an evaluation completed to determine the need for any specialized services while residing in the facility. Review of the results of the Level II evaluation for Resident #17 dated 05/17/24 from the state Department of Developmental Disabilities Division of Medicaid Development and Administration revealed based on the information reviewed describing the resident's current physical and medical needs, as well as her functional abilities, they made two determinations. The first determination was that the resident required the level of services provided by a nursing facility and the resident may continue to reside in the nursing facility. The second determination was that the resident did not need specialized services provided or arranged by the county board at that time. Further review of Resident #17's medical record revealed another PASRR Identification Screen had been completed on 06/02/25. Again, that PASRR Identification Screen indicated the identification screen was completed for a significant change in condition for a decline. Section E. ) of the identification screen, where the assessor (SSD #141) documented the resident's mental disorders, included a mood disorder that had not been identified during the prior PASRR screen completed on 04/26/24. Again, a referral had been made for a Level II evaluation. As of the time of the PASRR review, the results of that Level II evaluation was still pending. On 06/03/25 at 1:05 P.M., an interview with SSD #141 revealed she completed the second PASRR Identification Screen on 06/02/25 for Resident #17, after she completed a self audit on PASRR's the prior week, and noted the the resident's PASRR Identification Screen completed on 04/26/24 was not completed accurately. She claimed she did the self audits on PASRR's every three or four months to ensure they were all completed accurately. She reported the prior PASRR Identification Screen did not accurately reflect Resident #17 had a mood disorder despite her having Bipolar disorder. She denied she had any documented evidence to support she recognized the inaccuracy of the resident's prior PASRR, as part of a self audit last week. She was asked, if she had noted the PASRR was not accurate the previous week, then why was an updated PASRR Identification Screen not completed prior to 06/02/25. She stated she had several that were not accurate and needed new PASRR's completed. She further acknowledged, if she was completing PASRR audits every three to four months as indicated, the resident's inaccurate PASRR completed on 04/26/24 should have been identified as being inaccurate prior to 06/02/25. She confirmed the resident's results notice for her Level II evaluation was still pending. Review of the facility's policy on PASRR updated 01/01/19 revealed the purpose of the policy was to assure that all admissions to the nursing facility were screened for indications of serious mental illness or developmental disabilities in an effort to prevent inappropriate admissions to the nursing facility. The Admissions Director or designee would complete the resident review (RR) if the resident had experienced a significant change in condition. All level I and level II residents with newly diagnosed or possible serious mental disorder, intellectual disability, or a related condition for level II would be referred for resident review to the Ohio Department of Aging or appropriate required organization upon a significant change in status assessment.

3. Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included adult onset diabetes mellitus. Review of Resident #1's quarterly MDS assessment dated [DATE] revealed the resident was coded as having received an insulin injection during the seven day assessment period (05/19/25- 05/25/25). Section N. ) of the MDS (Medications) coded the resident as having received one insulin injection during the last seven days. Review of Resident #1's medication administration record (MAR) for May 2025 revealed there was no evidence of the resident having been given any insulin between 05/19/25 and 05/25/25. The resident was only noted to have received Trulicity that was given as a subcutaneous (SQ) injection, but Trulicity was not considered to be an insulin. Review of a drug reference information from Medscape on Trulicity revealed it was classified as an antidiabetic, Glucagon-like Peptide-1 Agonist used in the treatment of adults with adult onset (type 2) diabetes mellitus. It acted as a GLP-1 receptor agonist to increase insulin secretion in the presence of elevated blood glucose. It was not classified as an insulin, as it only promoted the pancreas to secrete insulin naturally. 4. Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included adult onset diabetes mellitus. Review of Resident #3's quarterly MDS dated [DATE] indicated the resident had received an insulin injection during the seven day assessment period of 04/15/25 through 04/21/25. Section N. ) of the MDS indicated that he had received one insulin injection during that seven day period. Review of Resident #3's medication administration record (MAR) for April 2025 revealed there was no evidence of the resident having been given any insulin between 04/15/25 and 04/21/25. He was noted to have an order for Wegovy given as a SQ injection, but that was not an insulin injection. In addition, the resident had refused the dose of Wegovy that was scheduled to be received on 04/16/25. No injections had been given to the resident during that time. Review of a drug reference information from Medscape on Wegovy revealed it was classified as an antidiabetic, Glucagon-like Peptide-1 Agonist used in the treatment of adults with adult onset (type 2) diabetes mellitus. It acted as a GLP-1 receptor agonist to increase insulin secretion in the presence of elevated blood glucose. It was not classified as an insulin, as it only promoted the pancreas to secrete insulin naturally. On 06/10/25 at 11:04 A.M., an interview with the Director of Nursing (DON) confirmed Resident #1 and Resident #3's quarterly MDS assessments were not coded accurately under the medication section of the MDS. She acknowledged both Wegovy and Trulicity, although given for diabetes mellitus, was not classified as insulin and should not have been coded on the MDS as such. She suspected the two MDS nurses, who had completed those MDS assessments, just did not realize Trulicity and Wegovy were not classified as insulin. Based on record review and interview the facility failed to ensure Minimum Data Set (MDS) assessments were accurate. This affected four residents (Resident #1, #2, #3 and #9) of 14 residents reviewed for accurate assessments. The facility census was 42. Findings include: 1. Review of Resident #2's medical record revealed an admission date of 04/28/25 and diagnoses including chronic obstructive pulmonary disease, dementia, dysphagia, hypothyroidism, hypertension, anxiety, schizoaffective disorder, and depression. Review of a care conference dated 04/29/25 and held with Resident #2 and her daughter revealed the resident had concerns about her broken lower denture. Review of Resident #2's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15. Further review of the MDS revealed section L (Oral/Dental Status) question A regarding broken or loosely fitting full or partial denture was marked as no. In an interview on 06/02/25 at 4:21 P.M. Resident #2 stated that her dentures were broken at her previous facility. A follow-up interview on 06/04/25 at 3:54 P.M. revealed her bottom dentures were broken and her upper dentures were loose. She stated that she does not have any of her natural teeth. An observation made at the time of the interview revealed Resident #2 was wearing an upper denture but was edentulous on the bottom. In an interview on 06/05/25 at 11:11 A.M. the Director of Nursing (DON) verified the MDS section L question A was marked inaccurately. 2. Review of Resident #9's medical record revealed an admission date of 12/12/19, a re-entry/readmission date of 01/18/25 and diagnoses including acute respiratory failure, paraplegia, unspecified psychosis, asthma, and chronic hepatitis. Review of Resident #9's therapy records revealed an occupational therapy evaluation completed on 07/04/24 that indicated the resident did not require occupational therapy and referred/recommended the resident to the restorative nursing program. Review of Resident #9's annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 and indicated that restorative nursing programs were performed for at least 15 minutes a day on five days for passive range of motion, active range of motion and bed mobility in the past seven days. Review of Resident #9's physicians orders for the past year revealed no orders for a restorative program. Review of Resident #9's medical record failed to reveal any documentation of restorative nursing program minutes being provided for passive range of motion, active range of motion or bed mobility in the past year. In an interview on 06/10/25 9:31 A.M. the Director of Nursing (DON) verified there was no documentation of restorative nursing program minutes being provided for passive range of motion, active range of motion or bed mobility in the past year could be found in Resident #9's medical record. The DON verified the restorative nursing programs, marked as being performed for at least 15 minutes a day on five days for passive range of motion, active range of motion and bed mobility in the past seven days on the 04/20/25 MDS assessment, were marked inaccurately.

Based on review of a facility self reported incident (SRI), review of the facility's related investigation, staff interview, and policy review, the facility failed to ensure a resident was free from physical abuse when another resident with a history of aggressive behaviors struck the resident in the face. This affected one (Resident #1) of two residents reviewed for abuse. Findings include: Review of an SRI with the tracking number 249042 revealed an allegation of physical abuse was made on [DATE]. The initial source of the allegation was from a staff member and the alleged perpetrator was identified as being another resident. The involved residents identified included Resident #1 (alleged victim) and Resident #9 (alleged perpetrator). Both residents were indicated to have been able to provide meaningful information when interviewed. Resident #1 was indicated to have a scratch on his face by his nose and Resident #9 was indicated not to have any injury or harm to him. The narrative summary of the incident revealed both residents were in the dining room when Resident #9 got very angry when he was not able to get through. Resident #1's chair battery had died, so he was not able to move. Resident #9 was trying to maneuver around Resident #1, but was getting very irritated with him. When Resident #9 went to go around Resident #1, Resident #1 was shaking his finger/ fist at him (Resident #9) in his face. Resident #9 then struck Resident #1 in the face and knocked his glasses off. Resident #9 admitted that Resident #1 did not hit him, but was reaching over trying to hit him and shaking his fist. Resident #1 had a rough time communicating, but stated he did not hit the other resident. The two residents were separated immediately and the investigation was started. The residents were put on heightened monitoring. Skin assessments were completed. Resident #1 was the only one of the two with an injury (scratch on the side of his nose). As a result of the facility's investigation, they unsubstantiated the allegation as the evidence indicated that abuse did not occur. The facility's investigator was the prior Administrator, who no longer worked in the facility. Review of the facility's investigation revealed statements were obtained from the two involved residents from an interview by the facility's prior administrator. A typed statement of Resident #1's interview revealed he reported Resident #9 hit him. Resident #1 denied saying anything to Resident #9 and denied shaking his fist at him or trying to swing at him. His electric wheelchair was dead and would not move. A statement obtained from Resident #9 on [DATE] revealed he reported Resident #1 had his wheelchair stopped in the middle of the isle. The wheelchair battery was dead, so he was not able to move. Resident #9 began yelling at Resident #1 and they had a verbal altercation. Resident #9 stated that Resident #1 started shaking his fist at him (like he was going to hit him) and he (Resident #9) hit his (Resident #1's) face and knocked his glasses off. A Personal witness statement from Dietary Employee #300 (undated) revealed she witnessed Resident #1 and Resident #9 fight. She watched Resident #9 hit Resident #1 in the dining room. She then got the nurse and informed her the residents were fighting. She observed the incident when she was putting the smoking materials up, after taking the residents out for a smoking break. She denied she saw Resident #1 hit Resident #9 during the altercation. She then observed Resident #9 drive off while saying what had happened. A clarification statement was added at the end of the witness statement by the prior administrator that indicated the staff member saw Resident #9 hit Resident #1, but did not see Resident #1 hit Resident #9. A personal witness statement from Licensed Practical Nurse (LPN) #191 revealed on [DATE] at 4:00 P.M. she was passing medications in the hallway when Dietary Employee #300 came to her and said Resident #9 and Resident #1 were in the dining room fighting. Upon the nurse entering the dining room, Resident #9 was leaving. The nurse asked Resident #1 what happened and he said Resident #9 slapped him. She assessed Resident #1 and left dietary with him while she went to the administrator to report it. The facility's investigation file included the face sheet and diagnoses of the involved residents. Resident #1's diagnoses included hemiplegia affecting his right dominant side, aphasia (speech difficulty), Alzheimer's disease, dementia without behavioral disturbances, bipolar disorder, contracture of the muscle of the right upper arm/ right leg and right hand, a brain injury as a result of a motor vehicle accident, and dependence on a wheelchair. A BIMS Evaluation completed on [DATE] at 4:10 P.M. revealed the resident was cognitively intact with a BIMS of 13. A skin assessment dated [DATE] at 5:14 P.M. revealed Resident #1 was noted to have a small scratch noted to his right nares. No bleeding was noted. First aid was provided to include cleansing and leaving the scratch open to air. They included his care plan for an alteration in mood and behavior related to being easily angered at times. It was updated on [DATE] to reflect he liked to shake his fist at other residents. Resident #9's face sheet revealed he was admitted to the facility on [DATE]. His diagnoses included paraplegia, unspecified psychosis, anxiety disorder, depression, and panic disorder. A BIMS evaluation completed on [DATE] at 4:11 P.M. revealed he was cognitively intact with a BIMS of 15. A skin assessment completed on [DATE] at 5:17 P.M. revealed the resident had no injuries. A copy of Resident #9's care plans the facility included in the investigation file noted the resident had a care plan in place for an alteration in mood with depression and anxiety related to being easily annoyed, angered at placement and care, persistent anger with others, and showing physical aggression with items in his room. His care plan was updated on [DATE] to reflect the resident to be hitting other residents. The interventions included calmly, but firmly remind the resident of unacceptable behaviors as warranted and to ensure his basic needs were met when noted having increased agitation and anxiety such as pain/ hunger/ thirst/ toileting needs etc. Review of the facility's history of their SRI's revealed Resident #9 had a prior resident to resident altercation noted to have occurred on [DATE]. It involved him hitting another resident, but that incident of him hitting another resident was in response to him being hit first by the other resident. On [DATE] at 8:50 A.M., an interview with LPN #191 revealed she was the floor nurse working on [DATE] when the resident to resident altercation occurred between Resident #1 and #9. She denied she was present in the dining room when the altercation occurred, but recalled a dietary employee came and got her. When she went to the dining room, Resident #9 was leaving and Resident #1's glasses were noted to be crooked on his face. She reported Resident #1 was laughing about the incident. The dietary employee reported Resident #9 hit Resident #1. She assessed Resident #1 and noted he had a small scratch on the side of his nose. It looked like the scratch that was caused by his metal framed glasses. Resident #9 said Resident #1 was sitting in his electric wheelchair and would not move, after they came in from smoking. She told Resident #9 that was no reason to put his hands on someone. They separated the two and placed them on heightened monitoring. She was not aware of Resident #9 having had prior altercations with any residents, but she had only worked there for a couple of months at that time. He (Resident #9) had not been involved with any resident to resident altercations since she had been there. She could not recall if Resident #9 had anything in his care plans about any prior resident to resident altercations, or if he was known to have aggressive behaviors. She stated she notified the administrator of the incident and the administrator and the assistant directors of nursing (ADON's) at the time took over from there. She gave her statement for the facility's investigation. She was asked what she would consider to be physical abuse. She stated it would be anytime someone put their hands on another without consent. She was not sure how to answer if she felt this incident was physical abuse, as she said Resident #1 was laughing about it. She then stated she was not sure if Resident #9 physically put his hands on Resident #1 or if he only made contact with Resident #1's glasses. She then stated but anytime you put your hands on someone it would be considered physical abuse, if the other resident did not allow them to. She then reported she did not really recall if the dietary employee reported to her if the residents were just arguing or if the dietary employee actually saw Resident #9 hit his glasses. She reported the dietary employee mentioned no longer worked there and she could not even recall her name. She was not aware of what the dietary employee had said about the incident when giving her statement. On [DATE] at 9:06 A.M., an interview with the Director of Nursing (DON) revealed she had only been the facility's interim DON since [DATE]. She was not the DON when the incident occurred between Resident #1 and #9. She reviewed the SRI and the statements obtained by the facility's prior administrator as part of the facility's investigation. She indicated that she likely would not have substantiated the allegation of physical abuse either based on there not being a willful intent to harm the other resident. She was informed the definition of willful intent was changed from an intent to cause harm to a deliberate act. She acknowledged hitting someone in the face would be a deliberate act. She stated their corporate nurse would have more information, as she would have been part of that investigation, and was there at the time the resident to resident altercation occurred. On [DATE] at 9:15 A.M., an interview with Regional Director of Quality Assurance #210 revealed she was serving in her current role as the Regional Director of Quality Assurance when the incident occurred between Resident #1 and #9. She was provided the SRI report and statements obtained from Resident #1 and #9. She supported the facility's prior Administrator not substantiating the allegation of physical abuse due to no willful intent to harm Resident #1 by Resident #9. She acknowledged the definition of willful intent did not mean that Resident #9 intended to harm Resident #1, but the act was deliberate. Hitting another resident was a deliberate act. She felt the incident was provoked by Resident #1, who allegedly raised his fist to the other resident and attempted to hit him. She felt Resident #9's response was reactionary. She agreed residents in the facility had the right to be free from physical abuse and physical abuse included one resident hitting another, no matter if that resident was provoked or not. Review of the facility's abuse policy revealed the facility prohibited physical abuse. Residents would not be subjected to abuse by anyone. Abuse was defined as the willful infliction of injury with resulting physical harm, pain, or mental anguish. Physical abuse included but was not limited to hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Under prevention, residents identified to be potentially abusive should have an individualized care plan with interventions in an effort to prevent abuse, as well as possible psychological services. After all possible interventions were implemented, if the potentially abusive resident continued to be considered threatening to other residents, then the facility would issue a transfer in accordance with government regulations. Under protection, the facility recognizes it was obligated to keep it's residents safe and to protect them from any harm to whatever extent possible and within acceptable standards of practice.

