Every finding on record at Riverside Lifelong Health & Rehabilitation Salud

Based on observations, resident interview, staff interview, clinical record review, and facility document review, the facility failed to maintain an infection prevention and control program to provide a safe sanitary environment and assist in the prevention, development, and transmission of communicable disease and infection for all facility residents and the facility staff failed to utilize appropriate droplet precaution signage for (4) four of (6) six residents identified for droplet precautions, Resident #2, Resident #16, Resident #32, and Resident #48 and the facility staff failed to utilize appropriate personal protective equipment (PPE) for (2) two of (6) six residents on droplet precautions, Resident #16 and Resident #22 and the facility staff failed to utilize appropriate PPE during a medication pass and pour observation, Resident #48. The survey team informed the facility on 3/5/26 at 10:50 AM of the Immediate Jeopardy situation regarding Resident #2 due to the facility failing to: (1) prevent Resident #2 from eating breakfast in a common area with other residents while on droplet precautions with pending influenza test results thus placing facility residents at risk of exposure to influenza, (2) provide droplet precaution education to Resident #2. The scope and severity were originally cited at Level IV, pattern. On 3/6/26 at 10:25 AM, the Immediate Jeopardy was removed and lowered to Level II, pattern. The findings included:1. For Resident #2 the facility staff failed to prevent Resident #2 from eating breakfast in a common area with other residents while on droplet precautions with pending influenza test results and the facility staff also failed to provide droplet precaution education to Resident #2. Resident #2's diagnosis list indicated diagnoses, which included, but not limited to schizophrenia, bipolar disorder, and schizoaffective disorder. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 1/6/26 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating the resident was cognitively intact. Requested and received a Flu Outbreak Line Listing report which disclosed Resident #2 began experiencing respiratory symptoms on 3/2/26. Resident #2 was seen by the nurse practitioner (NP) on 3/2/25, the progress note read in part, .Pt (patient) is seen today, 3/2/26 regarding new onset of cough.COVID [and] Flu tests were ordered, the results will be F/U (followed up). A Health Status progress note dated 3/2/26 read in part, .Resident received an {sic} covid-19 test. Results came back negative. A medical provider order with a start date of 3/3/26 read in part, .Combined Droplet and Contact Precautions.Nurse must document if the following occurred using YES or NO in the Supplementary Documentation:1. Resident in Room alone without roommate? Y 2. Resident remains in Room? Y 3. All services (rehab, activities, meals etc.) brought to room? Y every shift for Influenza-Start Date-03/03/2026 1500 (3:00 PM). On 3/4/26 at 8:25 AM, Resident #2 was observed to be sitting alone at a table in the facility dining room. There were four other residents observed at that time to be present in the room at nearby tables, approximately 6 feet away from Resident #2. On 3/4/26 at 10:34 AM, the infection preventionist (IP) and director of nursing (DON) were interviewed. The IP stated the facility staff are sending the resident flu tests out after they are obtained. The DON stated the protocol is to put residents with respiratory symptoms on droplet precautions while the tests are pending. On 3/4/26 at 10:52 AM, a droplet precaution sign was observed to be outside of Resident #2's room. Resident #2 was interviewed and stated that they walked to breakfast this morning. On 3/4/26 at 10:57 AM, certified nursing assistant #1 (CNA#1) was interviewed. When asked how Resident #2 prefers to have meals, CNA#1 stated that it varies on how the resident feels if they prefer to eat in the room or dining area. Resident #2 is able to ambulate without assistance to the dining area and had breakfast in the dining room this morning. CNA#1 reported that they did not see Resident #2 go into the dining room or they would have stopped the resident due to isolation precautions. On 3/4/26 at 11:15 AM, the IP was interviewed and asked about the process for preventing ambulatory/independently mobile residents from exiting their rooms while on droplet precautions and the IP stated that they highly encourage residents to stay in their rooms. When asked how the facility staff redirect cognitively impaired residents from exposing other residents, the IP responded that food is a good redirection for Resident #2. The IP stated that they have morning meetings where the dining director is made aware of which residents need to have meals served in their rooms while on isolation precautions. On 3/4/26 at 1:01 PM, the IP was interviewed and stated Resident #2 was tested for the flu today (3/4/26) and they were awaiting the results. A Lab Results progress note dated 3/4/26 with a reported time of 12:47 PM read in part, .Lab results for Influenza A & B, positive for Influenza A. A review of Resident #2's comprehensive person-centered care plan read in part, .is experiencing respiratory symptoms of cough.Flu test positive. with a revision date of 3/4/26. An intervention associated with this focus read in part, .Initiate transmission-based precautions until test results return and/or infection clears. (Combined Droplet and Contact Precautions for SPECIFY Nurse must document if the following occurred using YES or NO in the Supplementary Documentation: 1. Resident in Room alone without roommate? Y 2. Resident remains in Room? Y 3. All services (rehab, activities, meals etc.) brought to room? Y) Date Initiated: 03/04/2026.Revision on: 03/04/2026. This concern was discussed on 3/4/26 at 4:30 PM at the end of day meeting with the administrator and DON. The DON stated more resident flu results have come in. Resident #2 and two additional residents have tested positive for the flu. Three residents are still pending results. On 3/4/26 at 5:25 PM, the dietary manager (DM) and certified nursing assistant #3 (CNA#3) were interviewed and confirmed that Resident #2 had been eating in the dining room at breakfast and had been sitting at a table alone at the left corner table in the dining area closest to the kitchen. The DM confirmed there were four residents sitting to the right of Resident #2 and two residents were sitting with a CNA at the table across from Resident #2. On 3/5/26 at 8:26 AM the IP was interviewed and stated with the current flu outbreak the first resident tested positive on 2/25/26, Three residents tested positive yesterday (3/4/26). Currently there are three residents with results pending. Requested and reviewed a facility policy titled, Droplet Precautions Procedure with a revision date of 8/19/22, which read in part, .Droplet Precautions apply to patients with known or suspected infections that are transmitted by the droplet route. Respiratory droplets are generated when an infected person coughs, sneezes, talks, or during procedures.the most common diseases requiring Droplet Precautions 1) Influenza.The resident will wear a mask if the resident has to leave the room. On 3/5/26 at 10:50 AM, the survey team notified the administrator, DON, IP, regional staff educator, and assistant chief nursing officer of the Immediate Jeopardy situation regarding Resident #2 and the facility's failure to maintain an infection prevention and control program to prevent the spread of influenza as evidenced by failing to prevent Resident #2 from eating breakfast in a common area with other residents while on droplet precautions with pending influenza test results and the facility's failure to provide droplet precaution education to Resident #2. On 3/5/26 at 2:18 PM the administrator presented the following immediate jeopardy removal plan regarding Resident #2: 1. Resident #2 will be educated by DON/designee on appropriate infection prevention and control practices, to include masking, hand hygiene, importance of remaining in room when respiratory symptoms are present and use of appropriate PPE using CDC/APIC/OSHA handouts with pictures and graphics for better understanding. 2. All independently mobile residents with a BIMS greater than 12 will be educated by the DON/Designee will on infection prevention and control practices, to include masking, hand hygiene, the importance of remaining in room when respiratory symptoms are present, and use of appropriate PPE when leaving the room using CDC/APIC/OSHA handouts and the droplet precautions with pictures and graphics for better understanding. 