Based on record review and interview, the facility failed to ensure enhanced barrier precautions were in place and failed to properly map infections in the facility. This had the potential to affect all 46 residents in the facility. Findings included: 1. Record review revealed Resident #3 admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, hypertensive heart and chronic kidney disease with heart failure, type II diabetes, and neuromuscular dysfunction of bladder. Review of physician orders revealed Resident #3 had an order in place dated 04/05/23 for may change 16 French 10 cc indwelling catheter related to neurogenic bladder as needed for blockage and dislodgement. Review of a care plan dated 05/01/24 revealed Resident #3 had an alteration in elimination and neurogenic bladder which resulted in needing an indwelling foley catheter 16 French 10 milliliter balloon. Observation on 04/23/24 at 8:45 A.M. revealed Resident #3 had an uncovered catheter bag which was visible from the hallway. There was no visible indication of enhanced barrier precautions. Interview on 04/24/24 at 10:55 A.M. with Licensed Practice Nurse (LPN) #361, who is also the Infection Preventionist, revealed the facility had not initiated enhanced barrier precautions in place yet for any resident who would require them due to not having a Director of Nursing (DON) in place to inform her of the new regulations. LPN #361 stated any resident who has a wound, tube feed, or IV should be in enhanced barrier precaution. LPN #361 stated she had not read the whole policy yet and was not up to date, but any indwelling device which could draw an infection should have enhanced barrier precautions. LPN #361 stated she had been the Infection Preventionist since 10/24/22. She stated she will typically get emails regarding infection control policy and changes but did not receive anything for enhanced barrier precautions until 04/23/24. LPN #361 stated all staff would be educated on 04/30/24, then enhanced barrier precautions would be rolled out. Review of a policy titled Enhanced Barrier Precautions dated 03/2024 revealed enhanced barrier precautions should be in place for any resident in the facility with an infection or colonization with a CDC-targeted MDRO when contact precautions do not otherwise apply or for wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO. Indwelling medical devices may include central lines, urinary catheters, feeding tubes, and tracheostomies. Chronic wounds include pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous status ulcers. 2. Record review revealed Resident #27 admitted to the facility on [DATE] with diagnoses including paraplegia, emphysema, neuromuscular dysfunction of the bladder, and need for assistance with personal care. Review of a quarterly Minimum Data Set (MDS) completed on 01/12/24 revealed Resident #27's cognition remained intact, she did not have any behaviors, she was dependent on staff for toileting hygiene, she had an indwelling catheter, and she had frequent pain. Interview on 04/23/24 at 4:08 P.M. with Resident #27 revealed she went to the hospital on 04/22/24 and the hospital gave her a catheter because she was not voiding all the way on her own. Resident #27 stated when they inserted the catheter, she drained a chunky, yellow, milky substance and has felt much better since. There was no indication Resident #27 was on enhanced barrier precautions. Interview on 04/24/24 at 10:55 A.M. with LPN #361, who is also the Infection Preventionist, revealed the facility had not initiated enhanced barrier precautions in place yet for any resident who would require them due to not having a DON in place to inform her of the new regulations. LPN #361 stated any resident who has a wound, tube feed, or IV should be in enhanced barrier precaution. LPN #361 stated she had not read the whole policy yet and was not up to date, but any indwelling device which could draw an infection should have enhanced barrier precautions. LPN #361 stated she had been the Infection Preventionist since 10/24/22. She stated she will typically get emails regarding infection control policy and changes but did not receive anything for enhanced barrier precautions until 04/23/24. LPN #361 stated all staff would be educated on 04/30/24, then enhanced barrier precautions would be rolled out. Review of a policy titled Enhanced Barrier Precautions dated 03/2024 revealed enhanced barrier precautions should be in place for any resident in the facility with an infection or colonization with a CDC-targeted MDRO when contact precautions do not otherwise apply or for wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO. Indwelling medical devices may include central lines, urinary catheters, feeding tubes, and tracheostomies. Chronic wounds include pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous status ulcers. 3. Review of the infection control log revealed the facility mapping of infections for May 2023 was incomplete. Five infections were logged but the color code was the same for multiple different infections. In addition there were three UTI's, four wound infections, one skin infection, one fungal infection, and one yeast infection. Interview on 04/24/24 at 11 A.M. with LPN #361 confirmed the infection control mapping for May 2023 was inaccurate and hard to read. 32801 4. Record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, enterocolitis due to clostridium difficile, dysphagia, and gastrostomy placed 12/07/23. Review of Resident #44's current order dated 04/2024 revealed no evidence the resident was ordered to be in enhance barrier precautions related to the gastrostomy tube. Review of Resident #44's plan of care revealed no evidence the resident was in enhance barrier precautions. Observation on 04/22/24 at 2:29 P.M. revealed the resident had a gastrostomy tube with no evidence the resident was in enhance barrier precautions. Interview on 04/24/24 at 10:55 A.M. with the LPN #361 confirmed Resident #44 should have been placed in enhance barrier precautions because she had gastrostomy tube. LPN #361 reported she just found out yesterday about enhance barrier precautions and the facility plans to have a staff meeting next week to educate staff. The LPN reported she depends on corporate staff to provide her updates with infection control practices, and she was unaware of the new updates. 5. Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including stage four chronic kidney disease, congestive heart failure, Guillain-Barre syndrome, and neuromuscular dysfunction of bladder. Observation and interview on 04/29/24 at 9:56 A.M., of Resident #3's urinary catheter care with State tested Nurse Assistant (STNA) #321 revealed the STNA washed the meatus with a soapy washcloth and placed the washcloth back into the water basin after she used it, then she got a new washcloth and used the same water out of the water basin to wet the washcloth to rinse the meatus. After she rinsed the area, she placed the dirty rinse washcloth in the same water basin. She grabbed another washcloth and dried the meatus and placed that cloth in the same water basin. She then washed, rinsed, and dried the shaft of the penis in the same manner and placed all 3 dirty wash clothes in the same basin of water that the three previous washcloths were still in. She then cleansed and rinsed the tubing using the same manner; however, she had used a towel to dry. There was a total of eight wash clothes in the water basin. The STNA confirmed she should have placed the used wash clothes in the trash bag after each use instead of putting them and leaving them in the water basin. The STNA covered the resident back up with her gloved hands, took all the wash clothes out of the basin and placed in trash bag, and emptied the water in the toilet and flushed. The STNA reported she has not performed catheter care for some time. The trash can did not have a bag in it and she had placed the basin and her personal protective equipment (PPE) in the trash can anyways and reported she would go get a trash bag for those items and dispose of them properly later. The STNA washed her hands and checked on the resident and exited the room with the trash bag with the wash clothes in it. Review of the catheter care urinary competency assessment dated 2018 revealed to gather supplies and position male resident, into the supine position. Put on gloves and place bed protector under the resident. Wash the resident's genitalia and perineum thoroughly with soap and water. Rinse the area well and towel dry. Pour wash water down the commode and flush commode. For catheter care wash hands and put on clean gloves. Provide privacy and cover residents exposing perineal area. For a male use a washcloth with warm water and soap to cleanse around the meatus. Cleanse the glans using circular strokes form the meatus outwards. Change the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the above technique. Return the foreskin to normal position. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. Secure catheter and check drainage tube. Reposition the bed covers. Interview on 05/29/24 at 10:54 A.M., with LPN #361 (ADON/IP) confirmed the STNA should have placed the dirty wash clothes in a trash bag and not put them back into the water basin and had a bag for the PPE and water basin. The ADON reported she had provided education to STNA #321 and staff. 6. A review of Resident #8's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included history of MRSA, paraplegia; unspecified psychosis not due to a substance or known physiological condition; anxiety disorder; depression; panic disorder; abnormal posture; muscle wasting and atrophy; muscle weakness; and generalized anxiety disorder. Review of Resident #8's orders dated 04/2024 revealed the resident the resident to maintain colostomy to right upper quadrant every shift and to wash wound to interior back with quarter Dakin, pack with alginate silver and cover with dressing daily and as needed. Review of Resident #8's orders dated 04/2024 revealed no evidence the resident was ordered enhance barrier precautions. Review of Resident #8's current plan of care revealed no evidence the resident was ordered enhance barrier precautions. Observation on 04/23/24 at 11:10 A.M. of Resident #8 revealed no evidence the resident was placed in enhance barrier precautions. Interview on 04/24/24 at 10:55 A.M. with ADON/LPN #361 confirmed Resident #8 should have been placed in enhance barrier precautions because he had colostomy and wound.

Based on review of the staffing daily posting, review of the schedule, review of timecards, review of the facility assessment, review of the quality assurance/performance improvement (QAPI), and interview the facility failed to ensure there was a Registered Nurse (RN) for eight consecutive hours and a full time Director of Nursing (DON). This had the potential to affect all 46 residents residing in the building. Findings included: 1. Review of the daily staffing posting dated 01/31/24 to 04/30/24 revealed there was no RN coverage for 01/06/24, 01/07/24, 01/13/24, 01/14/24, 01/20/24, 01/21/24, 01/27/24, and 01/28/24. Review of the facility assessment undated revealed the facility would have an RN at least eight hours daily. Review of the QAPI dated 02/01/24 to 03/01/14 revealed the problem was lack of RN coverage. The intervention was that the RDO would send out requests from other buildings to assist with coverage, offer sign on bonuses for RN coverage as of 02/22/24, and request requested others to participate from other buildings as of 03/2024. There was no evidence audits were completed or RN staff were hired to meet the facilities needs and to ensure RN coverage daily. Interview on 05/01/24 at 8:43 A.M., 12:00 P.M., 1:43 P.M and 4:01 P.M., with the Administrator confirmed the facility still doesn't have a full time RN except for the new DON that just started last month. The facility has an RN that works three days a week as MDS nurse and the facility was using sister facility staff to cover RN coverage for the weekends. The Administrator confirmed there were eight days in January when the facility did not have eight hours of RN coverage. The facility initiated QAPI, however there were no audits completed to ensure RN coverage. The facility can't not find RN's and they have advertised and offered bonuses. 2. Review of the facilities timeline for DON coverage undated revealed from February 21, 2024, to April 8, 2024, the DON was Corporate Nurse #334 and April 9, 2024, to current the DON is DON #605. Review of the daily postings dated 02/21/24 to 02/29/24 revealed there were only two days (02/27/24 and 02/08/24) the facility had a DON. The DON name listed for 02/27/24 and 02/28/24 was for the DON was Corporate Nurse #334. Review of the daily posting dated 03/01/24 to 03/31/24 revealed there was only one day (03/01/24) a DON was posted. The name listed for the DON on 03/01/24 was Corporate Nurse #334. Review of the daily posting dated 04/01/24 to 04/14/24 revealed no evidence a DON was listed. Review of March 2024 staffing schedule revealed the DON schedule was blank. Review of the facility assessment undated revealed the facility would have a DON on staff. Review of time sheets revealed the only time sheet provided for the DON from 01/23/24 to present was the Agency DON #603. Interview on 05/01/24 at 11:43 A.M., with Assistant Director of Nursing (ADON)/ Licensed Practical Nurse (LPN) #361 and RN #335 (MDS nurse) confirmed the facility didn't have a full time DON from February 21, 2024, to April 8, 2024. Interview on 05/01/24 at 3:42 P.M. with Corporate Nurse #334 confirmed she did not work full time as the DON from February 21, 2024, to April 8, 2024. The Corporate Nurse reported she was available to the staff 24/7 and visited the facility three or four times a week. The Corporate Nurse reported there was no documented evidence of the days she was at the facility during that timeframe, and she declined to put anything in writing stating which days she was present in the facility, however confirmed she was not there full time. Interview on 05/01/24 at 4:01 P.M., with the Administrator confirmed the Corporate Nurse #334 was listed as the DON from February 21, 2024, to April 8, 2024, however, was not full time. The Administrator reported the Corporate Nurse was the facility a few days a week and reported the MDS nurse works three days at the facility and two days at the sister facility as an MDS nurse, however she was not designated as the full time DON.