3. All staff will be educated by the DON, Educator, or designee on the importance of ensuring appropriate infection prevention and control practices, to include masking, hand hygiene, appropriate PPE usage, including donning and doffing, and to encourage residents on transmission-based precautions to remain in their room using transmission-based precaution signage, CDC and World Health Organization handouts, and the facility droplet precautions policy/procedure. If staff are unable to participate due to scheduling, they will be educated prior to their next scheduled shift. All residents and/or their representative will be provided with education materials by administrator/designee on appropriate infection prevention and control practices, to include masking, hand hygiene, residents remaining in room when respiratory symptoms are present, and use of appropriate PPE when leaving the room using materials from the CDC, APIC, and/or World Health organization. Meals will continue to be served in resident rooms for residents on droplet precautions. There will be continued coordination with and adherence to guidance from local epidemiologists. 4. Observations will be completed three times per shift for 10 days by Infection Preventionist/designee to ensure that residents are following appropriate infection prevention and control practices, such as resident masking in common areas, resident hand hygiene, and that residents on transmission-based precautions remain in their room, to prevent the spread of influenza. This plan will be approved and monitored through the QAPI team. 5. All corrective actions will be completed by March 5, 2026, at 6 p.m. On 3/5/26 at 3:15 PM, the survey team informed the administrator that the facility's immediate jeopardy removal plan was accepted. The facility presented credible evidence that the removal plan had been implemented, including evidence of facility staff and resident education as outlined in the removal plan. Interviews with the facility staff, licensed nursing staff, and residents also verified education as outlined in the removal plan. Observations were conducted on facility resident dining and common areas and it was verified that residents identified for droplet precautions were not present in these areas and received meals and activities in their rooms. Observations were conducted for proper droplet precaution signage for those residents identified to be on droplet precautions and all the droplet precaution signs were appropriate. Facility staff were interviewed for the proper protocol and the proper use of PPE prior to entering resident rooms identified for droplet precautions. Facility staff were interviewed for the proper protocol if a resident identified for droplet precautions wishes to come out of their room for the use of appropriate PPE, cough etiquette, hand hygiene, and proper practice and prevention of infection control. Observations and interviews with facility residents were performed to include their education and knowledge of symptoms of respiratory illness, hand hygiene, and the use of proper PPE when on droplet precautions for facility residents and facility staff. Residents were observed to have masks present in their rooms for utilization as needed/indicated. On 3/6/26 at 10:25 AM, the survey team notified the Administrator that the immediate jeopardy was removed. No further information regarding this concern was presented to the survey team prior to the exit on 3/6/26. 2. For the facility, the facility staff failed to utilize appropriate droplet precaution signage for the rooms of Resident #2, Resident #16, and Resident #32, and the facility staff failed to utilize appropriate personal protective equipment (PPE) prior to entrance into rooms identified for droplet precautions for Resident #16 and Resident #22. On 3/4/26 at 8:49 AM, Resident #16's room was observed with a droplet precautions sign visible outside of the door. The sign read in part, .Wear a N95 and face shield to enter room. Make sure eyes, nose and mouth are fully covered before entering room. All team members must wear gown and gloves. Other staff#1 (OS#1) was observed to be in Resident #16's room donning only a surgical face mask. When asked what PPE was to be utilized for a droplet precaution room, OS#1 stated care was not being given, and if not performing care PPE does not have to be utilized. A review of the facility line listing for a current flu outbreak disclosed Resident #16 was on droplet precautions pending results for an influenza test. On 3/4/26 at 8:55 AM, the director of nursing (DON) was interviewed about which PPE is appropriate for residents on droplet precautions and the DON stated the expectation is not for N95 masks, a surgical mask is appropriate and facility staff should be wearing gowns and gloves as well. The DON stated the droplet precaution policy would have to be reviewed for the utilization of goggles/eye protection for droplet precaution rooms. The DON stated the expectation is for all staff to don PPE prior to entering a droplet precaution room. On 3/4/26 at 9:00 AM, other staff #2 (OS#2) was observed entering Resident #16's room without any PPE visible. When asked the protocol for entering a droplet precaution room, OS#2 stated as long as the resident is not being touched, then they do not have to wear PPE. On 3/4/26 at 9:06 AM, Resident #22's room was observed with a droplet precautions sign visible outside of the door. The sign read in part, .Wear mask to enter room.If contact with secretions is likely, wear gown, gloves and eye protection. Certified nursing assistant #1 (CNA#1) and other staff #3 (OS#3) were observed to be assisting Resident #22 with breakfast. CNA#1 and OS#2 were observed to be sitting close to the resident's bed and were observed to be wearing gowns and surgical masks. No gloves or eye protection were visible on either staff member. A review of the facility line listing for a current flu outbreak disclosed Resident #22 was on droplet precautions pending results for an influenza test. On 3/4/26 at 9:14 AM, the infection preventionist (IP) observed the droplet precaution sign on Resident #16's room and stated they are assuming the resident has a respiratory infection and the protocol is to be on droplet precautions and wear a gown, face mask, protective mask, goggles, and gloves. The IP attempted three other droplet precaution signs; these signs did not note eye protection was required. On 3/4/26 at 9:40 AM, the IP brought a droplet precaution sign for Resident #16's room. The IP stated this fourth sign was the appropriate droplet precaution sign. The sign read in part, .Make sure their eyes, nose and mouth are fully covered before room entry. The IP and facility staff were observed to change the droplet precaution signs on the rooms of the other four residents on droplet precautions on the unit to the fourth sign that was chosen by the IP. These concerns were discussed at the end of day meeting on 3/4/26 at 4:30 PM with the administrator and DON. On 3/4/26 at approximately 4:43 PM, Resident #32's room was observed to have a droplet precaution sign outside the door which read in part, .Wear mask to enter room.Patient to wear mask if transported out of room.If contact with secretions is likely, wear gown, gloves and eye protection. The IP was made aware and corrected the sign. On 3/5/26 at 8:26 AM, the IP, DON and staff education specialist (SES) were interviewed. The DON stated if a staff member is observed to not be following appropriate isolation precautions with appropriate PPE, then the staff members are stopped. The DON stated staff were educated this morning during a huddle meeting related to the flu outbreak in the facility. When asked about the confusion with the droplet precaution signs on 3/4/26, the SES stated the droplet precaution signs that were observed on 3/4/26 were COVID-19 isolation signs requiring an N95 mask and the correct signs were located at the nurse's station. The DON stated that the floor nurses put those signs up. A new droplet precautions sign was provided and read in part, .Everyone Must wear a mask, eye protection, gown, gloves to enter room. Make sure eyes, nose and mouth are fully covered before entering room.Patient must wear a mask if transported out of room. On 3/5/26 at 9:56 AM, Resident #2's room was observed to have a droplet precaution sign outside of the door which read in part, .Wear mask to enter room.Patient to wear mask if transported out of room.If contact with secretions is likely, wear gown, gloves and eye protection. On 3/5/26 at 10:00 AM, the IP was interviewed and observed the droplet precaution sign outside of Resident #2's room. The IP agreed this was not the correct droplet precaution sign and stated it would be replaced immediately. The IP stated staff have been wearing appropriate PPE prior to entering the room, as she has been doing observations of this room. Requested and reviewed a facility policy titled, Droplet Precautions Procedure with a revision date of 8/19/22, which read in part, .Droplet Precautions apply to patients with known or suspected infections that are transmitted by the droplet route. Respiratory droplets are generated when an infected person coughs, sneezes, talks, or during procedures.the most common diseases requiring Droplet Precautions 1) Influenza.Healthcare staff must wear a mask, eye protection, gown, and gloves upon room entry. No further information was provided to the survey team prior to exit on 3/6/26. 