Based on record review, facility self-reported incident (SRI) review, policy review and interview, the facility failed to ensure residents were free from abuse. This affected five residents (#2, #6, #17, #20, and #21) of seven residents reviewed for abuse. The facility census was 46. Findings included: 1. Record review revealed Resident #2 admitted to the facility on [DATE] with diagnoses including traumatic hemorrhage of cerebrum, spastic hemiplegia affecting left nondominant side, type II diabetes, bipolar disorder, panic disorder, and anxiety disorder. Review of a personal witness statement by Licensed Practical Nurse (LPN) #328 dated 12/14/23 revealed LPN #328 was sitting in the nurse's station charting when she heard screaming from the dining room. She went to the dining room, and Resident #2 stated she had screamed due to another resident slapping her in the mouth, there was no swelling or redness noted. LPN #328 stated another male resident was in the dining area and witnessed Resident #2 getting slapped. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had mild cognitive impairment, had physical and verbal behaviors daily, and required maximum assistance for bed mobility and transfers. Review of SRI tracking number 246210 dated 04/10/24 revealed a staff member observed a male resident [Resident #31] grabbing Resident #2's breast. Resident #2 had denied incident occurred. Review of a witness statement from Activity Director #363 dated 04/10/24 revealed she witnessed a male resident [Resident #31] inappropriately touch a female resident [Resident #2], immediately separated the residents, and reported the incident to the Administrator. Interview on 04/24/24 at 3:31 P.M. with the Administrator confirmed a male resident [Resident #31] grabbed Resident #2. Interview on 04/25/24 at 8:49 A.M. with Resident #2 revealed she recalled a male resident touching her inappropriately in the beginning of April. Resident #2 stated the male still resides in the facility, and staff did not do anything to keep the incident from reoccurring. Resident #2 stated the incident made her uncomfortable, sad, and made her feel unsafe. Resident #2 stated she does see the male resident, and he tries to talk to her, but she tells him to leave her alone. 2. Record review revealed Resident #6 admitted to the facility on [DATE] with diagnoses including dementia, chronic pulmonary obstructive disease, hypertension, anxiety disorder, major depressive disorder, and mild cognitive impairment. Review of the quarterly MDS assessment completed on 03/23/24 revealed Resident #6 had severely impaired cognition and required maximum to dependent assistance from staff for activities of daily living. Review of a progress note dated 03/06/24 at 4:47 P.M. by the Administrator revealed Resident #6's family and nurse practitioner were made aware of resident-to-resident contact. Review of a progress note dated 03/06/24 at 7:36 P.M. by Licensed Practical Nurse (LPN) #361 revealed Resident #6 had no skin issues noted. Review of SRI tracking number 244923 completed on 03/06/24 revealed a male resident [Resident #23] touched Resident #6's breast. The facility determined sexual abuse was unsubstantiated due to no harm occurring to Resident #6 since she was cognitively impaired. Review of a witness statement completed by the Administrator and witnessed by Social Services Designee (SSD) #347 revealed the Administrator interviewed Resident #23 who admitted to touching the breasts of two differed residents, including Resident #6. Review of a witness statement by the Administrator and witnessed by SSD #347 dated 03/06/24 revealed Resident #6 was interviewed and did not recall the incident, did not appear to be in any distress or anguish, and had a smile on her face. Review of a progress note from 03/07/24 at 12:21 P.M. by SSD #347 revealed a follow up was completed with Resident #6 who was pleasantly confused per baseline, did not demonstrate fear or behaviors that would indicate mental anguish. Interview on 04/25/24 at 3:17 P.M. with SSD #347 revealed if Resident #6 was alert and oriented, using reasonable person concept, she believes Resident #6 would be upset. SSD #347 stated there were no interventions in place to prevent incident from reoccurring, but the staff do try to redirect Resident #23 approach Resident #6. Interview on 04/29/24 at 3:52 P.M. with Resident #6's representative (RP) #101 revealed she was notified Resident #6 was okay, but someone had touched her breast. RP stated she told the facility to keep the other resident away from Resident #6, and if she was aware of what happened, Resident #6 would smack the other resident and tell him to get away. RP #101 stated Resident #6 was a Christian, was married to one man and would be upset if she knew what occurred. Interview on 04/30/24 at 8:43 A.M. with Administrator revealed Resident #23's inappropriate behaviors towards female residents initially began in February 2024. Administrator confirmed the intervention for the incident on 03/06/24 was to implement 15-minute checks and confirmed on 03/08/24 15 minute-checks were not completed between 7 A.M. and 2 P.M. The Administrator confirmed 15-minute checks stopped on 03/11/24. Interview on 05/01/24 at 8:25 A.M. with State tested Nursing Assistant (STNA) #351 revealed she was aware of an incident where Resident #23 attempted to touch Resident #6's breast, but it was reported. STNA #351 stated Resident #23 is alert and oriented but will pretend he doesn't know what happened and increased supervision should have been started sooner than it did. 3. Record review revealed Resident #17 admitted to the facility on [DATE] with diagnoses including senile degeneration of the brain, dementia with behaviors, major depressive disorder, and anxiety disorder. Review of the quarterly MDS assessment completed on 02/05/24 revealed Resident #17 had severely impaired cognitive function, had delusions, physical behaviors four to six days a week, verbal behaviors one to three days a week, wandered daily, and required maximum assist to dependent assistance from staff for activities of daily living (ADL). Review of a progress note dated 04/09/24 at 7:15 P.M. by LPN #361 revealed male resident [Resident #23] made contact with Resident #17, and holding hands was noted. A skin assessment was completed, and the physician and family were updated. Review of SRI tracking number 246138 completed on 04/09/24 revealed Resident #23 was kissing Resident #17 on the lips and holding her hands. The Administrator spoke with both residents who were unable to recall the incident. Review of a witness statement dated 04/09/24 by STNA #313 revealed Resident #23 was kissing Resident #17 on the lips, and they were holding hands. STNA #313 reported the incident immediately after separating the residents. Review of a witness statement completed on 04/09/24 by LPN #359 revealed she was called to the hallway due to a resident [Resident #23] kissing another resident [Resident #17], the residents were separated, assessments were completed per facility policy, physician, administrator and Assistant Director of Nursing (ADON) were notified. Resident #23 recalled the incident directly after it occurred and confessed to kissing Resident #17. Resident #23 was placed on 15-minute checks from 04/09/24 through 04/16/24. Interview on 04/25/24 at 9:38 A.M. with STNA #313 revealed she did not believe Resident #17 had the ability to provide consent for intimate interactions with others. Interview on 04/25/24 at 3:17 P.M. with SSD #347 revealed she did not have any concerns related to Resident #17's room being directly across the hall from Resident #23's. SSD #347 stated she did not believe Resident #17 could give consent for a relationship but Resident #17 did not have adverse reactions. Interview on 04/29/24 at 4:43 P.M. with Resident #17's RP #102 revealed he was not notified of any incident occurring and he did not believe Resident #17 was able to consent to any type of relationship. RP #102 stated Resident #17 would not have approved of that interaction, would have been angry, and told the guy to get away. Interview on 04/29/24 at 3:20 P.M. with STNA #332 revealed Resident #17 cannot give consent to intimate interactions with other residents. Interview on 04/29/24 at 5:16 P.M. with STNA #313 revealed she observed Resident #17 with Resident #23, holding one of his hands and the other arm wrapped in an embrace as they kissed in the hallway. STNA #313 stated Resident #17 did not appear to be in distress. Interview on 04/30/24 at 8:43 A.M. with Administrator revealed Resident #23 initially began having sexually inappropriate behaviors in February 2024 with hand holding and attempts to kiss residents. Medications were started at that time as an intervention, then after an incident on 03/06/24 15-minute checks were started then stopped on 03/11/24. After a third incident on 04/09/24, 15-minute checks were started again, and a discharge notice was issued which was currently being appealed. Interview on 05/01/24 at 8:25 A.M. with STNA #351 revealed she had seen Resident #23 attempt to kiss Resident #17 multiple times but was not at the facility when events occurred. STNA #351 stated Resident #23 was alert and oriented but liked to pretend he was confused, and she was concerned since Resident #17's room was directly across from Resident #23's. STNA #351 stated Resident #17 would not be able to yell out for help if needed. STNA #351 stated Resident #17 would be upset related to incident of kissing with Resident #23 if she was aware using reasonable person concept. 4. Record review revealed Resident #20 admitted to the facility on [DATE] with diagnoses including sepsis, pneumonia, acute respiratory failure, type II diabetes, schizoaffective disorder, and anxiety disorder. Review of a care plan completed on 12/06/23 revealed Resident #20 had an alteration in cognitive function related to schizoaffective disorder. Review of the MDS assessment completed on 04/02/24 revealed Resident #20 had a Brief Interview for Mental Status BIMS of 12 out of 15, indicating moderate cognitive impairment. Review of a Medication Administration Record (MAR) for April 2024 revealed Resident #20 was given an as needed order for hydroxyzine HCI oral tablet 25 milligrams (antihistamine used to treat anxiety) give 25 milligrams by mouth every eight hours as needed for anxiety. Hydroxyzine was first administered on 04/28/24. Review of a progress note dated 04/27/24 at 3:00 P.M. by LPN #368 revealed Resident #20 was placed on 15-minute checks for 72 hours related to sexual behaviors towards another resident. Review of a BIMS evaluation for Resident #20 dated 04/27/24 at 3:34 P.M. by LPN #327 revealed a score of two out of 15, indicating severe cognitive impairment. Interview on 04/29/24 at 1:05 P.M. with LPN #368 revealed Residents #20 and #23 were placed on 15-minute checks due to Resident #23 kissing Resident #20 on the cheek. Interview on 04/29/24 at 2:26 P.M. with the Administrator revealed Resident #23 had an alarm placed on his door, was placed on 15-minute checks, and was on a different hallway than Resident #20. Interview on 04/29/24 at 3:20 P.M. with STNA #332 revealed Resident #20 was not able to give consent for intimate touching or kissing. STNA #332 stated Resident #20 had increased behaviors since 04/26/24 including anger outbursts and not letting anyone touch her, which was unusual, but the nurse had stated, her dementia was kicking in. Interview on 04/30/24 at 2:49 P.M. with Regional Quality Assurance (QA) Nurse #334 revealed an order for Resident #23 to be placed on one-to-one supervision while he was out of his room was in place since there was now an alarm on his door. 32801 5. Record review revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, depression, and intellectual disabilities. Review of Resident #21's nursing note dated 03/06/24 revealed the resident had reported that male resident [Resident #23] had inappropriately touched her. Education was provided to both residents. Review of Resident #21's plan of care dated 03/06/24 revealed on 03/06/24 a male resident [Resident #23] had touched the resident inappropriately. The residents BIMS was eight out 15 at the time of the incident, indicating moderate cognitive impairment. The intervention included notifying the family and physician, separating residents immediately, and staff were to give the resident time to discuss the incident. Review of SRI tracking number 244923 dated 03/06/24 revealed Resident #6 and Resident #21 were sexually abused by a male resident [Resident #23]. Residents #21 and #23 were able to provide meaningful information, however Resident #6 was not able to provide meaningful information when interviewed. Resident #21 had requested to speak to the Administrator on 03/06/24 at 4:15 P.M. Resident #21 reported Resident #23 had touched her breast when she was sitting in the common area. Resident #23 confirmed he touched Resident #6 and #21's breast. Resident #23 had dementia and was not always cognitively intact. Resident #23 voiced understanding of keeping hands to himself and accepted the education on what was appropriate/inappropriate. The incident was not observed by staff. The facility reported the allegation was unsubstantiated due to the evidence being inconclusive. Review of the facility investigation for SRI tracking number 244923 revealed Resident #21 told two staff members that Resident #23 had grabbed her breast, without consent. Resident #21 and pointed the resident [Resident #23] out to a staff member and stated he had done it twice, and she didn't want him to grab her. Review of Resident #21's typed statement dated 03/07/24 revealed SSD #347 interviewed the resident on 03/06/24. The resident reported on 03/06/24 a man [Resident #23] grabbed and pinched her breast on the outside of her clothing in the dining room with other residents present. The resident reported it was uncalled for, and she was unsure why he did it. The resident seemed to have minimal mental anguish and stated she felt safe if he was not around. SSD #347 offered counseling services to help her deal with this new trauma to which the resident declined. The resident was comfortable coming to administration if something changed, and she wished to speak with someone regarding the incident. Review of Resident #23's typed statement by the Administrator and witnessed by SSD #347 dated 03/06/24 revealed the resident reported there were two different occurrences that took place yesterday with two residents. The resident admitted to touching the breasts of two female residents [Resident #6 and Resident #21]. Resident #23 asked for an increase in Tagamet (antihistamine and antacid) yesterday per psych. The resident doesn't seem to fully comprehend the severity of his actions. The resident has a diagnosis of vascular dementia. Review of Resident #6's typed statement typed by the Administrator dated 03/06/24 revealed the resident did not recall the incident that took place yesterday. The resident did not appear to be in any distress or anguish from the incident. Review of the census sheet dated 03/06/24 revealed head to toe assessments were completed on six residents that were not able to be interviewed, and the 35 residents that were interviewed and felt safe. Interview on 04/23/24 at 2:24 P.M., with Resident #21 revealed a man named maybe (name given) touched her breast and attempted to touch her private areas below her waistline. Resident #21 confirmed she felt the resident had sexually abused her and it bothered her. Resident #21 reported she feared him, and he still resided in the building. Review of the facilities policy titled Abuse, Neglect, Exploitation of Residents and Misappropriation of Property, dated 05/2018, revealed it was the goal of the facility that its residents would be protected from sexual abuse. Residents would not be subjected to abuse by anyone.

Based on record review, staff interview, and policy review, the facility failed to ensure Resident #7 was free from abuse when Resident #29, a resident with a known history of aggressive behaviors and homicidal ideations abused the resident. This affected one resident (#7) of two residents reviewed for abuse. Actual physical and psychosocial harm occurred, applying the reasonable person concept, on 11/05/22 to Resident #7, a resident with impaired cognition, when Resident #29 struck Resident #7 multiple times in the face, was found with a choke hold around the resident's throat and threatened to kill the resident. Findings include: A review of Resident #7's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included dementia with behavioral disturbances, unspecified psychosis, and senile degeneration of the brain. A review of Resident #7's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech and adequate hearing. She was usually able to make herself understood and was able to understand others. Her cognition was severely impaired and she was not known to have any behaviors during the seven day assessment period. A review of Resident #7's care plans revealed she had a care plan in place for mood and behaviors related to her cognitive decline, restlessness and agitation. She was known to become anxious at meal time and would yell out to be served. Interventions included attempting to identify what triggered her behaviors. They were to introduce the resident to other residents on unit of similar status and compatibility. They were also to observe and report any changes in her mental status, provide one on one sessions with the resident as needed, and to refer her to counseling/psychiatry as needed. A review of Resident #7's progress notes revealed a nurse's note dated 11/05/22 at 12:00 P.M. that indicated a staff member witnessed another male resident (Resident #29) become physically aggressive with the resident putting her in a choke hold. The male resident verbalized he was going to kill the resident. The two residents were immediately separated to ensure safety. Resident #7 was assessed for injury with none being noted. She later was not able to respond to questions asked regarding the previous incident. The facility staff reinforced to the resident that they would not let that happen again and she was safe. She smiled with no response or complaints voiced. A review of Resident #29's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included post traumatic stress disorder (PTSD), pre-excitation syndrome, bipolar disorder, and homicidal ideations. A review of Resident #29's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues. His cognition was moderately impaired. No behaviors were indicated to have been noted during the seven days of the assessment period. He required an extensive assist of two for transfers and required supervision with one person physical assist for locomotion on and off the unit. A wheelchair was used as a mobility device. A review of Resident #29's progress notes revealed he had active care plans in place for being at risk for alteration in mood/ behavior. He was known to have hit a staff member at a prior facility. He had a history of assaulting care givers. His care plan was updated on 10/27/22 to reflect he was known to be yelling at other peers that have impaired cognition. The care plan was updated again on 11/06/22 that indicated he was at risk for physical behaviors due to a history of behaviors. The interventions included monitoring his mood/ behavior, remove him from areas of escalation, and one on one to monitor behaviors. He had a care plan for the use of antipsychotic medications related to depression, bipolar, PTSD, outburst of frustration, mumbles/ [NAME] to self and yelling out at others. The interventions for that care plan included administering medications as ordered. A review of Resident #29's progress notes revealed he was documented as having behaviors in the facility beginning on 10/22/22. The staff heard a verbal altercation coming from the activity room and upon entering witnessed the resident agitated drawing back his right closed fist while threatening a female resident. He continued to yell and get closer to the female resident before being separated by staff and redirected. A nurse's note dated 10/27/22 revealed Resident #29 was heard yelling at a female resident for coming into his room. He was calling the female resident names and was threatening to hit her if she did not leave his room. He was given an order for Haldol (an antipsychotic) 0.5 milligrams (mg) by mouth three times a day and Ativan 1 mg three times a day by mouth as needed. A nurse's note dated 10/31/22 revealed Resident #29 was noted with behavioral outbursts in the activity room related to staff and other residents talking to one another. The resident screamed out, used foul language because he stated they should all shut the f*** up so he could hear the community TV rather than watching the one in his room. A nurse's note dated 11/04/22 revealed Resident #29 was noted to be very agitated yelling and cursing, threatening another resident with physical harm. Multiple staff attempted to decrease the resident's agitation, but he stated he didn't care he will kill him as he pounded his fist in his hand. He attempted to wheel himself towards the other resident, but was taken to the social service office to cool down. He was educated on not making threats towards other residents and that it was not acceptable. They also informed him, if he made physical contact with others, that would result in the police being called. The Director of Nursing (DON) informed him, if he wanted to stay in the facility to receive the care he needed to be able to return home, the aggressive behavior needed to cease. He stated understanding but continued to make verbal threats to kill anyone who messed with him. A nurse's note dated 11/05/22 revealed Resident #29 became agitated towards another female resident due to the other resident repeatedly yelling. He became physically aggressive placing her in a choke hold. Staff immediately intervened and removed Resident #29 placing him in the common area for his meal so he could be monitored. He was sent to the emergency room for an evaluation but was sent back three hours after he was sent with no new orders. He was sent back to the hospital for further evaluation at the direction of the resident's psychiatrist's nurse practitioner. Information was sent to the crisis team at the hospital and the facility shared their concerns with the safety of other residents. He returned the following day. He was transported to another hospital on 11/06/22 where he remained until he was readmitted to the facility on [DATE]. A review of facility self-reported incident (SRI), tracking number 228879 revealed an SRI was submitted on 11/05/22 for an allegation of physical abuse. The alleged perpetrator was Resident #29 and the resident/ victims were identified as Resident #29 and Resident #7. No witnesses were identified in the SRI. The date of discovery was 11/05/22 and the brief description of the allegation/ suspicion was a resident to resident altercation. The initial source of the allegation was staff. Resident #7 was not able to provide meaningful information. Her diagnoses included a stroke, dementia with behavioral disturbances, and altered mental status. Resident #29 was noted to be able to provide