3. During a medication pass and pour observation, the facility staff failed to follow droplet precautions for Resident #48. While observing licensed practical nurse (LPN) #1 on 03/04/26 at 8:30 am, during a medication pass and pour, LPN #1 was observed entering Resident #48's room wearing a mask, gown and gloves. LPN #1 was not observed wearing eye protection/face shield. Certified nurse's aide (CNA) #2 was also observed entering Resident #48's room, wearing a mask, gown and gloves, but no eye protection/face shield. A Droplet Precautions sign was observed posted outside of Resident #48's room, which read in part, EVERYONE MUST: Wear a N95 and face shield to enter room. Make sure eyes, nose and mouth are fully covered before entering room. Resident #48's clinical record was reviewed and contained a physician's order summary which read in part, Combined droplet and contact precautions for .every shift for Flu type A for 10 days with a start date of 02/25/26 and an end date of 03/07/26. A facility policy entitled Droplet Precautions Procedure was provided on 03/04/26 and read in part, Below is a list of the most common diseases requiring Droplet Precautions 1) Influenza.Required Action Steps. Mask-Healthcare staff must wear a mask, eye protection, gown, and gloves upon room entry. The concern of the facility staff not following infection control procedures was discussed with the administrator and director of nursing during an end of day meeting on 03/04/26 at 5:05 pm. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review the facility staff failed to ensure medications were available for administration for 2 of 22 current residents in the survey sample, Residents #9 and resident #31. The findings included: 1. For Resident #9, the facility staff failed to ensure the medications Parlodel and Lansoprazole (Prevacid) were available for administration. Resident #9's diagnoses included spastic quadriplegic cerebral palsy, epilepsy and gastro esophageal reflux disease. Section C (cognitive patterns) of Resident #9's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 01/21/26 was coded to indicate Resident #9 had problems with long-and short-term memory and was severely impaired in cognitive skills for daily decision making. Resident #9's clinical record included provider orders for Parlodel give 1.25 mg via J-tube two times a day for dystonia and Lansoprazole oral suspension give 10 ml via J-tube one time a day for heartburn. A J-tube is a type of enteral feeding device placed through the abdomen directly into the small intestine to deliver nutrition, fluids, and medication. Resident #9's comprehensive care plan included the intervention administer medications as ordered. A review of Resident #9's medication administration records (MARs) for February 2026 revealed that for 02/20/26 the nursing staff had documented a 9 on 02/20/26 at bedtime for the medication Parlodel. The facility nursing staff had documented a 9 on the MARs for the medication Lansoprazole on 02/19/26-02/22/26 and on 02/24/26. For 02/23/26 the nursing staff documented the medication had been administered. Per the preprinted code on the MARs a 9=other/see progress notes. On 02/20/26 the facility nursing staff documented for the medication Parlodel they were Waiting on delivery from pharmacy. For the medication Lansoprazole the facility nursing staff had documented the following-02/19/26 pharmacy notified, 02/20/26 not in, reordered from pharmacy, 02/21/26 hasn't arrived from pharmacy, 02/22/26 still not in from pharmacy, and on 02/24/26 the facility nursing staff documented time changed back to 6:00 a.m. The surveyor was unable to locate any documentation to indicate this medication was administered on 02/24/26. A review of the facility med bank list (back up medications) revealed neither of these medications would have been available for administration. On 03/03/2026 at 4:20 p.m., during a meeting with the Administrator and Director of Nursing the issue with Resident #9's medications not being available for administration was reviewed. On 03/04/26, the survey team requested the facility policy on unavailable medications. The facility provided the survey team with a copy of a diagram indicating if medication was not available the procedure was to contact the provider for an alternate order and/or consider a stat run from the pharmacy. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For resident #31 the facility staff failed to ensure the medication pantoprazole was available for administration. Resident #31's quarterly minimum data set (MDS) assessment with an assessment reference date of 1/28/26 assigned the resident a brief interview for mental status score (BIMS) of 01/15 indicating severe cognitive impairment. On 3/1/26 at 7:31 PM a progress note was made that read, Pantoprazole Sodium Oral Tablet Delayed Release 20 MGGive 1 tablet by mouth at bedtime for GERDNot in pixis - on order. The Medication Administration Record (MAR) was reviewed. On 3/1/26 the medication pantoprazole was coded with a 9 instead of a check mark which indicates to see nurses' notes. The med bank list, which is a list of medications available in back up stock did not include the medication pantoprazole. On 03/03/2026 at 4:20 p.m. the survey team met with the Administrator and Director of Nursing. This concern was discussed with them at that time On 03/04/26, the survey team requested the facility policy on unavailable medications. The facility provided the survey team with a copy of a diagram indicating if medication was not available the procedure was to contact the provider for an alternate order and/or consider a stat run from the pharmacy. No further information was presented to the survey team prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to ensure laboratory results were reported to the provider for 2 of 22 current residents in the survey sample, Residents #6 and #31. The findings included: 1. For Resident #6, laboratory tests obtained on 01/29/26 and 02/06/26 were not reviewed by the provider until 03/05/26. Resident #6's diagnoses included vascular dementia, diabetes, and hyperlipidemia. Section C (cognitive patterns) of Resident #6's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 01/21/26 included a brief interview for mental status (BIMS) score of 5, indicating Resident #6 was severely impaired in cognitive skills for daily decision making. Resident #6's clinical record included provider orders dated 01/26/26 for a complete blood count, comprehensive metabolic panel, hemoglobin A1C, vitamin B12, lipid panel, vitamin D, and magnesium. The exact same laboratory tests were ordered again on 01/31/26. During the clinical record review, the surveyor was unable to locate the results for these laboratory tests. On 03/04/26, the Nurse Officer Assistant provided the surveyor with copies of laboratory results that were collected on 01/29/26 and 02/06/26. The laboratory results included initials to indicate they had been reviewed. They did not include a date. On 03/06/26 at 8:20 a.m., during an interview with the Nurse Officer Assistant this staff stated the laboratory results were not reviewed by the provider until 03/05/26. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For resident #31 the facility staff failed to report the results of laboratory tests obtained on 2/5/26 to the provider. Resident #31's diagnoses included but were not limited to: chronic kidney disease, vitamin D deficiency, deficiency of other B group vitamins, hypertension, and vascular dementia. Resident #31's minimum data set (MDS) assessment with an assessment reference date of 1/28/26 assigned the resident a brief interview for mental status (BIMS) score of 01 out of 15 indicating severe cognitive impairment. A Nurse Practitioner (NP) note entered into the clinical record on 1/30/26 read in part, Iron deficiency anemia, unspecified *: Patient has chronic anemia. Currently managed with ferrous sulfate 325mg (65mg iron) tablet daily and folic acid 1mg tablet daily. CBC (complete blood count), comprehensive metabolic panel (CMP), vitamin D, and magnesium level were ordered by pharmacy recommendation at this visit. Will continue current treatment regimen and monitor lab results for effectiveness. A nurses note entered into the record on 2/5/25 at 4:05 AM read, CBC, CMP, VIT (vitamin) D, MAGNESIUM was drawn on top of right wrist/arm without difficulty. On 2/9/26 an NP read in part, Iron deficiency anemia, unspecified *: Patient has chronic anemia. Currently managed with ferrous sulfate 325mg (65mg iron) tablet daily and folic acid 1mg tablet daily. CBC, comprehensive metabolic panel, vitamin D, and magnesium level were ordered by pharmacy recommendation at this visit; however, patient's blood was not drawn for the labs and will be followed up. On 2/27/26 an NP note read in part, CBC, CMP, vitamin D, & magnesium level ordered by pharmacy recommendation at this visit - not sure the reason, but pt's (patients) blood was not drawn for the labs, will be F/U (follow-up). On the January physician's order summary, an order entered on 1/30/26 read, CBC, CMP (comprehensive metabolic panel), Vitamin D and magnesium level one time only for 2 days for pharmacy recommendation please d/c (discontinue) it after blood draw. The test was scheduled to be drawn on 2/5/26 according to the order. The results of the test were not located in the clinical record. The Director of Nursing (DON) was asked at 1:20 PM on 3/4/26 to provide the laboratory results for resident #31 that were drawn on 2/5/26. On 3/4/26 at 3:00 PM the DON brought the labs results for resident #31 which were dated 2/5/26. The DON stated, Our labs go to three different labs based on the resident's insurance. Only one of the labs is set up to send results through to the medical record portal. I had to call the lab and request these results be sent today. When asked to clarify whether or not the provider has reviewed the lab results yet she stated they have not reviewed them yet. Normally the NP will ask if she is waiting or looking for lab results and I will call the lab to get the results but I wasn't aware these hadn't been sent to us yet. When asked if there was one staff member responsible to ensure labs are done and results received timely, the DON stated there is not. On 3/5/26 at 3:28 PM the survey team met with the Administrator, Regional Executive Director and DON. This concern was reviewed at that time. No further information was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review the facility staff failed to file provider ordered laboratory test results in the clinical record for 2 of 22 current residents in the sample, Residents #6 and #31. The findings included:1. For Resident #6, the facility staff failed to ensure provider ordered laboratory results were filed in the clinical record. Resident #6's diagnoses included vascular dementia, diabetes, and hyperlipidemia. Section C (cognitive patterns) of Resident #6's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 01/21/26 included a brief interview for mental status (BIMS) score of 5, indicating Resident #6 was severely impaired in cognitive skills for daily decision making. Resident #6's clinical record included provider orders dated 01/26/26 for a complete blood count, comprehensive metabolic panel, hemoglobin A1C, vitamin B12, lipid panel, vitamin D, and magnesium. The provider ordered the exact same laboratory tests on 01/31/26. During the clinical record review, the surveyor was unable to find the results for these laboratory tests in the clinical record. On 03/04/26, the Nurse Officer Assistant provided the surveyor with a copy of laboratory results obtained on 01/29/26 and 02/06/26. On 03/05/2026 at 8:25 a.m., during an interview with the Director of Education this staff stated the laboratory results should have been included in the clinical record. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For resident #31 the facility staff failed to report the results of laboratory tests obtained on 2/5/26 to the provider. Resident #31's diagnoses included but were not limited to: chronic kidney disease, vitamin D deficiency, deficiency of other B group vitamins, hypertension, and vascular dementia. Resident #31's minimum data set (MDS) assessment with an assessment reference date of 1/28/26 assigned the resident a brief interview for mental status (BIMS) score of 01 out of 15 indicating severe cognitive impairment. A Nurse Practitioner (NP) note entered into the clinical record on 1/30/26 read in part, Iron deficiency anemia, unspecified *: Patient has chronic anemia. Currently managed with ferrous sulfate 325mg (65mg iron) tablet daily and folic acid 1mg tablet daily. CBC (complete blood count), comprehensive metabolic panel (CMP), vitamin D, and magnesium level were ordered by pharmacy recommendation at this visit. Will continue current treatment regimen and monitor lab results for effectiveness. A nurses note entered into the record on 2/5/25 at 4:05 AM read, CBC, CMP, VIT (vitamin) D, MAGNESIUM was drawn on top of right wrist/arm without difficulty. On 2/9/26 an NP read in part, Iron deficiency anemia, unspecified *: Patient has chronic anemia. Currently managed with ferrous sulfate 325mg (65mg iron) tablet daily and folic acid 1mg tablet daily. CBC, comprehensive metabolic panel, vitamin D, and magnesium level were ordered by pharmacy recommendation at this visit; however, patient's blood was not drawn for the labs and will be followed up. On 2/27/26 an NP note read in part, CBC, CMP, vitamin D, & magnesium level ordered by pharmacy recommendation at this visit - not sure the reason, but pt's (patients) blood was not drawn for the labs, will be F/U (follow-up). On the January physician's order summary, an order entered on 1/30/26 read, CBC, CMP (comprehensive metabolic panel), Vitamin D and magnesium level one time only for 2 days for pharmacy recommendation please d/c (discontinue) it after blood draw. The test was scheduled to be drawn on 2/5/26 according to the order. The results of the test were not located in the clinical record. The Director of Nursing (DON) was asked at 1:20 PM on 3/4/26 to provide the laboratory results for resident #31 that were drawn on 2/5/26. On 3/4/26 at 3:00 PM the DON brought the labs results for resident #31 which were dated 2/5/26. The DON stated, Our labs go to three different labs based on the resident's insurance. Only one of the labs is set up to send results through to the medical record portal. I had to call the lab and request these results be sent today. When asked to clarify whether or not the provider has reviewed the lab results yet she stated they have not reviewed them yet. Normally the NP will ask if she is waiting or looking for lab results and I will call the lab to get the results but I wasn't aware these hadn't been sent to us yet. When asked if there was one staff member responsible to ensure labs are done and results received timely, the DON stated there is not. On 3/5/26 at 3:28 PM the survey team met with the Administrator, Regional Executive Director and DON. This concern was reviewed at that time. No further information was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review the facility staff failed to ensure the clinical record was complete and accurate for 1 of 22 current residents in the survey sample resident #10. The findings included:For resident #10 the facility staff failed to ensure the Durable Do Not Resuscitate (DDNR) order was complete and accurate in the medical record.Resident #31's diagnoses included but were not limited to vascular dementia, cerebral infarction, venous insufficiency, heart failure, and hypertension.The admission minimum data set (MDS) assessment with an assessment reference date of 2/20/26 assigned the resident a brief interview for mental status score of 7/15 indicating the resident was severely cognitively impaired. The MDS also indicated that resident #10 had a condition or chronic disease that may result in life expectancy of less than 6 months and resident was receiving hospice services.The physician's orders were reviewed. Resident #10 had an active order for do not resuscitate documented. Under miscellaneous documents the resident had a DDNR form that was signed by the Power of Attorney (POA) listed on the face sheet and dated 2/13/26. The form read, I the undersigned, state that I have a [NAME] fide physician/patient relationship with the patient named above. I have certified in the patient's medical record that he/she or a person authorized to consent on the patient's behalf has directed that life-prolonging procedures be withheld or withdrawn in the event of cardiac or respiratory arrest. I further certify (must check 1 or 2): 1. The patient is capable of making an informed decision about providing, withholding, or withdrawing a specific medical treatment or course of medical treatment. 2. The patient is incapable of making an informed decision about providing, withholding, or withdrawing a specific medical treatment or course of medical treatment because he/she is incapable to understand the nature, extent or probable alternatives to that decision. Neither box was checked. The form went on to state that if box #2 was checked then check A, B, or C below. A. While capable of making an informed decision the patient has executed a written advanced directive which directs that life prolonging procedures be withheld or withdrawn. B. While capable of making an informed decision the patient has executed a written advanced directive which appoints a person authorized to consent on the patient's behalf with authority to direct that life-prolonging procedures be withheld or withdrawn (signature of person authorized to consent on the patient's behalf is required.) C. The patient has not executed a written advanced directive (living will, or durable power of attorney for healthcare .On 3/3/26 at 4:20 PM the survey team met with the Administrator and Director of Nursing. This concern was discussed with them at that time,No further information was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to offer education for the declination of a pneumococcal vaccine for (1) one of (5) five residents sampled for immunization review, Resident #57. The findings included:Resident #57's diagnosis list indicated diagnoses, which included, but not limited to atherosclerosis of native arteries of extremities with rest pain, right leg, allergic rhinitis, polyneuropathy, and encounter for surgical aftercare following surgery on the circulatory system. The most