meaningful information. His diagnoses included Post Traumatic Stress Disorder (PTSD) and homicidal ideations. The narrative summary of the incident revealed Resident #29 had suspected had borderline personality disorder and antisocial disorder. Resident #7 had a history of behavioral disturbances. During the facility's investigation they interviewed both residents and staff regarding the resident-to-resident altercation. Witness statements said Resident #7 kept repeatedly yelling she was hungry and she wanted food in dining room. Resident #29 became frustrated by the repetitive statements and he started yelling at her. He then slapped Resident #7 in the face and proceeded to wrap his arm around her. Resident #29 was unable to stand and was strictly confined to a wheelchair. Staff members separated the residents and diffused the situation. Resident #29 started yelling threatening statements and Resident #7 continued to yell as well. Resident #29 was removed from the area and placed on one on one. Resident #29 was sent out for a psychiatric evaluation at a local hospital. Resident #7 was standing up at the time of the incident and was yelling at Resident #29. She did not cry or show any emotion. She did not have any marks or bruises. The facility unsubstantiated the allegation of physical abuse stating the evidence was inconclusive and abuse was not suspected. The facility indicated as a result of their investigation they did the following: Resident #29 was treated at the hospital for acute illness. He will have medication changes prior to or on admissions. Resident #29 would remain on one on one status until his behaviors were stable. His care plan was updated to recommend or encourage quiet-low traffic areas. Resident #7 had a medication change as well and her care plan was updated appropriately. The facility's investigation file included a SRI Form for an initial report. It indicated the incident was witnessed by STNA #300 on 11/05/22 at 12:05 P.M. and occurred in the dining room. Resident #29 reported all specifics and details regarding the incident. He did not show any remorse for what he had done. He sat calmly eating a snack while he spoke of what he did. An interview statement from Resident #29, after the witnessed incident in the dining room on 11/05/22, was obtained by the DON. The DON asked Resident #29 what happened at lunch in the dining room. He reported another resident in the dining room kept yelling out like she always did. He stated he was tired of hearing her and that no one was doing anything about her. She asked him if he noticed any staff members and he said no. He said he told the other resident if she yelled one more time, he was coming to kick her f****** a**. He reported the other resident said that she did not care. He then indicated he went after her, slapped her, and put her in a choke hold. He said that she started screaming and scratched him on his face. He also said that she had no f****** right to be in there yelling like that and he was going to f****** kill her because she had no right to act that way. He said the nurses took him to another room and let that b**** stay in the dining room. He said he f****** took care of her and he got punished. The DON asked him if he was aware that the other resident was confused at times and did not know what was going on. He said she knew more that they thought, and he did not care if she was confused. He was going to kick her a**. A witness statement from STNA #300 dated 11/05/22 revealed she went to the kitchen to get lunch for the assisted living residents. A kitchen staff member said he had a hold of her. She went to the dining room to see Resident #29 have Resident #7 in what looked like a choke hold. She told him to let go, he had a strong grip on her. She had to pry his hands from her and then took him out to the common area. While taking him out, he kept cursing you f****** b****, I'll do it again. The nurse was made aware and came in while she was separating the residents. She then went back to make sure Resident #7 was okay and she stated she was. She returned to her unit (assisted living) and told her nurse what had happened. She asked her nurse if she should call the DON and was advised to do so. She called the DON after speaking with her nurse. A personal witness statement from RN #320 dated 11/05/22 revealed she heard a loud noise (yelling) coming from the dining room. The nurse immediately responded and found female resident leaning towards a male resident. Staff separated the two residents as stated the female resident had been yelling, which agitated the male resident. He became physically aggressive and put the female resident in choke hold. The male resident was heard threatening to murder the female resident. Male resident was brought to the common area seated by himself. He continued to threaten to murder. Male resident was identified as Resident #29 and the female resident was identified as Resident #7. A personal witness statement from STNA #310 regarding the incident occurring on 11/05/22 revealed she was bringing another resident to the dining room and heard Resident #7 yell. She heard other residents yelling for them and was saying Resident #29 had Resident #7 in a headlock. By the time she got to the dining room, the nurse was wheeling Resident #29 out of the dining hall and he had a bloody nose. The facility's investigation indicated Resident #7 was not able to respond to any questions asked regarding the assault. A personal witness statement from Resident #1 dated 11/05/22 revealed the DON spoke with him about the lunch incident. He wasn't able to verbalize the incident. He showed her with his arms. He grabbed the DON around the neck and said choke, then he pointed towards Resident #7. A personal witness statement from Resident #33 dated 11/05/22 revealed the DON spoke with the resident regarding the lunch incident. The resident reported he was sitting at the same table as Resident #29. Resident #29 was mad because Resident #7 was yelling she wanted her food. He said Resident #29 told her (Resident #7) to shut the f*** up or he was going to shut her up. The resident stated Resident #29 turned around and started slapping her and got her in a choke hold. Then the nurse came running in. A personal witness statement from Resident #6 dated 11/05/22 revealed the DON spoke with him about the incident occurring in the dining room. The resident reported Resident #7 was asking repeatedly for her food and drink. Resident #29 yelled at her to shut the f*** up or he was coming after her. He said Resident #29 went over and slapped her four to five times and then he grabbed her around the neck in a choke hold. He immediately started yelling for the nurses and they came running in. Nurses took Resident #29 out of the room. On 02/16/23 at 5:10 P.M., an interview with the DON revealed she did participate in the investigation into the allegation of physical abuse that occurred on 11/05/22 between Resident #7 and #29. She was asked how the facility determined that physical abuse did not occur or that they did not have sufficient evidence that was conclusive to show physical abuse had occurred. The facility's investigation showed staff and other residents in the dining room witnessed the incident and confirmed Resident #29 threatened, slapped and put Resident #7 in a choke hold. She was not able to provide a rationale as to why the physical abuse allegation was not substantiated. A review of the facility's Abuse Policy revised September 2020 revealed the facility prohibited mental or physical abuse. Residents would not be subjected to abuse by anyone. Abuse was defined as the willful infliction of injury with resulting physical harm, pain, or mental anguish. Verbal abuse was defined as the use of oral language that willfully included disparaging and derogatory terms to residents or within their hearing distance. Physical abuse included but was not limited to hitting, slapping, pinching, kicking and controlling behavior through corporal punishment. Residents identified to be potentially abusive shall have individualized care plans with interventions in an effort to prevent abuse. After all possible interventions were implemented, if the potentially abusive resident continued to be considered threatening to other residents, then the facility will issue a transfer in accordance with government regulations. The facility recognized its obligation to keep its residents safe and to protect them from any harm to whatever extent possible and within acceptable standards of practice.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated [DATE], The Department of Health and Human Services, Center for Medicare and Medicaid (CMS) Memo QSO ,d+[DATE]-NH, revised [DATE], Nursing Home Guidance from the Centers for Disease Control (CDC), record review, review of the county community COVID-19 positivity rate, review of facility COVID-19 testing log, review of staff time sheets, review of staffing schedules, review of staff and visitor screening forms, review of resident and staff COVID-19 rapid point of care (POC) test results, review of local health department communication, review of the facility infection control log, review of the facility COVID-19 procedure policy, staff interviews, interview with the local health department and observation the facility failed to implement effective and recommended infection control practices to prevent the transmission of COVID-19 in the facility. The facility failed to ensure staff timely reported signs and symptoms of COVID-19, failed to ensure staff did not provide direct resident care to residents while symptomatic of COVID-19, failed to ensure staff and visitor screening for COVID-19 upon entrance into the facility was monitored, and failed to ensure resident contact tracing was completed to ensure additional precautions were implemented, during a COVID-19 outbreak to help reduce the spread of COVID-19 throughout the facility. This resulted in Immediate Jeopardy on [DATE] when Temporary Nursing Assistant (TNA) #144 inaccurately documented on the facility screening log for COVID-19 she was asymptomatic and proceeded to work/providing direct care to all residents in the facility. TNA #144 worked a 12-hour shift on [DATE] from 6:58 A.M. until 7:13 P.M. On [DATE] TNA #144 again inaccurately documented on the COVID-19 screening at the beginning of her shift she was asymptomatic for signs and symptoms of COVID-19. TNA #144 worked on [DATE] from 7:03 A.M. to 8:00 A.M. at which time she reported to the nurse, she had a scratchy throat and congestion and wanted tested for COVID-19. The facility performed a rapid COVID-19 test per the TNA's request and the TNA tested positive for COVID-19. At that time, TNA #144 reported her symptoms had started on [DATE]. The facility failed to ensure TNA #144, who was symptomatic of COVID-19 was timely removed from providing resident care when she first exhibited symptoms, failed to ensure contact tracing was completed to identify any staff or residents at risk for COVID-19 due to exposure to TNA #144 and failed to ensure any residents/staff with possible exposure were placed in quarantine to prevent the spread of COVID-19 in the facility. In addition, Housekeeper (HK) #114, who worked on [DATE] and [DATE] (with TNA #144) started to exhibit symptoms (stuffy nose/head) of COVID-19 on [DATE] and worked her scheduled shifts on [DATE], [DATE], [DATE], [DATE] and for five hours on [DATE], until she was tested (on [DATE]) via a rapid test which was positive for COVID-19. HK #114 reported she was in every resident's room on [DATE] and [DATE] and did not report her symptoms on the screening log because she did not think a stuffy head was one of the screening questions. HK #114 returned to work on [DATE] on the COVID-19 unit, while still exhibiting symptoms and before her isolation period (provided by the local health department) was completed. The facility failed to ensure HK #114, who was symptomatic of COVID-19 was timely removed from working in resident care areas when she first exhibited symptoms, failed to ensure contact tracing was completed to identify any staff or residents at risk for COVID-19 due to exposure to HK #114 and failed to ensure any residents/staff with possible exposure were placed in quarantine to prevent the spread of COVID-19 in the facility. The facility identified five unvaccinated residents (#9, #15, #18, #22, and #23) who had not had COVID-19 in the past 90 days who were not placed in quarantine following their possible exposure to TNA #144 or HK #114. Two additional residents (#1 and #21), who were unvaccinated were noted to be quarantined because they were new admissions and unvaccinated. The facility identified 16 residents, Resident #1, #3, #6, #12, #13, #14, #15, #16, #18, #20, #21, #23, #25, #27, #28, and #31 and three additional staff, Dietary Aide (DA) #124, Licensed Practical Nurse (LPN) #128 and LPN #129 who subsequently tested positive for COVID-19 from [DATE] to [DATE]. The risk for hospitalization , serious harm and/or death are likely related to a COVID-19 outbreak in the nursing home resident population. This had the potential to affect all 30 residents residing in the facility, with the exception of Resident #4, who was admitted to the facility from the attached Assisting Living (AL) on [DATE] with COVID-19. On [DATE] at 2:25 P.M. the Administrator, Director of Nursing (DON), Regional Quality Assurance (RQA) #149 and Regional Director of Operations (RDO) #151 were notified Immediate Jeopardy began on [DATE] when TNA #144 worked a 12-hour shift providing director care to residents while symptomatic with signs and symptoms of COVID-19. TNA #144 also worked on [DATE] with continued symptoms of COVID-19 providing direct resident care. TNA #144 tested positive for COVID-19 from a rapid test obtained on [DATE]. HK #114, who worked with TNA #144 on [DATE] and [DATE] subsequently developed symptoms of COVID-19 and tested positive for COVID-19 on [DATE]. HK #114 was symptomatic and returned to work on [DATE], before an isolation period was finished. Continued observations during the onsite investigation revealed the facility was not following acceptable infection control practices to prevent the spread of COVID-19 related permitting symptomatic staff to provide direct care, not conducting contact tracing for unvaccinated residents/staff with exposure to COVID-19 positive staff and insufficient monitoring of the staff/visitor COVID-19 screenings for COVID-19 upon entrance into the building. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following correction actions: · On [DATE] Regional Quality Assurance (RQA) #149/Designee initiated an audit for all staff currently at the facility for symptoms of COVID-19. · On [DATE] all residents were rapid tested for COVID-19 and infection control procedures were implemented for the one additional positive resident (Resident #21). Testing was completed by the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #103. · On [DATE] Resident #9 and Resident #22 who were unvaccinated and not positive for COVID-19 were placed on quarantine per CDC recommendations. · On [DATE] RQA #149 educated the Administrator, DON and ADON #103 on the policies for screening staff, not permitting staff to work with symptoms consistent with COVID- 19 and the requirements for quarantining unvaccinated residents who had close contact with positive staff or residents. · On [DATE] a Quality Assessment Performance Improvement (QAPI) meeting was held with the Administrator, RQA #149 and the Medical Director via phone regarding the following: Review of the policies for screening staff and visitors. Review of the requirement of not permitting staff to work if symptomatic for signs and symptoms of COVID- 19. The requirement to quarantine unvaccinated residents who had close contact with COVID-19 positive staff or residents. · On [DATE] the facility department heads (ADON #103, Human Resource (HR) #127, Director of Housekeeping (DOH) #152, Administrator and the DON) initiated education for all facility staff which included but was not limited to screening of staff and not permitting staff members to work who were symptomatic and that both visitor and employee screening logs were to be completed in their entirety and to notify the administration if any staff were experiencing any COVID-19 symptoms. A plan for any staff not contacted prior to midnight on this date for education would not be permitted to work until receiving education. · On [DATE] the transmission-based policy was reviewed and revised by RQA #149 and/or Director of Clinical Service (DOCS) #153 to include unvaccinated residents should generally be restricted to their rooms, even if testing was negative and cared for by health care personnel (HCP) using N95 or higher-level respirator (masks), eye protection, gloves and gown. These residents should not participate in group activities. · On [DATE] the Administrator, DON and ADON #103 were educated by RDOP #151 on following the local health departments guidance and not permitting employees to not return to work until deemed appropriate (cleared) by the local health department. · On [DATE] a plan for ongoing audits to be completed by the supervisor or designee on duty for each shift to monitor proper screening procedures to prevent symptomatic staff/visitors from entering facility and track for any trends for four weeks and then randomly thereafter was implemented. The audit will include: Screening log filled out in its entirety and that staff who were symptomatic were not permitted to work if they were symptomatic or positive for COVID-19. · On [DATE] at plan for ongoing audits to be completed by the Administrator or designee by selecting five employees three times a week and asking staff if they know the signs and symptoms of Covid, who to report symptoms to and if they know not to work with symptoms, for four weeks, then randomly thereafter was implemented. · On [DATE] all current staff in the facility were re-screened by the DON for COVID-19 symptoms. At the time of re-screening there were no staff members identified to have signs or symptoms of COVID-19. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the Centers for Medicare and Medicaid (CMS) QSO-,d+[DATE]-NH memo, revised [DATE] revealed Nursing homes have been severely impacted by COVID-19, with outbreaks causing high rates of infection, morbidity, and mortality. The vulnerable nature of the nursing home population combined with the inherent risks of congregate living in a healthcare setting have required aggressive efforts to limit COVID-19 exposure and to prevent the spread of COVID-19 within nursing homes. Review of the county community COVID-19 positivity rate, dated [DATE] revealed the community transmission rate was high (red) and the facility was in a county with a positivity rate of 25%. 1. Review of the undated staff vaccination log, revealed TNA #144 received a COVID-19 vaccination on [DATE]. Review of the staff screening logs for COVID-19 dated [DATE], [DATE] and [DATE] revealed documentation the TNA had no signs or symptoms of COVID-19 nor had the employee been in close contact with anyone with COVID-19. Review of TNA #144's time sheets, revealed TNA #144 worked [DATE] from 6:58 A.M. to 7:15 P.M., [DATE] from 6:58 A.M. to 7:13 P.M. and [DATE] from 7:03 A.M. to 8:00 A.M. Review of TNA #144 COVID-19 rapid test results, dated [DATE] revealed TNA #144 tested positive for COVID-19 on this date. There was no additional information related to symptoms the TNA was experiencing at that time. Review of a letter from the local health department (dated [DATE]) revealed TNA #144 was in isolation for COVID-19 from [DATE] to [DATE]. On [DATE] at 10:13 A.M. and 12:41 P.M. interview with the DON revealed the facility was not aware TNA #144 had started exhibiting COVID-19 symptoms on [DATE]. The DON confirmed TNA #144 had worked a 12 hour shift on [DATE] and [DATE] and worked one hour on [DATE]. The DON confirmed during the dates worked, when the TNA was symptomatic of COVID-19, she had possibly provided direct care to all of the residents residing in the facility. The DON revealed she did not document TNA #144's symptoms; however, she could remember the TNA reporting she had a sore throat. TNA #144 was rapid tested by the facility on [DATE] after she verbally reported she was having symptoms. The TNA tested positive and was sent to urgent care for confirmation. The urgent care confirmed the TNA was positive for COVID-19 and the TNA had reported to the physician her symptoms had started on [DATE]. The DON confirmed the local health department had provided a letter indicating TNA #144's isolation period was from [DATE] to [DATE] due the TNA first exhibiting symptoms of COVID-19 on [DATE]. On [DATE] at 1:21 P.M. interview with TNA #144 revealed she started with a head cold on either [DATE] or [DATE]. She verified she had worked 12 hours shifts in the facility on [DATE] and [DATE] providing direct care to residents on all three hallways. TNA #144 revealed her scratchy throat started on [DATE] and she thought she better report her symptoms to the nurse and be tested . The nurse rapid tested her on [DATE] and she tested positive for COVID and then went directly to the doctor for a second confirmation. TNA #114 reported she thought she had marked on the screening log she had symptoms but had only been working at the facility for a month and really didn't know what the facility policy and procedure was for working with symptoms. The facility failed to ensure TNA #144, who was symptomatic of COVID-19 was timely removed from providing resident care when she first exhibited symptoms, failed to ensure contact tracing was completed to identify any staff or residents at risk for COVID-19 due to exposure to TNA #144 and failed to ensure any residents/staff with possible exposure were placed in quarantine to prevent the spread of COVID-19 in the facility. On [DATE] at 10:05 A.M. interview with Local Health Department Nurse (LHDN) #150 revealed TNA #144 reported to the local health department (LHD) she had symptoms of COVID-19 including coughing, shortness of breath, nausea/vomiting, headache, fatigue, and diarrhea that had started on [DATE]. LHDN #150 revealed the employee was recommended to be placed in isolation from [DATE] to [DATE]. On [DATE] at 7:59 A.M. interview with the DON revealed from [DATE] until [DATE] facility staff were wearing only surgical masks and eye protection during this time period. 