recent admission minimum data set (MDS) with an assessment reference date (ARD) of 2/28/26, assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating the resident was cognitively intact. A review of Resident #57's pneumococcal vaccination history disclosed the resident received the Prevnar 13 vaccine on 05/16/2022. No evidence could be located on the clinical record that Resident #57 was offered a PCV20 (Prevnar 20) or PCV21 (21-valent Pneumococcal Conjugate Vaccine) at least one year after the administration of the PCV13, while a resident at the facility. The Centers for Disease Control and Prevention (CDC) guideline titled, Recommended Adult Immunization Schedule for Ages 19 Years or Older dated 12/28/23 read in part that adults aged 65 years or older who have previously received a dose of PCV13, should receive one dose of PCV20 or PCV21 at least one year after administration of PCV13. On 3/5/26 at 9:31 AM, the director of nursing (DON) provided an Influenza, Pneumococcal, COVID-19 and RSV Vaccine Informed Consent and Declination consent form signed by Resident #57 and dated 2/27/26. A review of the consent form disclosed Resident #57 did not consent to have a pneumococcal vaccine. In further review of the consent form, a section which read in part, .I attest that I have been provided enough education for me to make an informed decision regarding the information for the.pneumococcal.vaccines and have had all my questions answered. was not marked and was left unchecked. This concern was discussed on 3/5/26 at 3:20 PM at the end of day meeting with the administrator, director of nursing, regional director of education, and divisional executive director. Requested and received a facility policy titled, Influenza and Pneumococcal Immunization for Residents Policy with an effective date of 4/21/25 which read in part, .Education will be provided for those that.decline the vaccination. No further information was provided prior to exit on 3/6/26.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to review and revise the comprehensive care plan for 1 of 22 current residents in the survey sample, Residents #48. The findings included: The facility staff failed to review and revise the comprehensive care plan (CCP) when the resident was placed on droplet precautions. Resident #48's diagnoses included dementia, chronic diastolic congestive heart failure, and anxiety. Section C (cognitive patterns) of Resident #48's significant change in status minimum data set (MDS) assessment with an assessment reference date (ARD) of 12/22/25 was coded to indicate the resident had problems with long-and short-term memory and was severely impaired in cognitive skills for daily decision making. During initial tour Resident #48 was identified by the facility staff as being positive for the flu. A droplet precaution sign and personal protective equipment (PPE) were observed outside of Resident #48's room. Resident #48's clinical record included a progress note transcribed by the nursing staff on 02/25/26 stating Resident #48 had tested positive for the flu and isolation precautions were in place. On 02/25/26, the provider ordered combined droplet and contact precautions. The end date for this order was documented as 03/07/26. A review of Resident #48's CCP revealed the facility staff had not reviewed and revised Resident #48's CCP to include droplet precautions. On 03/03/2026 at 4:10 p.m., during an interview with the Clinical Reimbursement Director this staff reviewed Resident #48's CCP and confirmed Resident #48's isolation status was not on the CCP. On 03/03/2026 at 4:20 p.m., during an end of the day meeting with the Administrator and Director of Nursing the issue with the CCP not being reviewed and revised to include Resident #48's droplet precautions were reviewed. On 03/04/26, the administrative staff provided the survey team with a copy of their policy titled, Comprehensive Care Planning. This policy read in part, .Each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, staff interview, clinical record review and facility document review the facility staff failed to develop a comprehensive care plan that included enhanced barrier precautions for one of 22 current residents in the survey sample, resident #1.The findings included:Resident #1's diagnosis list indicated diagnoses, which include, but not limited to colostomy, Parkinson's Disease and Dementia. The most recent admission minimum data set (MDS) with an assessment reference date (ARD) of 2/18/2026, assigned the resident a brief interview for mental status (BIMS) summary score of 12 out of 15 for cognitive abilities, indicating the resident was moderately cognitive impaired. Section GG revealed functioning level of non-ambulatory, and wheelchair-bound, incontinent and colostomy, requiring assistance with activities of daily living (ADLs). Observation on 3/3/2026 10:40 am revealed an enhanced barrier precautions (EBP) sign posted near the door for Resident #1, along with gloves and gowns to be used during high contact care. Review of revised Care Plan dated 1/9/2026, revealed that Resident #1 did not have Enhanced Barrier Precautions listed on his care plan. The care plan addressed his colostomy care.On 3/4/2026 at 11:00 am, interview with Licensed Practical Nurse (LPN) #2 revealed, that Resident #1 has Enhanced Barrier Precautions because he has a colostomy and recently developed a pressure ulcer and that she follows facility policies and procedures/protocols for the prevention and treatment of skin breakdown.On 03/03/2026 at 4:24 p.m., the Administrator and Director of Nursing (DON) were present at the end of day meeting where it was discussed that the care plan for Resident #1 did not include Enhanced Barrier Precautions. On 3/5/2026 at 9:55 am, an interview with MDS Coordinator revealed that she oversees the care plans and explained that all nursing staff can update the care plan but very few of the nurses do. She will recommend more training for staff, especially upon admission. The care plan was updated during the conversation to include Enhanced Barrier Precautions (EBP) for Resident #1's care plan.On 03/04/26, the administrative staff provided the survey team with a copy of their policy titled, Comprehensive Care Planning. This policy read in part, .Each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.Review of policy titled, LLP-IC-Enhanced Barrier Precautions, revised on 9/25/25, read in part, .Enhanced Barrier Precautions are indicated for residents meeting the criteria below for the duration of their stay or when risk of exposure has ended: 1)Chronic wounds such as pressure injuries, diabetic foot ulcers, unhealed surgical wounds, and venous statis ulcers, and/or indwelling medical devices (e.g. central line, urinary catheter, feed tub, tracheostomy/ventilator), regardless of MDRO colonization status. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, staff interview, clinical record review and facility document review, the facility staff failed to follow provider orders for two of 22 residents in the survey sample, resident #3 and resident #31. 1.For Resident #3 the facility staff failed to follow a medical provider order for 1/2 side rails. Resident #3's diagnosis list indicated diagnoses that included, but were not limited to, muscle spasm, psychotic disorder with delusions, insomnia, abnormalities of gait and mobility, abnormal posture, extrapyramidal and movement disorder, difficulty in walking, and repeated falls. The most recent significant change minimum data set (MDS) with an assessment reference date (ARD) of 1/23/26 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 for cognitive abilities, indicating Resident #3 was cognitively intact. On 3/4/26 at 10:40 AM, Resident #3's bed was observed to have 1/4 bilateral side rails in place and up on both sides of the bed. A review of the clinical record disclosed the following documentation: A medical provider order dated 1/19/26 read in part, .Siderails x 2 as tolerated: 1/2 side rails every shift for bed mobility and positioning and safety. A review of the TAR (treatment administration record) for 1/1/26 through 1/9/26 disclosed 1/4 side rails were in place every shift. From 1/19/26 through 1/31/26, the TAR disclosed 1/2 side rails were in place every shift. A review of the TARs for February and March 2026 disclosed 1/2 side rails were in place every shift. A review of the comprehensive person-centered care plan had a focus which read in part, .resident's preference is to perform own ADL (activities of daily living) care. The focus included an intervention which read in part, .SIDE RAILS: Bilateral 1/4 side rails for safety during care provision, to assist with bed mobility. with a revision date of 12/6/22. On 3/4/26 at 3:33 PM, the director of nursing (DON) was interviewed and stated the order for 1/4 side rails was discontinued when Resident #3 was transferred to the hospital. The DON agreed the care plan stated 1/4 side rails and when Resident #3 returned from the hospital the order was put in incorrectly for 1/2 side rails, but the resident is supposed to have 1/4 side rails. The DON provided a medical provider order dated 3/4/26 which read in part, .Siderails - Siderails x 2 as tolerated: 1/2 side rails every shift. with a discontinue date of 3/4/26. The DON also provided a medical provider order dated 3/4/26 which read in part, .Siderails x 2 as tolerated. with a start date of 3/4/26. This concern was discussed on 3/4/26 at 4:30 PM at the end of day meeting with administrator and DON. Requested and received a facility policy titled, Bed / Side Rail Entrapment Policy with an effective date of 1/17/23 which read in part, .14. The physician will be notified and a specific order for the use of bed rails (identify how many/type of bed rails, which side of the bed, and when they are to be in place) will be obtained. No further information was provided prior to exit on 3/6/26. 2. For resident #31, the facility staff failed to follow physician's orders for side rails. Resident #31's pertinent diagnoses included but were not limited to vascular dementia, dizziness and giddiness, macular degeneration, anxiety disorder and major depressive disorder. The quarterly minimum data set (MDS) assessment with an assessment reference date of 1/28/26 assigned the resident a brief interview for mental status (BIMS) score of 01/15 indicating severe cognitive impairment. The MDS also reflected that resident #31 is hearing and vision impaired and requires supervision to touching assistance with bed mobility. On 3/2/26 at 2:20 PM resident #31 was observed lying in bed with one side rail up on the right-hand side of the bed. On 3/4/26 at 9:50 AM resident #31 was observed lying in bed with the side rail on the right-hand side of the bed up, the left side rail was not up. The clinical record was reviewed and included a physician's order dated 10/25/24 that read, Siderails: 1/2 siderails x 2 as tolerated every shift for bed mobility and positioning. The most recent bed rail assessment dated [DATE] was reviewed. Under Section I, question #8 read, Has the resident expressed a desire to have side rails/assist bars for safety and/or comfort? The question was marked yes. Under Section II, the third question indicated that bilateral side rails should be up. The side rail consent form with a date of 12/17/20 also stated that 1/2 side rails should be up bilaterally. The care plan was reviewed. A focus that read in part, ADL (activities of daily living) self-care deficit included an intervention that read, Bilateral 1/4 side rails for safety during care provision to assist with bed mobility. On 3/4/26 at 3:20 PM the Director of Nursing (DON) was interviewed. When informed of the discrepancy between the side rail order, the care plan and the observations of just one rail up the DON stated, Let me go check into it. The DON returned and stated that resident #31 has 1/4 rails on the bed and that the care plan is correct. We've changed rooms and beds around so much, but his bed has quarter rails now, not half rails. I'm not sure why one side was down but they are up now. The DON stated that the order will be changed. When asked if the side rail assessment and consent will also be corrected the DON indicated that they would be updated. The policy entitled, Bed/side Rail Entrapment Policy with an effective date of 1/17/23 was reviewed. Under the heading entitled, Evaluate the Resident, item number 10 reads: The Bedrail/Entrapment Risk Evaluation is completed: a. Admission, b. Quarterly, c. Significant Change, and d. Any time the resident's bed complement is changed (e.g. addition of an air mattress or an additional bed rail. Item number 14 reads, The physician will be notified and a specific order for the use of bed rails (identify how many bed rails, which side of the bed, and when they are to be in place) will be obtained. The facility will document use of the bed rail in the medical record. On 3/5/26 at 3:28 PM the survey team met with the Administrator, Regional Executive Director and DON. This concern was reviewed at that time. No further information was provided to the survey team prior to the exit conference.

Based on observations, staff interview, facility documentation review and clinical record review, the facility staff failed to provide privacy for 4 Residents (Resident #31, 20, 1, 29) in a survey sample of 26 Residents. The findings included: 1. For Resident #31, the facility staff failed to protect his personal privacy by leaving him unclothed and visible from the hallway wearing only an incontinence brief. On 12/13/22 at 12:03 PM, during tour, Surveyor C observed Resident #31 from the hallway. Resident #31 was observed lying in bed, no clothes on, wearing an incontinence brief and a urinary catheter was noted. Upon entry of the room, Resident #31 was interviewed but did not respond to Surveyor C. On 12/14/22, on numerous occasions throughout the day, Resident #31 was observed lying in bed with no clothes on and no covers. He was able to be observed from the hallway to have only an incontinence brief on. On 12/16/22 at 11:30 AM, Resident #31 was observed lying in bed with a blanket covering him. Upon further review, it was noted that there was no privacy curtain that could be pulled to protect his privacy, since it was a private room. On 12/16/22 at approximately 11:35 AM, an interview was conducted with CNA B, who was assigned to Resident #31. CNA B said it is important to protect a Resident's privacy for their dignity. When asked how she protects someone's privacy she said, tell them what you are going to do, close the door and pull the curtain during care. On 12/16/22, a review of Resident #31's clinical record was conducted. There was a care plan initiated 12/6/22, that read, [Resident #31's name redacted] has preference of only wearing his brief while in bed. The goal for this focus area was, Resident Preferences Will Be Considered When Providing Care. The intervention read, Choosing clothes to wear: Somewhat Important to Resident. There was no indication within the care plan of how the facility would honor this preference while maintaining the Resident's privacy and dignity. The facility policy regarding Resident Rights was requested and received. Review of the facility provided document read, Resident's Rights and Responsibilities .Privacy and Confidentiality: The Resident has a right to personal privacy and confidentiality of his or her personal and medical records . On 12/19/22, during an end of day meeting, the facility Administrator, Director of Nursing (DON) and corporate staff were made aware of the multiple observations of Resident #31 noted above. On 12/20/22 at 9:45 AM, the DON provided Surveyor C with a care plan for Resident #31 that was more elaborate than what Surveyor C had seen in the clinical record. The DON acknowledged that the care plan she provided was from the previous electronic health record (EHR) system. When asked if this was still the active care plan or the one in the electronic health record system/program currently being utilized by the facility, she said she didn't know. Surveyor C then interviewed RN B, the MDS (minimum data set) coordinator. RN B said that the one in the current EHR system was the current care plan. No further information was provided. 2. For Residents #1, #20, and #29, the facility staff failed to ensure their medical information was private and not accessible to others. On 12/16/22 from 7:45 AM until 8:30 AM, RN D, the nursing supervisor, was observed during Resident #1, #20 and #29's medication administration. Throughout the medication administration RN D would prepare the medications at the medication cart, in the hallway. RN D would then enter the Resident's room to administer medication, discard water not consumed by the Resident and trash, then RN D washed her hands before returning to the medication cart. Each time RN D left the Resident's information which included medications, diagnosis, and other protected health information on the computer screen, unattended in the hallway, where other Residents, visitors and staff could observe the information. On 2 occasions during this process, Surveyor C returned to the medication cart and was able to review the Resident information on the screen. Following the medication administration observation when RN D was asked about this and notified, she had left the Resident information on the screen she responded, I'm sorry. The facility policy titled; Medication Administration was reviewed. This policy didn't address ensuring Resident protected health information is not left accessible/visible when the information is left unattended. Review of the facility policy regarding Resident Rights was reviewed. The policy stated, .Privacy and Confidentiality: The Resident has a right to personal privacy and confidentiality of his or her personal and medical records. The resident has a right to secure and confidential personal and medical records. The resident has the right to refuse the release of personal and medical records except as provided under 483.70(i)(2) or other applicable federal or state laws . On 12/16/22 at 9:23 AM, a meeting was held with the Director of Nursing (DON) and corporate staff. The above observations and findings from the medication administration observation were shared. No additional information was provided.