2. Review of the staff screening logs, dated [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] revealed no written documentation HK #114 reported she was exhibiting any signs or symptoms of COVID-19. Further review of the staff screening logs dated [DATE], [DATE], [DATE], and [DATE] revealed no evidence HK #114 was screened prior to working. Review of HK #114's time sheet documentation revealed HK #114 worked [DATE] from 6:57 A.M. until 3:08 P.M., [DATE] from 6:55 A.M. until 2:56 P.M., [DATE] from 6:55 A.M. until 2:58 P.M., [DATE] from 6:55 A.M. until 2:25 P.M., [DATE] from 6:55 A.M. until 3:05 P.M., [DATE] from 6:55 P.M. until 12:00 P.M., and [DATE], [DATE] and [DATE] from 7:00 A.M. until 2:00 P.M. HK #114 was working 7:00 A.M. to 3:00 P.M. on [DATE]. Review of HK #114's COVID-19 rapid test results, dated [DATE] revealed HK #114 tested positive for COVID-19 on this date. Record review revealed no documentation of the symptoms exhibited by the HK at that time. A letter from the LHD, faxed [DATE] and dated [DATE] revealed a recommendation for HK #114 to be in isolation for COVID-19 from [DATE] to [DATE]. Review of the housekeeping schedule, dated ,d+[DATE] revealed there were six staff members not including HK #114 to provide housekeeping services for 30 residents. The facilities bed capacity was 50. On [DATE] at 10:13 A.M., 12:40 P.M., and 2:00 P.M. interview with the DON revealed HK #114 had worked on [DATE] and [DATE] (the time period when TNA #144 tested positive for COVID-19). The DON revealed she thought HK #114 was asymptomatic but tested positive for COVID-19 on [DATE] as part of the facility outbreak testing. The facility asked HK #114 to return to work on [DATE] to work as a housekeeper on the COVID unit because they thought she was asymptomatic. The DON revealed the facility was not aware HK #114 had been symptomatic of COVID-19 since [DATE] and still currently had symptoms. On [DATE] at 1:41 P.M. interview with HK #114 revealed she was rapid tested for COVID-19 on [DATE] as part of the outbreak testing and tested negative for COVID-19. HK #114 reported she had a stuffy nose on [DATE] and continued to work with the stuffy nose, working throughout the entire facility on all three units on this date and over the weekend [DATE] and [DATE]. HK #114 revealed she had been in every resident room throughout these dates. HK #114 reported she still had a stuffy nose, but the facility had asked her to return to work to help in the COVID unit on [DATE] before her isolation was completed. HK #114 confirmed she did not report her stuffy head on the screening log because a stuffy head was not one of the questions on the screening form. HK #114 confirmed congestion was an option on the log, however, she stated she never thought about that as a symptom or consistent with a stuffy head. The facility failed to ensure HK #114, who was symptomatic of COVID-19 was timely removed from working in resident care areas when she first exhibited symptoms, failed to ensure contact tracing was completed to identify any staff or residents at risk for COVID-19 due to exposure to HK #114 and failed to ensure any residents/staff with possible exposure were placed in quarantine to prevent the spread of COVID-19 in the facility. On [DATE] at 3:00 P.M. observation of the COVID-19 unit revealed the only staff member on the unit was HK #114. HK #114 revealed the nurse had left the unit and it was only her and the nurse working the unit on this date. The nursing assistant staff from the other units (non COVID) would come over to help the nurse if needed. The COVID unit had a keypad lock on the entrance and exit doors. On [DATE] at 7:59 A.M. interview with the DON revealed the facility was not able to provide information/evidence the facility was in staffing crisis mode to justify HK #114 working in the facility with symptoms of COVID-19. In addition, during the interview, the DON revealed HK #114 did not report signs and symptoms of COVID-19 on the screening logs for [DATE] to [DATE] and she had not been screened for COVID-19 from [DATE] to [DATE]. The DON revealed the facility was not aware HK #114 was symptomatic or had symptoms. The DON then revealed HK #114 had reported she had a stuffy head yesterday. On [DATE] at 10:05 A.M. interview with LHDN #150 revealed HK #114 was ordered isolation from [DATE] to [DATE] due to the employee reporting symptoms of COVID-19 beginning on [DATE]. LHDN #150 revealed she had communicated to the facility on [DATE] that HK #114 should not have returned to work until [DATE]. LHDN #150 revealed the facility had not previously reported staffing issues or that they were in a staff crisis to allow for the consideration of HK #114 working during her isolation period. LHDN #150 reported the facility should not have allowed a symptomatic positive COVID-19 employee to work, even on the COVID-19 unit. 3. In addition to the above concerns related to TNA #144 and HK #114, review of the staff screening logs revealed the following additional concerns: a. The log dated [DATE] revealed LPN #129 had cough, congestion/runny nose, muscle pain, headache, and exposure to COVID positive person. There was no evidence the LPN was immediately removed from the facility at the beginning of the shift. Review of the COVID-19 testing log, dated [DATE] revealed LPN #129 tested positive for COVID-19 via a rapid test. Review of the nursing schedule dated ,d+[DATE] revealed LPN #129 was scheduled to work on [DATE] from 8:00 A.M. to 5:00 P.M. On [DATE] at 2:34 P.M., interview with the DON confirmed the screening log, dated [DATE] indicated LPN #129 had cough, congestion/runny nose, muscle pain, headache and exposure to COVID positive person. On [DATE] at 7:59 A.M. interview with the DON revealed the facility was not able to provide information/evidence the facility was in staffing crisis mode to justify LPN #129 working in the facility with symptoms of COVID-19. On [DATE] at 8:31 A.M. interview with the DON revealed LPN #129 worked on [DATE] from 8:00 A.M. to 5:00 P.M. while symptomatic of COVID-19. The DON revealed the LPN was scheduled on the COVID-19 unit and had possibly assisted with resident COVID testing as well. b. Review of the screening log dated [DATE] revealed State tested Nursing Assistant (STNA) #122 reported she had cough, congestion/runny nose, and sore throat on this date. There was no evidence the STNA was removed from the schedule based on the identification of COVID-19 symptoms at that time. Review of STNA #122's time sheet, dated [DATE] to [DATE] revealed the STNA worked on [DATE] from 6:59 A.M. until 7:17 P.M., on [DATE] from 1:53 P.M. until 7:24 P.M. and clocked in on [DATE] at 6:59 A.M. The STNA was scheduled to work on [DATE] until 7:00 P.M. c. Review of staff screening log dated [DATE] revealed Activities Assistant (AA) #137, who was unvaccinated reported she had fatigue, headache, loss of taste and smell, had contact with a positive COVID-19 person and did not have contact with a COVID-19 positive resident. There was no evidence the AA was removed from the schedule based on the identification of COVID-19 symptoms at that time. Review of AA #137's time sheet revealed AA #137 worked [DATE] from 9:13 A.M. until 5:16 P.M. and on [DATE] from 9:02 A.M. to 5:03 P.M. On [DATE] beginning at 9:27 A.M. AA #137 was observed going from residents' room to room providing residents with activities scheduled for the day. An interview with AA #137 at the time of the observation revealed she was providing activities to residents on Units B and C. On [DATE] at 7:59 A.M. interview with the DON confirmed AA #137 had been providing one on one activities with residents not in isolation for COVID-19 that may have been for over 15 minutes in a 24 hour period. The DON confirmed AA #137 had reported symptoms consistent with COVID-19, however, was permitted to work. On [DATE] at 10:05 A.M. interview with LHDN #150 revealed the expectation of the LHD would be for symptomatic staff to not work even if they had a rapid test that was negative for COVID-19. LHDN #150 revealed this guidance was especially important to follow since the facility currently had a COVID-19 outbreak. Review of the CDC's Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, dated [DATE] revealed health care personal (HCP) should not work while acutely ill, even if COVID-19 testing was negative, to minimize the risk of transmission of other infectious pathogens, including respiratory pathogens such as influenza. 4. Review of an unvaccinated resident vaccination status form, provided by the facility revealed the list contained eight unvaccinated residents, Resident #1, #4, #9, #15, #18, #21, #22 and #23 who were residing in the facility. a. On [DATE] at 8:08 A.M. and on [DATE] at 1:31 P.M. observation revealed no evidence Resident #9 and #22 had been placed in quarantine or encouraged to stay in their rooms related to possible exposure to COVID-19 positive staff in the facility. In addition, observations during these time periods revealed staff did not wear full personal protective equipment (PPE) when entering these residents' rooms. b. On [DATE] at 8:19 A.M. interview with LPN #147 revealed the LPN reported Resident #21 was on isolation for a wound infection and not related to COVID-19. A follow up interview on [DATE] at 12:05 P.M. with LPN #147 revealed the LPN had checked Resident #21's medical record and confirmed Resident #21 was on droplet precautions related to COVID-19 and not for a wound infection. c. On [DATE] at 12:03 P.M. observation with the DON present revealed TNA #144 entered Resident #23's room. Resident #23 was in quarantine for COVID-19 related to a new admission status and being unvaccinated and identified to have been possibly exposed to COVID-19 from a roommate (Resident #1) TNA #144 did not apply proper PPE, including a gown or gloves before entering the room. TNA #144 assisted the resident from a lying position to a sitting position on the side of the bed by pulling on the resident's arms. After providing care, TNA #144 exited the room and did not change her N95 mask or clean the eye protection she was wearing. Interview with TNA #144 at the time of the observation revealed she was told by a housekeeper that Resident #23's isolation was discontinued. The DON then responded no and reminded the TNA there was a sign to see nurse and a PPE cart sitting outside the resident's room. The DON confirmed the findings during the observation after the surveyor brought the observation to her attention and verified the resident was on droplet precautions for COVID-19. Resident #23 subsequently tested positive for COVID-19 on [DATE]. 5. On [DATE] at 10:13 A.M. and 12:40 P.M., on [DATE] at 7:59 A.M. and on [DATE] at 9:30 A.M. interviews with the DON revealed the following: Resident #4 had tested positive for COVID-19 on [DATE], however she was a resident in the attached assisting living at the time she tested positive. Resident #4 was moved to the nursing home side of the facility on [DATE] when she started to decline and was placed in isolation. Resident #1 and #21 were placed on quarantine because they were both new admissions, however Resident #1 contracted COVID-19 on [DATE] and Resident #21 on [DATE]. Resident #9, #15, #18, #22 and #23 were not placed on quarantine after potential close contact with TNA #144 or HK #114. The staff did not wear appropriate PPE while providing care or encourage the residents to stay in their rooms after the exposure as well. Unvaccinated residents, Resident #1, #15, #18, #21, and #23, who were not placed in quarantine, later tested positive for COVID-19 after potential exposure to the positive staff members. Unvaccinated residents, Resident #9 and #22, who were not placed on quarantine, had not tested positive for COVID-19 as of this time. During the interviews, the DON confirmed it was possible TNA #144 and HK #114 could have had close contact with all unvaccinated residents because there were not dedicated staff for each unit. The staff members were also responsible for assisting on the COVID-19 unit and then returning to the non-COVID units to provide direct care. The facility had not completed contact tracing or an investigation to determine how the COVID-19 outbreak occurred. The DON reported she thought it was the LHD's responsibility to complete the contact tracing. On [DATE] at 10:05 A.M., interview with LHDN #150 revealed the facility should have immediately placed all non-vaccinated residents on quarantine after potential exposure to the positive staff members. LHDN #150 reported the facility was small and contact tracing should have been completed or the facility should have reached out to her or the LHD for assistance with contact tracing if they needed assistance. LHDN #150 revealed the LHD was responsible for contact tracing outside the facility, however it was the facility's responsibility to perform contact tracing within the building. During the interview, LHDN #150 voiced concerns of the facility not performing contact tracing, not encouraging staff to stay home when symptomatic of COVID-19 and not utilizing dedicated staff on the COVID-19 unit. LHDN #150 revealed these concerns had been previously voiced to the health department medical director and the regional epidemiologist. 6. During the complaint investigation, the following infection control concerns and COVID-19 timeline were reviewed which included but was not limited to: a. On [DATE] at 8:08 A.M. an initial tour of the facility and interview with LPN #147 revealed outside the COVID-19 unit there was one room (A hall / room number provided) with two residents who were positive for COVID-19 and one room (C hall / room number provided) for a resident in isolation for a wound infection. There was no evidence of any other rooms for resident's in quarantine/isolation. Resident #28 tested positive for COVID-19 on [DATE]. At the time Resident #28 tested positive, her roommate, Resident #5 was not placed in quarantine. On [DATE] at 9:30 A.M. interview with the DON revealed Resident #5 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 1:31 P.M. observation revealed no evidence Resident #5 was in quarantine. There was no signage on the resident's door or PPE cart outside the room. At this time, Resident #5 was observed in the common area of the facility sitting less than six feet from Resident #19, without a mask. There was no evidence staff had encouraged resident to stay in their room or wear a mask. b. Record review revealed Resident #31 tested positive for COVID-19 on [DATE] after exhibiting symptoms (headache and nasal congestion). On [DATE] the resident was assessed to have an audible gurgle/rattle with exhalation breathing. The resident's skin was cool/clammy to touch and the resident was pale in color. The resident's oxygen level was 83% on three liters of oxygen via mask. The resident's temperature was 104.6 degrees. The physician was notified and new orders were received to send the resident to the emergency room . However, the resident expired seven minutes later. Resident #31 contracted COVID-19 while residing in the facility. The resident had not left the facility or had any visitors recently. c. Unvaccinated Resident #18 and vaccinated Resident #6 shared a room and both tested positive for COVID-19. Resident #18 on [DATE] and Resident #6 on [DATE] after exhibiting symptoms (non-productive cough and hoarse voice). Resident #18 was moved to the COVID-19 unit and Resident #6 was placed in a quarantine room with unvaccinated Resident #23 who tested positive on [DATE], however was exhibiting symptoms (temperature 100.1) on [DATE] and was ordered Tylenol for temperature. Resident #23 became lethargic and had poor appetite on [DATE] when she tested positive for COVID-19. Resident #23's roommate prior to quarantine was Resident #14 who tested positive for COVID-19 on [DATE]. d. Resident #3 and Resident #16 shared a room. Resident #3 tested positive for COVID-19 on [DATE] and was exhibiting symptoms (fever, weakness, and wheezes) and Resident #16 on [DATE]. Resident #20 and #27 shared a room and both tested positive for COVID-19 on [DATE]. On [DATE] Resident #27 was treated with Tylenol for a temperature of 99.2 and sore throat, however there was no evidence she was tested for COVID-19 at that time. Resident #20 started exhibiting symptoms of weakness and hoarse voice on [DATE] so the facility tested both residents. Unvaccinated Resident #15 and roommate Resident #25 shared a room. Resident #15 was exhibiting symptoms (lethargic) of COVID-19 and tested positive on [DATE]. Resident #25 was moved to a quarantine unit, started exhibiting symptoms (weakness, hoarseness, non-productive cough) of COVID-19 and subsequently tested positive on [DATE]. Resident #12 and #13 shared a room. Resident #12 started to exhibit symptoms (lethargic, febrile, and poor appetite) of COVID-19 and tested po [TRUNCATED]

Based on record review, review of a medication error report, review of hospital records, facility policy review and staff interview the facility failed to ensure Resident #36 was free of a significant medication error. Actual Harm occurred on 11/21/20 when Resident #36 was administered medications, including cardiovascular medication prescribed for Resident #42 and which Resident #36 did not have a physician order [REDACTED].#36) of four residents reviewed for medication administration. Findings include: A review of Resident #36's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed the resident was hosptalized on [DATE] and re-admitted to the facility on [DATE] A review of Resident #36's physician's orders [REDACTED]. A review of Resident #36's admission Minimum Data Set (MDS) 3.0 assessment, dated 11/17/20 revealed the resident was sometimes able to make herself understood and was sometimes able to understand others. She had short and long term memory impairment and her cognitive skills for daily decision making were severely impaired. A review of Resident #36's nursing progress notes revealed a note dated 11/21/20 at 10:31 A.M. that revealed the resident was out of the facility and had been transported to the emergency room by squad per the physician's orders [REDACTED]. A review of a telehealth evaluation note for Resident #36 dated 11/21/20 at 12:07 P.M. for a date of service of 11/21/20 at 8:14 A.M. revealed the primary chief complaint was medication given in error. The history of present illness indicated the resident had a history of [REDACTED]. The medications that were given included Carvedilol 12.5 mg, [MEDICATION NAME] 75 mg, [MEDICATION NAME] 20 mg, [MEDICATION NAME] 60 mg, [MEDICATION NAME] 40 mg, [MEDICATION NAME] 80 mg and Ranolazine 500 mg. The nurse informed the physician they had been pushing oral fluids and were checking the resident's blood pressure and heart rate. The resident was feeling tired and not well after receiving the medications. At the time the physician saw her, the resident reported she was feeling a little better however, she was turning pale and becoming more lethargic. She was having symptoms of dizziness, fatigue, feeling hot, sedation, weakness and a slight headache. Her heart rate was 53 beats per minute (BPM) and her blood pressure was 80/44. Her heart rate had been reported to be between 40- 50 BPM earlier. The resident was sent to the hospital for being symptomatic of [MEDICAL CONDITION] and [MEDICAL CONDITION]. The physician determined she needed to be transferred to the emergency room immediately for management and 911 was called. A review of a health status note, dated 11/21/20 at 12:20 P.M. and completed by Licensed Practical Nurse (LPN) #102 revealed, after all but one pill was given to Resident #36 that morning, she checked the electronic Medication Administration Record [REDACTED]. LPN #102 notified the RN right away. The RN stated to monitor her, gather her vitals and check her again in a hour. She checked the resident's blood pressure and pulse every few minutes. She noted the resident's vital signs were going down. She attempted to contact the Director of Nursing (DON) but was unsuccessful. The staff helped the nurse look for the Administrator's number but it could not be located. The nurse then called the facility's Assistant Director of Nursing (ADON) and was told she would be on her way. Third Eye Medical was called as advised and they asked for the nurse to video call them. At that time an STNA came to tell the nurse Resident #36 was getting clammy and sweating. The local fire department was called for transport. The physician from Third Eye Medical spoke with the resident via video call and told her that she needed to be seen at the emergency room . Paper work was given to the EMT to include the resident's face sheet, her current medication list, and the other residents' medications that she had accidentally been given that morning. A review of a medication error report dated 11/21/20 at 9:30 A.M. revealed Resident #36 was given Carvedilol 12.5 mg, [MEDICATION NAME] 60 mg, [MEDICATION NAME] 20 mg, [MEDICATION NAME] 40 mg, [MEDICATION NAME] 75 mg, [MEDICATION NAME] 80 mg and Ranolazine 500 mg. The medication error report indicated medications were administered to the wrong resident. A brief explanation of the error indicated LPN #102 administered morning medication regimen to the wrong resident. Medications for Resident #42 were given to Resident #36. A nurse's progress note, dated 11/21/20 at 7:35 P.M. revealed the facility staff spoke with the resident's son and received an update on the resident. The son stated that the resident was stable but would be staying overnight at the hospital for monitoring. She was possibly going to be discharged in the morning and return to the facility. A review of Resident #36's eMAR for November 2020 revealed Resident #36's morning (am) medications for 11/21/20 were not signed as having been given to the resident that morning. The nurse added a 3 in the box on the eMAR which the legend indicated meant the resident was absent from the facility at the time of the administration. A review of Resident #36's discharge summary for her hospital stay between 11/21/20 and 11/22/20 revealed the resident was seen for [MEDICAL CONDITION] and [MEDICAL CONDITION] after she had received the wrong medications at the skilled nursing facility. An EKG demonstrated improvement in [MEDICAL CONDITION] after intravenous (IV) fluids and [MEDICATION NAME] were received. The resident was assessed to be status [REDACTED]. The medications she received in error included [MEDICATION NAME],[MEDICATION NAME] Renexa which led to the resident's subsequent [MEDICAL CONDITION] and [MEDICAL CONDITION]. The resident received [MEDICATION NAME] which improved the [MEDICAL CONDITION]. Poison control was notified and recommended close monitoring of the resident for over the next six hours as [MEDICATION NAME] longer [MEDICATION NAME] effects. A history and physical dated 11/21/20 revealed the resident was in a drug induced [MEDICAL CONDITION] and [MEDICAL CONDITION]. She received incorrect medications at the nursing facility which included [MEDICATION NAME], Imdur, Renexa and other antidepressants. Her heart rate was stabilized after one time [MEDICATION NAME] in the emergency room and a 250 milliliter (ml) bolus (of fluid). A review of the facility undated Medication Administration policy revealed medications were administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Prior to administration, the medication and dosage schedule on the eMAR was compared with the medication label. If the label and eMAR were different and the container was not flagged indicating a change in directions or if there was any other reason to question the dosage or directions, the physician's orders [REDACTED]. Medications were administered in accordance to written orders of the attending physician. Residents were identified before medication was administered. Methods of identification included checking identification band, checking photograph attached to the medical record, calling the resident by name, if necessary, and verify the resident's identification with other facility personnel. This deficiency substantiates Complaint Number OH 008.