Based on observation, staff interviews, facility documentation and clinical record review, the facility staff failed to follow standards of nursing practice affecting 4 Residents (Resident #1, 20, 41 and 262) in a survey sample of 26 Residents. The findings included: 1. For Resident #1 the facility staff crushed an extended-release medication that is not to be crushed. On 12/16/22 at 7:54 AM, RN D, the nursing supervisor, was observed during medication administration of Resident #1's medication. RN D removed a Venlafaxine ER capsule 150 mg and a Venlafaxine ER capsule 75 mg from the pharmacy bag which was labeled and indicated Do Not Crush. RN D opened both capsules emptying the contents into a plastic bag along with other medications for Resident #1 and crushed them all. RN D then mixed the crushed medications into apple sauce and entered the room of Resident #1 and administered the medications. Following the medication administration observation, Surveyor C asked RN D how she knew which medications to crush and which ones not to. RN D said they have a shift-to-shift report sheet that indicates how a Resident take their medications such as crushed, whole, with apple sauce, etc. When asked how they know if a medication can't be crushed, she said, If they get their medications crushed then all of them can be crushed. Between us and the pharmacy they make sure of that. If there is something that can't be crushed the pharmacy would call us. If it is something that can't be crushed, they would change it to liquid. When asked if she double checks if things can or cannot be crushed, RN D said, I wouldn't check each day, if it were something new, I probably would look. Surveyor C then asked about the medications that are ER (extended release), what this meant. RN D said, ER means extended release, meaning the medication is slowly released into the system. When asked what the potential problem is if an extended-release medication is released all at one, RN D said, It could result in overdose. RN D was shown the pharmacy package which contained Resident #1 and #20's medications that specifically read, Do Not Crush for medications that were crushed. RN D indicated she wasn't aware. A copy of the shift-to-shift report sheet was provided to the survey team. Review of this document revealed that Residents #1 was noted as taking medications crushed. The medication cart contained a Nursing 2022 Drug Handbook from [NAME] Kluwer. This book was reviewed and gave the following information for Venlafaxine ER: i. Page 1507-1508 read, Venlafaxine . Administration PO [by mouth] . For extended-release capsules and tablets, don't divide, crush, place in water, or allow patient to chew. May give pellet-filled capsules by carefully opening capsule and sprinkling the pellets on a spoonful of applesauce. Patient should swallow applesauce immediately without chewing, then follow with a glass of cool water to ensure that all pellets are swallowed . Review of the facility policy titled; Medication Administration was conducted. This policy read, .Crush only those meds that can be crushed. Refer to American Society of Consultant Pharmacists (ASCP) Crushed Medication list in each facility. Crushed meds can be thoroughly mixed individually with appropriate food to make swallowing easier . On 12/16/22 at 9:23 AM, a meeting was held with the Director of Nursing (DON) and corporate staff. The above observations and findings from the medication administration observation were shared. The DON was asked about extended-release medications and said, you can't crush those because they get more medication at one time if it is crushed. No additional information was provided. 2. For Resident #20, the facility staff crushed a medication that is not supposed to be crushed. On 12/16/22 at 8:07 AM, RN D was observed during her medication administration of Resident #20's medications. RN D proceeded to remove Resident #20's medications from the pharmacy bag, which included but was not limited to: Duloxetine DR capsule 60 mg. RN D opened the Duloxetine capsule and poured the contents into a plastic bag with the other medications and proceeded to crush all the medications together. The pharmacy bag containing the medications was labeled as follows: .Duloxetine DR [delayed release] Cap 60 mg. sub for Cymbalta Dizzy/Drowsy, Do Not Crush . RN D then proceeded into Resident #20's room and administered the medications. Following the medication administration observation, Surveyor C asked RN D how she knew which medications to crush and which ones not to. RN D said they have a shift-to-shift report sheet that indicates how a Resident take their medications such as crushed, whole, with apple sauce, etc. When asked how they know if a medication can't be crushed, she said, If they get their medications crushed then all of them can be crushed. Between us and the pharmacy they make sure of that. If there is something that can't be crushed the pharmacy would call us. If it is something that can't be crushed, they would change it to liquid. When asked if she double checks if things can or cannot be crushed, RN D said, I wouldn't check each day, if it were something new, I probably would look. RN D was shown the pharmacy package which contained Resident #1 and #20's medications that specifically read, Do Not Crush for medications that were crushed. RN D indicated she wasn't aware. A copy of the shift-to-shift report sheet was provided to the survey team. Review of this document revealed that Resident #20 was noted as taking medications crushed. The medication cart contained a Nursing 2022 Drug Handbook from [NAME] Kluwer. This book was reviewed and gave the following information for Duloxetine DR: Pages 479-480 read, Duloxetine hydrochloride .Administration PO, give whole; don't crush or open capsules . Review of the facility policy titled; Medication Administration was conducted. This policy read, .Crush only those meds that can be crushed. Refer to American Society of Consultant Pharmacists (ASCP) Crushed Medication list in each facility. Crushed meds can be thoroughly mixed individually with appropriate food to make swallowing easier . On 12/16/22 at 9:23 AM, a meeting was held with the Director of Nursing (DON) and corporate staff. The above observations and findings from the medication administration observation were shared. The DON was asked about extended-release medications and said, you can't crush those because they get more medication at one time if it is crushed. No additional information was provided. 3. For Resident #41, the facility staff administered a nicotine patch per physician orders and provided the Resident cigarettes, which also contained nicotine, without a physician order or notification to the physician, to afford the practitioner the opportunity to make alterations to the Resident's treatment plan. On 12/13/22, during an entrance conference with the Administrator, it was reported that Resident #41 smokes and leaves the property to do so. On 12/13/22-12/15/22, Resident #41 was observed to exit the facility on several occasions to go smoke. On 12/14/22 at 6:50 PM, an interview was conducted with LPN B and RN C. Both nurses confirmed that when Resident #41 got stronger and was able to walk she started smoking again. Both LPN B and RN C explained that Resident #41's cigarettes are kept by staff, and she will ask any staff member to get them for her when she wants to go out. Resident #41 will then sign a sign-out book kept at the nursing station and will leave the premises to smoke. Both nurses report that Resident #41 has been smoking for about 6 months now and is very complaint with giving staff her cigarettes upon her return but that they do not remove the residents nicotine patch prior to smoking. On 12/14/22 at 7:10 PM, an interview was conducted with the Director of Nursing in the presence of the corporate nursing staff. The DON stated the risk of smoking while having a nicotine patch on is that if she gets too much nicotine she could die. The Corporate nurse expressed that the concern for smoking while on a nicotine patch is nicotine toxicity. On 12/14/22 at 8:02 PM, a telephone interview was conducted with the Nurse Practitioner (NP) and Surveyor B and C. The NP stated that she had spoken with Resident #41 about smoking while on the nicotine patch and was not aware that the Resident was smoking. The NP also stated that since nursing staff keep her cigarettes, she was expecting nursing staff to notify her if the Resident was smoking, however she had not given this instruction to nursing or written an order for such. The NP expressed that she had been made aware on the evening of 12/14/22, that Resident #41 was smoking. The NP said, you can overdose on nicotine, and she is managing to smoke quite a bit, she is not supposed to be smoking on the patch. We need to have a team meeting and I plan to speak with [name of the attending physician redacted]. A clinical record review was conducted of Resident #41's chart and revealed no indication that nursing staff had advised the nurse practitioner or doctor that Resident #41 was still continuing to smoke while on a nicotine patch. There was no indication that nursing staff were removing the patch prior to the Resident being given her cigarettes. Review of the facility policy regarding smoking indicated that they were a smoke free facility. No further information was provided. 