Based on observation, medical record review, policy review and interview, the facility failed to provide timely incontinence care to dependent residents. Actual harm occurred when the facility failed to ensure Resident #24, who was dependent on staff for toileting, was routinely checked and provided incontinence care. The resident was found to be soaked with urine and stool that had dried and adhered to the resident's skin resulting in the development of a facility acquired Stage II pressure ulcer. This affected two (Resident #24 and #40) of three residents reviewed for bowel and bladder incontinence. Findings include: 1. Medical record review revealed Resident #24 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan: At Risk for Decline in ADL (activity of daily living) Function dated 04/08/15 revealed interventions including a hoyer lift for all transfers with assist of two staff, preventative skin care as needed (PRN) and to monitor for any skin breakdown. Peri-care was to be provided with each incontinence episode PRN. Review of the care plan: Alteration in Elimination: Incontinent of Bowel and Bladder revised 11/18/16 revealed the goal was to be clean, dry and odor free. Interventions included to provide incontinence care on a routine basis and PRN. Review of the care plan: At Risk for Impaired Skin Integrity related to limited mobility and incontinence dated 09/24/18 revealed the resident had a history of [REDACTED]. Interventions included peri-care after each incontinence episode, turn and reposition as tolerated every two hours and PRN, and inspect skin during routine daily care. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident was severely impaired for daily decision-making, was dependent on staff for bed mobility, transfers and toilet use, and was always incontinent of urine and bowel. Review of the Task List dated 05/13/19 revealed Resident #24 had a medium bowel movement at 12:57 P.M. and was incontinent of urine at 1:06 P.M documented by STNA #46. On 05/13/19, Resident #24 had been seen sitting in a specialized chair in the dining room for breakfast and in the lobby with other residents. On 05/13/19 at 2:50 P.M., observation of incontinence care revealed State tested Nurse Aide (STNA) #65 and STNA #80 gathered needed supplies and entered Resident #24's room. The resident was laying in bed on his left side covered with a blanket. STNA #65 and #80 washed their hands at the sink, applied gloves, and informed the resident of what they were going to do. The bed was raised, the blanket removed revealing the resident's clothing and linens were soaked with urine. The incontinence product was removed revealing the resident had been incontinent of urine and he had a large, loose bowel movement (BM). The top portion of the resident's buttocks and his coccyx was observed to have dried BM that was adhered to the resident's skin. A strong urine and fecal odor was noted and the resident's groin, scrotum and buttocks were bright red. STNA #65 and #80 used soap and water to soak the dried BM off the resident's skin and once the resident's skin was clean a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough) was observed on the coccyx. Interview with STNA #65 and #80 at the time of the observation stated the resident had been sitting in his specialized wheelchair since 5:00 A.M., and the resident had not been toileted or laid down throughout the shift. STNA #65 and STNA #80 stated the STNA responsible for his care had left for the day and stated she did not ask for anyone to help or assist her with the hoyer lift transfer or incontinence care. STNA #65 verified the resident's BM was contained in the incontinent product, dried and stuck to his skin and stated there was no way he had been changed at 1:06 P.M.; otherwise, it would not have been dried. STNA #65 and #80 stated the resident should be laid down after meals and checked for incontinence at least every two hours. On 05/13/19 at 3:04 P.M., interview with the Director of Nursing (DON) verified bowel incontinence would have had to have been there for a long time for it to dry and adhere to the skin. The DON verified the resident was at risk for skin breakdown, was left incontinent, was possibly up in his chair all day, and a new pressure ulcer had resulted. The DON stated it was her expectation that residents were to be toileted at least every two hours if they were dependent on staff for care. On 05/13/19 at 3:05 P.M., interview with STNA #65 and #80 verified Resident #24 had not had been changed since 5:00 A.M., denied assisting STNA #46 with care and stated the resident required the use of hoyer lift and two staff with transfers. STNA #65 further stated STNA #46 did not ask for any help. 2. Medical record review revealed Resident #40 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan: At Risk for Infection related to a history of urinary tract infections [MEDICAL CONDITION] dated 08/24/18 revealed interventions including to monitor for signs and symptoms of a UTI including foul smelling urine. Review of the care plan: Alteration in elimination: always incontinent of bowel and bladder dated 11/16/18 revealed the goal was for the resident to be clean, dry and odor free. Interventions included to monitor for skin redness, irritation and provide incontinence care PRN. Review of the annual MDS assessment dated [DATE] revealed Resident #40 was severely impaired for daily decision-making, required extensive assist with toilet use and was always incontinent of urine. Review of the Task List dated 05/13/19 revealed Resident #40 was incontinent of urine at 1:05 P.M On 05/13/19 between 2:37 P.M. and 3:00 P.M., observation of incontinence care revealed STNA #65 and STNA #80 gathered needed supplies and entered Resident #40's room. The resident was laying in bed on her back covered with a blanket. STNA #65 and #80 washed their hands at the sink, applied gloves, and informed the resident of what they were going to do. The bed was raised and the blanket was removed revealing the resident's clothing and linens were soaked with urine. The incontinence product was removed and the cotton filling was gathered throughout due to the amount of urine in the incontinence product. As STNA #80 placed the incontinence product in the plastic bag a thump noise was heard and an indentation was observed in the bag due to the weight of the incontinence product. A strong, foul urine odor was noted and the resident's groin and inner thighs were bright red. The resident was shaking her fists and stated it hurt as STNA #80 was washing the resident's groin, rectum and inner thighs. STNA #80 completed incontinence care, applied peri-guard skin protectant barrier to the resident's groin and inner thighs, placed a new incontinence product on the resident, pulled the residents blankets up to her chest and then removed her gloves. On 05/13/19 at 2:48 P.M., interview with STNA #80 verified the above observation and stated the resident's skin was bright red from the incontinence product being too small and being saturated with urine. STNA #65 and #80 stated Resident #40 had been up in her wheelchair since around 5:00 A.M. without being toileted, changed or laid down. STNA #65 stated the resident will urinate on the toilet if staff takes her and she can be continent of urine when prompted. Review of the Skin Assessment Weekly/Return/ER/LOA assessment dated [DATE] at 4:22 P.M., revealed the residents skin was intact and the residents groin and buttocks were red. On 05/13/19 at 4:55 P.M., interview with the DON verified Resident #24 and #40 were not provided timely incontinence care and residents should be toileted at least every two hours and prompted to void on the toilet if the resident was able. The DON also stated at this time there was no evidence of toileting schedules to alert staff of when residents needed to be toileted to restore or maintain bladder function. Review of the undated policy: Perineal Care revealed the purpose was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin condition.

Based on review of the medical record, emergency medical services (EMS) records, death certificate, the facility Mechanically Altered Diets policy, family interview and staff interview, the facility failed to ensure physician ordered nutritional interventions and adequate supervision were in place to prevent one resident (Resident #46) from choking on a marshmallow snack that was not approved by her diet consistency order. This resulted in Immediate Jeopardy when staff failed to assist Resident #46, who was assessed at risk for aspiration and choking, with a snack. Actual harm occurred when Resident #46 independently obtained and consumed the marshmallow snack, aspirated and died . This affected one of three residents reviewed for death. The facility identified 15 residents with a potential for aspiration/choking. (Resident #1, #3, #6, #11, #12, #17, #19, #20, #22, #25, #29, #26, #33, #34 and #147). The facility census was 41. On [DATE] at 5:10 P.M. the Administrator was notified Immediate Jeopardy began on [DATE] at approximately 2:30 P.M. when Resident #46, who was assessed to be at risk for aspiration/choking, had a recommendation for supervision with all oral intake per speech therapy and a physician order [REDACTED]. On [DATE] at 3:05 P.M. the resident was found unresponsive in bed. Cardiopulmonary resuscitation (CPR) was initiated and EMS was called. During resuscitation efforts a whole marshmallow was observed in the resident's airway. The marshmallow became dislodged and was removed from the resident's mouth. However, CPR efforts were unsuccessful and the resident was pronounced dead by EMS personnel following an EKG at 3:30 P.M. Cause of death documented on Resident #46's death certificate indicated the resident died of aspiration. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective action: · On [DATE] at 5:30 P.M., the Administrator, Director of Nursing (DON), Registered Nurse (RN) #33, Licensed Practical Nurse (LPN) 38, RN #78, Dietary Manager (DM) #57, Social Worker (SW) #81, and Social Service Assistant (SSA) #84 removed food items from the following residents (who were identified to be at risk for aspiration and choking and received mechanical altered diets): Resident #1 (cookies), Resident #3 (Little Debbie snack cakes), Resident #11 (small soft candy bars), Resident #20 (small candy bars), Resident #22 (candy bars and pudding), Resident #26 candy, suckers, crème horn), Resident #33 (little Debbie snack cakes and donuts), Resident #34 (donuts). As the items were found, the resident was notified the items would be taken to the Social Service or Activity office for safe keeping until the families/responsible parties could be notified and it deemed appropriate for the resident to have the food items. · On [DATE] from 6:45 P.M. to 9:00 P.M., SW #81 and SSA #84 educated 12 residents' family members (Resident #1, #3, #11, #12, #17, #19, #20, #22, #26, #29, #33, and #34) on the residents' current diet status and not to leave any food in the residents' rooms that could be an aspiration or choking risk. The families were informed that any food items brought in needed to be checked for appropriateness by the nurse and would be stored in the activity room. · On [DATE] at 6:50 P.M., the DON, Administrator, RN #33, and LPN #38 educated three RNs, 13 LPNs, 29 STNAs, and two activity staff members regarding no food items that were not compliant with diet orders were to be stored in any of the residents' rooms. Staff were not to assist the residents in ordering any non-compliant food items. Staff were also educated to remove any food items found in residents' rooms until the responsible party could be notified. All staff received education except for one LPN, who was out of state. The LPN was to receive education upon return to work. · On [DATE] and [DATE] the DON, RN #33, and LPN #38 reviewed 15 residents' medical records identified to be at risk for aspiration/choking, (Resident #1, #3, #6, #11, #12, #17, #19, #20, #22, #25, #29, #26, #33, #34, and #147). The current plan of care was reviewed to reflect the residents' current orders. · On [DATE] at 9:20 A.M. and 12:20 P.M., observation revealed no evidence of snacks in rooms of the 15 residents who were identified at high risk for choking/aspiration (Resident #1, #3, #6, #11, #12, #17, #19, #20, #22, #25, #29, #26, #33, #34 and #147). · On [DATE] at 3:30 P.M., the DON and DM #57 provided education to an Ambassador team, which included SW #81, SSA #84, DON, RN #33, LPN #38, Housekeeping/Laundry Supervisor (HLS) #54, Activity Director (AD) #80, Office Manager (OM) #78, Human Resource (HR) #79, Maintenance Director (MD) #100, and the Administrator related to a new system to have each resident room monitored five days per week by the Ambassadors with ongoing oversight by the nursing staff. The Ambassadors were provided with education on the types of diets offered by the facility and any high-risk foods associated with them. The Ambassadors were also educated on a new process of putting a copy of the resident's diet order and a list of appropriate and high-risk foods on the back of each resident's closet door in their rooms. This information would be updated by the nursing staff when needed. Education also included information on the new policy for families to bring the food items to the nurses and how the food would be stored in the activity room. · On [DATE] at 5:00 P.M., Speech Therapist (ST) #76 screened three residents (Resident #17, #20, and #29) who were identified as of having a current risk assessment completed to determine the appropriateness of current dietary orders and provide recommendations to nursing. The recommendations were addressed with the attending physician of each resident for any order changes and families were notified. · On [DATE] at 6:00 P.M. to [DATE] at 9:00 A.M., the DON, Administrator, and DM #57 provided education to seven dietary staff, 13 LPNs, 29 STNAs, three RNs, five housekeeping staff, and the receptionist on the types of diets, high risk foods associated with them, and the new process for placing the resident's diet sheet along with a list of high risk food associated with it on the back of the closet doors for easy references. A book with that same information would be kept in the cabinet in the dining room and updated as needed by nursing staff. Education also included information on the new policy for families to bring the food items to the nurses and how the food would be stored in the activity room. · On [DATE] at 7:00 P.M., the new diet sheet and types of diets and high-risk food sheets were hung on the back of each resident's closet door for reference by staff. These would be updated as needed by nursing staff. A book with copies of these sheets was also placed in the dining room cabinet and at the STNA station for easy reference. · [DATE] at 8:00 A.M., SW #81 and SSA #84 contacted family members again to further educate them regarding the altered diets and high risk associated foods that could cause choking/aspiration. An information packet was being mailed to the family of each of the residents on mechanically altered diets, (Residents #1, #3, #6, #11, #12, #17, #19, #20, #22, #25, #29, #26, #33, #34, and #147), indicating which diet their family member was on and the associated list of examples of allowed/not allowed foods for that diet. A copy of the mechanically altered diet, food supplied by family and visitor policy was being reviewed on the call and would also be included in the information sent to the families. · The facility implemented ongoing monitoring including having the ST screen residents with an altered diet to determine if there was any need to change any current recommendations. The recommendations would be addressed with the attending physician of each resident for any orders changes. The Ambassador team would be responsible for monitoring rooms for any non-complaint food items through the Ambassador round process. Each room would be monitored five days per week with ongoing oversight by the nursing staff. The Ambassadors were provided education by the DON and DM #57 on the types of diets and the high-risk foods associated with them. · New Employees would be educated through the orientation program before working directly with any residents. The DM would be responsible for this education. It would include the types of altered diets and the high-risk foods associated with those diets that may put the resident at risk for choking/aspiration. Also, it would include where they can find the information in the resident's room and the dining room so they can have the information on the type of diet and the high-risk food associated with them. · To monitor staff's knowledge of the mechanically altered diets, an audit would be completed by the DON or designee weekly until substantial compliance was achieved to verify that each employee was knowledgeable on the types of diets provided, the need to monitor those residents with altered diets, and the risk associated. The results would be reviewed by the Quality Assurance Committee to determine the need for continued monitoring. · New Admissions- Residents who were admitted with mechanically altered diets would be educated on the importance of following the diet to avoid choking/aspiration. The education would be conducted by the nursing staff or social service during the admission process. A copy of the policy would be provided to the residents and/or responsible party upon admission in the admission packet. They would also receive a list of examples of high risk foods associated with the various textures. · On [DATE] review of the facility admission packet revealed the packet was updated to include the policy on mechanically altered diets. The new hire orientation packets also included the new policy on mechanically altered diets. · On [DATE] at 11:47 A.M. and 12:00 P.M. interview with STNA #17 and STNA #31 revealed both staff members were knowledgeable regarding the facility's updated policy on mechanically altered diets and proper storage of snack items for those residents on a mechanically altered diet. The staff reported the facility put out binders that included a list of resident diets to identify those on a mechanically altered diet. There was also a sheet taped to the inside of the resident's closet in their rooms that identified their diet. Both knew residents on mechanically altered diets were not to have snacks kept in their room and if requested had to be stored in the activity room and the resident had to be monitored while eating those snacks. Both knew marshmallows were not appropriate for residents on a mechanical soft or a pureed diet. Both indicated if they found a snack in a room of a resident on a mechanically altered diet they would remove and take it to the nurses' station after explaining to the resident or family they were not permitted to keep them in the room. Although the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at Severity Level 2 (the potential for more than minimal harm that is not Immediate Jeopardy), as the facility was in the process of evaluating interventions and auditing staff performance in the provision of mechanical altered foods and food at high risk for aspiration/choking. Findings include: Record review revealed Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most current speech therapy service records, dated [DATE] to [DATE] revealed the resident was referred to therapy due to choking/coughing during meal presentation. Resident #46's speech therapy discharge orders indicated the resident required close supervision with oral intake. She was ordered a mechanical soft diet with thin liquids, mechanical soft ground meats, sandwiches cut into small pieces, and soft snacks with close supervision. Review of Resident #46's Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed the resident had severe cognitive impairment and required limited assistance of one staff for eating. Record review revealed Resident #46 had current care plans related to impaired feeding due to a contracture of the left hand, potential for alteration in nutrition and hydration related to hiatal hernia, dementia, depression, anxiety, [MEDICAL CONDITION], and mechanically altered diet related to potential for choking/aspiration. Interventions included diet and snacks as ordered, assure positioned correctly and up to table, cue, prompt and physical assist as needed, dining program daily, and adaptive equipment as needed. Further review revealed no documented information contained on the care plan of the resident's actual diet order. Review of the current physician monthly orders for (MONTH) (YEAR) revealed the resident's diet order was for a mechanical soft texture, thin consistency, soft snacks with close supervision, sandwiches cut into small pieces diet with a spout cup for drinks. Review of the nursing progress note, dated [DATE] at 3:43 P.M., revealed LPN #12 was walking past Resident #46's room and noticed the resident was blue and lying down on her bed. The LPN immediately yelled for assistance from LPN #48. LPN #48 performed a sternal rub with no results. LPN #12 listened for heart sounds, none noted and found no pulse present. The DON and RN #33 were also in the resident's room. The note indicated, Resident #46 took two breaths and CPR was initiated by the DON. The resident was assessed between rounds of CPR and was still void of pulse and heart sounds. The daughter had been notified and requested the resident be sent to the emergency room and EMS was called at 3:20 P.M. Upon EMS arrival, the resident was assessed and was void of pulse and heart sounds. EMS staff performed an electrocardiography (EKG) which revealed no pulse or heart rhythm. The physician was notified and the family was present at that time. Medical record review revealed this was the only notation contained in the resident's medical record regarding the acute change in condition experienced by the resident. Review of the EMS report, dated [DATE] revealed they were called by the facility at 3:19 P.M. for a female in [MEDICAL CONDITION]. EMS arrived to the resident's room at 3:27 P.M., confirmed the resident's code status was a Do Not Resuscitate Comfort Care- Arrest (DNRCC-A) and advised facility staff to discontinue all resuscitative measures. The EMS report documented EMS personnel assessed the resident for vital signs at 3:29 P.M. which were absent. An EKG, obtained at 3:30 P.M. confirmed the resident was asystole (the most serious form of [MEDICAL CONDITION], total cessation of electrical activity from the heart, irreversible). The county corner was notified of the resident's death and EMS left the facility at 3:34 P.M. Review of Resident #46's death certificate dated [DATE] and completed by the resident's primary care physician, Physician #101, revealed Resident #46's cause of death was aspiration. Record review revealed there was no documented evidence in Resident #46's medical record that the resident choked or aspirated on a food item or the specific circumstances surrounding the resident being found unresponsive. On [DATE] at 2:07 P.M., interview with RN #33 revealed the DON and herself started CPR on the resident due to Resident #46 having agonal (abnormal/gasping respirations in an abnormal breathing pattern) breathing. RN #33 revealed one of the staff members had called the resident's daughter and the daughter wanted the CPR continued. However, upon the daughter's arrival she requested resuscitative measures be stopped and EMS personnel pronounced the resident's death following an EKG. On [DATE] at 2:00 P.M. a follow up interview with RN #33 revealed when staff first entered Resident #46's room and found her unresponsive they did not observe anything in the resident's mouth. However, she was observed with brown secretions coming from her mouth. RN #33 stated the resident then took a couple of breaths and they initiated CPR/chest compression and suctioning due to the increased sections. She stated they did two or three rounds of compressions before they could locate an adult ambu bag (to give resuscitation breaths). During that time a marshmallow had become dislodged and staff were able to remove it from the resident's mouth. RN #33 revealed the resident had a carton of chocolate covered marshmallows within reach in her night stand. On [DATE] at 2:45 P.M., interview with the DON revealed upon entering Resident #46's room on [DATE] at 3:05 P.M. the resident had agonal breathing. She stated she thought she felt the resident had a carotid pulse and initiated CPR with RN #33 assisting. The DON stated staff performed CPR for about 15 minutes before EMS arrived and pronounced the resident dead. On [DATE] at 2:12 P.M. a follow up interview with the DON revealed after several compressions she did notice something in Resident #46's mouth and identified it to be a whole marshmallow. She stated staff continued CPR. The DON stated a carton of chocolate covered marshmallows was observed at Resident #46's bedside. Following the incident STNA #31 reported Resident #46 had requested one of the marshmallows but she told her no. The DON stated STNA #31 was upset that she told the resident no she could not have the marshmallow and then she choked on it. On [DATE] at 10:05 A.M., interview with Resident #46's daughter revealed she received a call from the facility on [DATE] at around 3:18 P.M., and was told her mom had choked on a marshmallow and they were working on her. She stated she told staff to continue CPR. She stated she arrived to the nursing home around 3:25 P.M. and confirmed her mom had choked on a chocolate covered marshmallow. The resident's daughter revealed her aunt had brought in snacks including chocolate covered marshmallows on Friday for the resident's birthday party. On [DATE] at 12:43 P.M., interview with LPN #48 revealed LPN #12 had called her back to Resident #46 room on [DATE]. She stated when she arrived the resident was unresponsive; her lips were purple and she would not respond to a sternal rub. She stated she did not check the resident's breathing. LPN #48 stated that LPN #12 stayed with the resident while she went and got the DON and RN #33 and CPR was initiated. EMS arrived, assessed the resident, obtained an EKG and pronounced the resident dead. On [DATE] at 1:40 P.M., interview with LPN #12 revealed she was walking past Resident #46's room on [DATE] and noticed the resident's color was off. She stated she entered the room, shook the resident, performed a sternal rub and checked for a heartbeat and respiration, which were absent. She stated she yelled for LPN #48. LPN #12 stated she did not notice anything in the resident's mouth at that time. The DON and RN #33 initiated CPR. EMS arrived and pronounced the resident dead. LPN #12 confirmed she was aware Resident #46 had snacks in her room and stated the resident would usually ask staff for them. On [DATE] at 5:00 P.M., interview with the Administrator revealed STNA #31 was the STNA who had refused to give Resident #46 the marshmallow after the resident requested the snack on [DATE]. The STNA reported she refused to give the resident the marshmallow because she had just laid her down in bed. The administrator confirmed the resident's snacks were within her reach and also indicated staff were aware family was bringing the resident snacks. During the interview, the Administrator indicated the family had not signed any type of risk assessment to allow snacks in the resident's room unsupervised nor did the facility complete any type of incident report following the choking incident on [DATE]. On [DATE] at 5:25 P.M., interview with Registered Dietary Technician (RDT) #75 and DM #75 confirmed Resident #46's diet order was for a mechanical soft texture, thin consistency, soft snacks with close supervision, sandwiches cut into small pieces diet with spout cup for drinks. They confirmed they did not have any type of risk agreement for the resident to be able to eat in her room unsupervised. The RDT and DM revealed a whole marshmallow would not be safe for a resident on a mechanically altered diet. RDT #75 and DM #75 both agreed residents that required supervision with food intake should not have snacks in their room unsupervised. The DM reported the facility would not serve marshmallows to any residents who were on a mechanically altered diet as they were a choking hazard. On [DATE] at 8:45 A.M., interview with ST #76, who had performed Resident #46's speech evaluation in (YEAR) revealed a whole marshmallow would be considered a regular food item. She confirmed Resident #46 needed supervision with all intakes, including snacks. On [DATE] at 9:10 A.M., interview with STNA #24 revealed she worked day shift the day Resident #46 expired. She reported the resident had snacks in her room and they were in her reach. The STNA indicated the resident could verbalize her needs and request snacks when she wanted them. STNA #24 confirmed she was not aware of the resident's diet order for soft snacks with close supervision. She indicated if a resident was on close supervision there should not have been snacks in the room. On [DATE] at 9:15 A.M., interview with STNA #21 revealed she was aware Resident #46 had snacks in her room on the bedside table and in her night stand. The STNA indicated the resident could reach both places from her bed. She was not aware the resident had orders for soft snacks with close supervision. On [DATE] at 10:00 A.M., interview with STNA #31 revealed on [DATE] she had worked during the day shift, but the facility was short staffed on the afternoon shift so she stayed over to help wash residents up. She stated she had assisted Resident #46 to lay down in bed around 1:00 P.M. She stated she went back into the resident's room between 2:30 P.M. and 3:00 P.M. and the resident asked her for a chocolate covered marshmallow. She reported the marshmallow was jumbo, like the ones you take camping. The STNA reported she did not feel comfortable giving the resident the marshmallow because the resident was lying down, the resident would take big bites at meals/requiring supervision and it was getting close to diner time. STNA #31 stated, Resident #46 threw a tantrum because she would not give her the marshmallow. The STNA indicated she was not aware the resident's diet orders included soft snacks with close supervision. She confirmed the chocolate covered marshmallow was left in the resident's reach when she exited the room. She stated she did not want to take the snacks out of the resident's room because she didn't want to make the daughter mad, however she stated she had been told by another STNA that residents with altered diets should not have snacks in their rooms. During the interview, STNA #31 revealed she had been provided education yesterday (on [DATE]) regarding mechanical diets and snacks in resident's rooms. Review of the facility undated policy and procedure for mechanically altered diets revealed mechanically altered diets shall be prepared and served as prescribed by the physician. Based on chewing ability and tendency to choke, an interdisciplinary approach, including ST, shall determine if a resident requires a mechanically altered diet. A physician's orders [REDACTED]. The diet card and care plan shall be maintained to be a current reflection of the status of each resident. In the event a resident was dissatisfied or non-complaint with the prescribed nutrition prescription, the interdisciplinary team, shall provide diet education and relevant, alternative treatment options to the resident/responsible party. Record review revealed at the time of the incident, the facility did not have a written policy regarding family bringing in food items for residents or food being left at the bedside for residents at risk for choking/aspiration.

Based on observation, medical record review, pain policy review, change in condition policy review, staff interview, and physician interview, the facility failed to ensure adequate pain management for one (Resident #31) of three residents reviewed for pain management. The facility identified 21 residents on pain management programs. Physical and psychological harm occurred to Resident #31 when the facility failed to respond and treat the resident's complaints of severe pain between 7:39 A.M. and 9:25 A.M. on 07/20/11. The resident had a [DIAGNOSES REDACTED]. Findings include: Medical record review revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's daily decision making was moderately impaired with no memory problems and the resident was on a scheduled pain medication regimen and complained frequently of pain that limited her day-to-day activities and made it difficult to sleep. On 07/19/11 at 5:07 P.M., Resident #31 was observed lying in bed on her back with facial grimacing, and the resident was complaining of pain in her buttocks. The resident rated her pain seven out of 10 (pain scale in which zero was no pain and 10 was severe pain) on the numeric pain intensity scale. Review of the medical record revealed no documented evidence the resident received nonpharmacological interventions for pain or any pain medication until 8:00 P.M. on 07/19/11. On 07/20/11, the following observations were made: a. At 7:39 A.M., Resident #31 was observed lying in bed on her back with facial grimacing. The resident rated her pain seven out of 10. The resident stated her scheduled pain medications were due at 8:00 A.M. and had not been administered yet. b. At 8:40 A.M., the resident was observed lying in her bed crying, stating her pain was worse. The resident rated her pain an eight out of 10. Licensed Practical Nurse (LPN) #3 was informed by the surveyor of the resident's complaints of pain. LPN #3 acknowledged the surveyor, and continued to pass medications to other residents on the opposite hall. c. At 8:55 A.M., State-tested Nurse Aide (STNA) #102 entered Resident #31's room. Resident #31 informed STNA #102 that she was having severe buttocks pain and needed pain medication. The resident was observed to be crying. STNA #102 notified LPN #3 of the resident's complaints of severe pain and request for pain medication. LPN #3 continued to pass medications on the opposite hall. d. At 9:04 A.M., Resident #31 was observed to be in pain, was crying, and put her call light on. e. At 9:08 A.M., STNA #102 entered the resident's room, told her the nurse was coming, and pulled the resident's door shut. f. At 9:12 A.M., Resident #31 could be heard yelling for help from her room with her door shut. Two staff members walked past the resident's room without acknowledging the resident's calls for help. g. At 9:18 A.M., LPN #3 prepared Resident #31's scheduled 8:00 A.M. medications that included a [MEDICATION NAME], 325 milligrams (mg) for pain. h. At 9:25 A.M., LPN #3 administered Resident #31 her 8:00 A.M. medications. The resident was observed to have tears running down her face. LPN #3 did not ask the resident if she was in pain or assess pain intensity, location, or frequency. On 07/20/11 at 9:25 A.M., during interview, LPN #3 stated Resident #31's pain was psychological and all in her head. LPN #3 stated the resident was not in pain. LPN #3 verified the resident's 8:00 A.M. scheduled [MEDICATION NAME] and [MEDICATION NAME] were administered late at 9:25 A.M. LPN #3 verified the resident was crying in pain when she entered the room, and verified she was told by STNA #102 and the surveyor that Resident #31 was in severe pain and that she did not address the pain until 9:25 A.M. LPN #3 verified no pain assessment was completed at the time of the 8:00 A.M. medication administration. On 07/20/11 at 11:00 A.M., Resident #31 was observed lying in bed on her back complaining of severe buttock pain. Resident #31 rated her pain a seven out of 10. At 11:05 A.M., Resident #31 was observed to have facial grimacing and moaning during repositioning with complaints of pain. Resident #31 asked LPN#3 for pain medication because she was still having severe pain. LPN #3 told the resident she had already given her pain medication that morning. LPN #3 verified she did not offer the resident any as-needed pain medication or nonpharmacological interventions for pain prior to rolling the resident on her right side to assess the resident's Stage III pressure ulcer. Review of Resident #31's pain assessment dated [DATE] at 2:30 P.M. revealed the resident complained of severe "bottom" pain that was rated eight of 10. The pain assessment revealed the resident described her pain as being a sharp, throbbing, and burning pain that was frequent and intermittent in duration. The assessment revealed the resident's pain affected her sleep and rest and affected the resident emotionally. LPN #3's comments included the resident frequently yelled out for pain medication. Review of the resident's nursing notes dated 07/18/11 through 07/21/11 revealed no documentation of the effectiveness of pain medication administered to Resident #31 or whether any nonpharmacological interventions were attempted. Review of the monthly physician's orders [REDACTED]., 8:00 A.M. and 10:00 P.M. Physician instructions included may give one hour after scheduled [MEDICATION NAME] dose. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of Resident #31's Pain care plan (revised 01/28/10) revealed interventions that included to administer medications as ordered, monitor the effectiveness of the interventions, offer backrub or warm blankets, and use the pain scale as reported by the resident. Review of the resident care plans revealed no documented evidence the resident was at risk for pain related to the resident having a Stage III sacrum pressure ulcer. On 07/21/11 at 10:23 A.M., phone interview with Resident #31's attending Physician #200 revealed Resident #31's Stage III sacrum pressure ulcer would cause the resident to have pain with movement and should have breakthrough pain medication an hour before doing any procedure or movement with the resident. Review of the Pain Management policy (revised April 2002) revealed the pain assessment was to begin with the patient self-report, listen to the resident's descriptive words about the pain, ask the resident to indicate the exact location, describe the intensity, ask when most and least pain was experienced, and observe for behaviors that suggest pain. The pain assessment was to be completed and documented in nurses' progress notes at each new report of pain and after pharmacological or nonpharmacological interventions were attempted. Review of the Change of Condition policy (revised April 2003) revealed significant changes in resident's clinical condition or status, including development of new pressure sores and change in the condition of a wound or pressure sore, the physician was to be notified immediately of all changes and documented in the medical record.

Based on observation, medical record review, Pressure Ulcer policy review, Change in Condition policy review, staff interview, and attending physician interview, the facility failed to treat a facility-acquired Stage II (partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater) sacrum pressure ulcer that deteriorated to a Stage III (full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep carter with or without undermining of adjacent tissue) sacrum pressure ulcer. The facility also failed to prevent the development of three avoidable Stage II left buttock pressure ulcers and prevent the deterioration to an unstageable Stage IV left buttock pressure ulcer (full-thickness tissue loss with exposed bone, tendon or muscle). This affected two of two residents reviewed for pressure ulcers (Residents #31 and #74). The facility identified two residents with pressure ulcers. Harm resulted to Resident #31 when the facility failed to initiate a treatment for [REDACTED]. The Stage III sacrum pressure ulcer was not being treated by the facility until 07/22/11. The facility also failed to notify Resident #31's attending physician of the deterioration of Resident #31's Stage II pressure ulcer to a Stage III pressure ulcer. Harm resulted to Resident #74 when the facility failed to treat an admission Stage II left buttock pressure ulcer, failed to prevent three facility-acquired Stage II pressure ulcers from developing on the resident's left buttocks above the admission Stage II pressure ulcer, and failed to prevent the deterioration of the Stage II pressure ulcers into an unstageable Stage IV left buttock pressure ulcer. The facility also failed to treat the unstageable Stage IV pressure ulcer with an appropriate treatment per facility policy. Findings include: 1. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's daily decision making was moderately impaired with no memory problems and the resident had no pressure ulcers. The resident required extensive assistance of two staff with bed mobility and extensive assistance of one with personal hygiene. Review of physician orders [REDACTED]. The survey observed this in place. Review of the annual pressure ulcer risk assessment dated [DATE] revealed Resident #31 was at high risk for pressure ulcer development. The surveyor identified during medical record review and observation of Resident #31's sacrum pressure ulcer that the facility interchanged the terms "coccyx" and "sacrum" pressure ulcers for Resident #31 for the same pressure ulcer site. On 07/22/11 at 3:40 P.M., interview with the director of nursing (DON) verified the facility interchanged "coccyx" and "sacrum" for the same sacrum pressure ulcer for Resident #31. Review of Resident #31's skin grid pressure assessment revealed the following: a. On 06/02/11, Resident #31 developed a facility-acquired Stage II sacrum pressure ulcer that measured 0.3 centimeters (cm) length (l) by <0.2 cm width (w) by 0.3 cm depth (d). The wound bed was pink with a scant amount of red drainage, and the wound was very tender, per the resident. The physician was notified of the wound on 06/02/11, and no documented treatment was initiated. b. On 06/08/11, 06/15/11, and 06/23/11, there was no change in the Stage II sacrum pressure ulcer. c. On 06/29/11, the Stage II sacrum pressure ulcer deteriorated to a Stage III pressure ulcer that measured 1.5 cm (l) by 2.0 cm (w) by 0.5 cm (d). d. On 07/07/11, the sacrum pressure ulcer measured 3.0 cm (l) by 2.0 cm (w) by 0.5 cm (d). The wound bed was red with moderate drainage. e. On 07/13/11, the Stage III sacrum pressure ulcer measured 4.0 cm (l) by 2.0 cm (w) by 0.4 cm (d); color pink, with scant red drainage. Review of the medical record revealed no documented evidence the physician was notified of the decline of Resident #31's facility-acquired Stage II sacrum pressure ulcer or that a treatment was initiated for the pressure ulcer until 07/22/11. On 07/20/11 at 11:05 A.M., observation revealed Resident #31 was complaining of severe pain, eight of 10, while Licensed Practical Nurse (LPN) #3 and State-tested Nurse Aide (STNA) #102 rolled the resident onto her right side to assess the resident's pressure ulcer. The lift pad on the bed was covered with dried red drainage that measured 10.0 cm by 5.0 cm. Observation of the resident's Stage III sacrum pressure ulcer revealed a 5.0 cm (l) by 3.0 cm (w) by >0.1 cm (d). The wound bed was red with yellow slough (necrotic, avascular tissue that separates from the viable portion of the body), and the perimeter of the wound was seeping red drainage. The skin around the Stage III sacrum pressure ulcer and bilateral buttock was macerated. LPN#3 then rolled Resident #31 back onto the soiled lift pad. On 07/20/11 at 11:13 A.M., LPN #3 and STNA #102 were observed positioning the resident in bed, and the resident's buttocks were observed to be indented into the mattress while being pulled up in bed and repositioned. On 07/20/11 at 11:15 A.M., interview with LPN #3 verified Resident #31 had no dressing applied to the Stage III sacrum pressure ulcer, stating the physician wanted the wound to drain onto the lift sheet. LPN #3 also verified the resident requested pain medication and was not provided any pain management. On 07/20/11 at 11:20 A.M., interview with STNA #102 verified the resident's buttocks were not off the mattress when the resident was pulled up in bed, and during nursing assessment of the resident's sacrum, the resident's lift pad was soiled with drainage from her wound and the resident was placed back on the soiled pad after the assessment. Review of the medical record revealed no physician notification of the pressure ulcer decline for Resident #31. Review of the At Risk for Impaired Skin Integrity care plan (revised 05/24/11) revealed no plan to address the Stage III sacrum pressure ulcer. Review of the Care Plan Cover (used by STNAs) revealed to reposition every two hours, reduce wrinkles, lift shift to reduce friction, and air mattress. The plan of care identified she was noncompliant with turning and repositioning. On 07/21/11 at 10:23 A.M., phone interview with Physician #200 revealed she did order the Stage II pressure ulcer to remain open to air; however, the facility did not notify her of the decline in Resident #31's Stage II pressure ulcer to a Stage III pressure ulcer. Physician #200 stated she had not instructed staff to allow the pressure ulcer to remain open to drain onto the lift pad. On 07/21/11 at 11:31 A.M., interview with the director of nursing (DON) revealed she was unaware the resident's pressure ulcer had declined to a Stage III pressure ulcer on 06/29/11. The DON verified Resident #31's Stage II pressure ulcer deteriorated to a Stage III, the physician was not notified of the decline, and no treatment was initiated after the pressure ulcer declined. 2. Medical record review revealed Resident #74 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 30-day MDS assessment dated [DATE] revealed Resident #74 was severely impaired for daily decision making with short- and long-term memory problems. The resident required extensive assistance of two staff for bed mobility, and required extensive assistance of one staff for personal hygiene. The resident was identified as frequently incontinent of urine and stool. Review of the readmission skin assessment dated [DATE] revealed Resident #74 was admitted with a Stage II left buttock pressure ulcer that measured 4.0 cm (l) by 3.0 cm (w) by >0.1 cm (d) and a Stage II coccyx pressure ulcer. Review of the admission physician's orders [REDACTED].#74's Stage II left buttock pressure ulcer; however, there was an order dated 06/07/11 to clean the coccyx area with normal saline and apply Allevyn dressing every three days. Review of the skin grid pressure ulcer left buttock assessment dated [DATE] the pressure ulcer measured 4.0 cm (l) by 3.0 cm (w) by 0.1 cm (d) with scant, red drainage. Medical record review revealed no pressure ulcer assessment or treatment for [REDACTED]. Review of Resident #74's At Risk for Skin Integrity care plan dated 05/27/11 did not identify the resident was readmitted to the facility on [DATE] with a Stage II coccyx and a Stage II left buttock pressure ulcer. The plan of care identified the resident was noncompliant for repositioning regularly and wanted to lie on his back most of the time. The plan of care was revised 07/15/11 and identified the resident had an open area on his buttock. Interventions included: Treat per physician's orders [REDACTED]. Review of the non-pressure skin grid assessment revealed the following: a. On 07/09/11, Resident #74 developed three additional Stage II pressure ulcers to the left buttock that measured 0.5 cm (l) by 0.5 cm (w) by <0.1 cm (d), 1.3 cm (l) by 1.4 cm (w) by <0.1 cm (l), and 1.0 cm (l) by 2.5 cm (w) by <0.1 cm (d). The surrounding tissue was bruised and firm. Review of the physician's orders [REDACTED]. b. On 07/15/11, the resident's left buttock pressure ulcer measured 6.0cm (l) by 4.5cm (w) by 0.3cm (d) with dark red edges. Wound bed was gray/black with a faint odor. Review of the medical record revealed no change in the treatment of [REDACTED]. c. On 07/17/11, the left buttock was a Stage III pressure ulcer that measured 4.0cm (l) by 7.0 cm (w). The wound bed was 100% necrotic (nonviable tissue). Review of the treatment administration record (TAR) dated June 2011 and July 2011 revealed no documented evidence a treatment was provided for Resident #74's Stage II left buttock pressure ulcer between 06/08/11 and 07/09/11. Documentation revealed on 07/15/11, Resident #74's Stage II left buttock pressure ulcer deteriorated with outer edges of the wound dark red with gray/black center. On 07/17/11, the facility documented the resident's leg and buttock as necrotic, Stage III, 4.0 cm by 7.0 cm. Review of the skin grid nonpressure dated 07/15/11 revealed the physician was notified but there were no documented new physician orders. Review of the physician orders [REDACTED]. Review of the TAR revealed no documented evidence a wound culture was obtained. On 07/19/11, the physician ordered a consult to the wound center due to deterioration of open wounds to the buttock. On 07/20/11 at 2:09 P.M., observation of Resident #74's left buttock revealed an Allevyn dressing with a moderate amount of yellow-tan-black drainage. A foul odor could be smelled coming from the dressing. Observation of the resident's left buttocks revealed a 6.0cm (l) by 6.0cm (w) necrotic wound with a 0.5cm (w) callused white perimeter. The unstageable, Stage IV pressure ulcer had tan-brown drainage seeping from the wound and the skin around the wound was red with regular edges. Above the Stage IV necrotic pressure ulcer were two (2) Stage II pressure ulcers that measured 1.0cm (l) by 1.0cm (w) by <0.1cm (d) and 0.5cm (l) by 1.0cm (w) by <0.1cm (d) that were not cleansed or treated prior to application of the Stage IV dressing application. On 07/20/11 at 2:19 P.M., interview with Licensed Practical Nurse (LPN) #3 verified the two (2) Stage II pressure ulcers above the Stage IV pressure ulcer were new areas that were not previously identified. On 07/20/11 at 2:26 P.M., interview with LPN #6 verified two new Stage II pressure ulcers were identified during the dressing change, were not cleansed and were covered by the border of the 12.5cm by 12.5 cm Allevyn plus adhesive dressing that covered the necrotic unstageable Stage IV pressure ulcer. Review of the medical record review revealed no documented evidence of the two Stage II pressure ulcers identified on 07/20/11 or treatment ordered. Review of the physician orders [REDACTED]. On 07/22/11 at 2:20 P.M., observation of the resident's left buttock pressure ulcer revealed a three inch strip of sterile gauze lying on top of the resident's necrotic wound that was covered with a four by four gauze. Foul odor was noted. Interview with LPN #8 at the time of the observation verified the wound did not have any depth, tunneling or undermining and the sterile gauze was just laid on top of the necrotic tissue. LPN #8 stated unknown if this was an appropriate treatment stating that was what the physician had ordered. LPN #8 verified the physician had not seen the resident's Stage IV left buttock pressure ulcer. On 07/21/11 at 3:50 P.M., interview with the DON verified the medical record revealed no documented evidence a treatment was ordered for the admission Stage II left buttock pressure ulcer between 06/07/11 and 07/15/11, no documented evidence of monitoring or daily pain assessments of the Stage II left buttock pressure ulcer between 06/10/11 and 07/15/11, the resident acquired three avoidable Stage II pressure ulcers superior to the left buttock pressure ulcer that merged together and deteriorated into a necrotic, unstageable Stage IV pressure ulcer on 07/17/11. The DON also verified Resident #74's necrotic pressure ulcer was inaccurately assessed as a Stage III pressure ulcer,and there was no documented evidence the resident had a pressure relieving mattress for an unstageable Stage IV pressure ulcer. On 07/22/11 at 7:48 A.M., interview with LPN #4 verified the wound culture was ordered on [DATE] and was observed lying on the nursing desk. LPN #4 stated the wound culture was obtained on 07/21/11 and the laboratory was picking up the culture this morning. LPN #4 verified the wound culture was not obtained until 07/21/11 because the facility did not have any wound cultures supplies within the facility. Review of the medical record revealed no documented evidence Resident #74's physician was notified Resident #74's wound culture was not obtained on 07/19/11 as ordered and was the culture was not sent to the lab until 07/22/11. Review of the wound culture results dated 07/22/11 revealed Resident #74's wounds were positive for staphylococcus capitis. The physician was notified and ordered intravenous [MEDICATION NAME] (antibiotic) for treatment. Review of the Skin-Pressure Ulcer Risk Assessment and Prevention policy (revision November 2006) revealed pressure ulcers were to be assessed weekly and report signs and symptoms of infection, changes in the wound characteristics, or failure of the wound to respond to the current treatment within 2 weeks. Review of the Skin-Pressure Ulcers policy (revision November 2006) revealed pain was to be assessed daily. Stage III and IV with eschar covering interventions included to contact wound service if available or attending physician, and apply a thin layer of [MEDICATION NAME] gel over wound, cover with [MEDICATION NAME] dressing, change every three days and prn per amount of drainage. Review of the Skin-Pressure Ulcers staging policy (revision dated 2007) revealed if eschar or slough was covering the ulcer preventing adequate staging, the assessor was to code the pressure ulcer as a Stage IV. Review of the Change of Condition policy (revised April 2003) revealed significant changes in resident's clinical condition or status including development of new pressure sores and change in the condition of a wound or pressure sore, the physician was to be notified immediately of all changes and documented in the medical record.