4. For Resident #262, the facility staff failed to elevate the head of the bed in a 30-45-degree position while tube feeding was infusing, failed to date the feeding and on one occasion facility staff stopped the tube feeding for a period of time without a doctor's order. On 12/13/22 at 01:05 PM, Resident #262 was observed lying in bed. She was noted to have tube feeding (Isosource) running at 50 ml., the bag was noted to have no date as to when it was hung. The bag of water for flushes was also noted to have no date. On 12/13/22 at 03:02 PM, Resident #262 was observed to be lying flat in the bed, with the head of the bed not elevated. The tube feeding formula was still noted to not have a date. Surveyor C then went to get to the nurse, LPN B, who was assigned to Resident #262. LPN B reported that Resident #262 was new to the facility and was status post a stroke. LPN B stated, She has continuous feeding with Isosource, is total care and can move left arm. LPN B was asked about the tube feeding, she stated, we change it on our shift, usually it pops up to be done between 2-4 PM, we change all of the tubing, make sure the peg site is clean, put drain gauze is in place, and make sure tube is flowing. On 12/13/22 at 3:10 PM, LPN B accompanied Surveyor C to the room of Resident #262. LPN B confirmed that the Resident was lying flat in bed and stated the CNA's must have left her that way after providing care. LPN B said that the Resident's head to be elevated 30-40 degrees to prevent aspiration. LPN B also confirmed that the tube feeding, and water flushes were not dated and therefore it was unknown when they were hung/put in place. LPN B stated she had come on shift at 7 AM, this morning and had not changed it. LPN B said she would assume it was hung yesterday but without the date she couldn't confirm that. LPN B then said, I'm going to get one now so you can see the correct way it should be done. On 12/13/22 at 3:15 PM, LPN B proceeded to change the tube feeding, water flush bag and tubing of both. LPN B dated each bag and indicated the time. LPN B proceeded to state that the tubing and everything is to be changed daily because if it gets any solidification in it and that goes back up, it will contaminate the feeding and risk the Resident getting a bacterial infection. On 12/13/22 at 4:34 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked to describe how to care for a tube feeding resident. The DON said, The head of the bed should be elevated 35-45 degrees. When asked what the purpose of this was, she said, to prevent aspiration. When asked about dating of the feeding and tubing, the DON said, We should label and date the bags and indicate the rate. When asked to explain the purpose of dating and the risks she indicated that tube feeding can spoil (go bad) after 24 hours. On 12/19/22 at 3:21 PM, Resident #262 was observed in bed, her tube feeding bag was empty and the pump was off. Surveyor C then asked LPN B about this. LPN B said, I try to give her a little rest, she gets fidgety at times. Review of the clinical record for Resident #262 revealed the following orders: i. Keep head of bed elevated at 30-45 degrees at all times during the administration of enteral feedings and 30 minutes after medication administration every shift for aspiration precaution, dated 12/9/22. ii. Tube feeding: Isosource 1.5 @ 50cc/hr. continuous document intake every shift every shift for nutrition, dated 12/9/22. The facility policy regarding the care of and administration of tube feeding was requested. An untitled document was provided which read, .23. Initiate enteral feedings as prescribed . 24. Elevate the head of the bed to a minimum of 30 degrees, but preferable to 45 degrees, when feedings are infusing. On 12/19/22 at 4:32 PM, during an end of day meeting, the facility Administrator, DON, and corporate staff were made aware of the above findings with regards to Resident #262. No further information was provided.

Based on staff interview, clinical record review, and facility document review, the facility failed to provide medications as ordered by a physician for one Resident (Resident #262) in a sample of 26 residents. The findings included: For Resident #262, the facility staff failed to administer four medications as ordered because they were not available. Resident #262 was admitted to the facility on [DATE]. A review of Resident #262'S clinical record was conducted. This review revealed the following excerpts from the progress notes: i. Note dated 12/09/2022 at 16:41, read, hydralazine HCL Tablet 50 MG, Give 1 tablet via G-Tube every 8 hours for HTN. Pharmacy has not delivered, new admission. ii. Note dated 12/10/2022 at 09:53, read, levetiracetam Solution 100 MG/ML. Give 5 ml via G-Tube every morning and at bedtime for Seizure disorder. None available. iii. Note dated 12/10/2022 at 09:53, read, Famotidine Tablet 20 MG. Give 20 mg via G-Tube one time a day for Ulcer prevention. None available. iv. Note dated 12/10/2022 at 09:54, read, Metoprolol Tartrate Tablet 75 MG, Give 75 mg via G-Tube in the morning for HTN. None available. According to the December 2022 MAR (Medication Administration Record), the above noted medications were not provided/administered. There was no documentation of the facility staff using medication from the Stat box or calling the physician to notify of the unavailable medications. On 12/16/22 at 8:30 AM, an interview was conducted with the RN D, who was administering drugs on the unit. RN D stated, if meds (medications) are not available, staff are to try to get them out of the cubex (in-house stock of medications), if they aren't there, they call the pharmacy. On 12/16/22 at 9:23 AM, the DON (Director of Nursing) confirmed that if mediations are not available nurses are to go check the medication bank (in-house emergency box) and if it isn't available there, they are to notify the provider. The DON added that they can check the medications for that Resident in the next day's supply as well. The facility's medication administration policy was reviewed. This policy didn't address what the facility staff are to do if a medication is not available for administration. No further information was received prior to the conclusion of the survey.

Based on observation, staff interview, clinical record review, and facility documentation, the facility staff failed to ensure the medication error rate was less than 5%. There were 2 medication errors (medications crushed that are not to be crushed) in 32 opportunities, resulting in an 6.25% error rate. The findings included: On 12/16/22 at 7:54 AM, RN D, the nursing supervisor, was observed during medication administration of Resident #1's medication. RN D removed a Venlafaxine ER capsule 150 mg and a Venlafaxine ER capsule 75 mg from the pharmacy bag which was labeled and indicated Do Not Crush. RN D opened both capsules emptying the contents into a plastic bag along with other medications for Resident #1 and crushed them all. RN D then mixed the crushed medications into apple sauce and entered the room of Resident #1 and administered the medications. On 12/16/22 at 8:07 AM, RN D was observed during her medication administration of Resident #20's medications. RN D proceeded to remove Resident #20's medications from the pharmacy bag, which included but was not limited to: Duloxetine DR capsule 60 mg. RN D opened the Duloxetine capsule and poured the contents into a plastic bag with the other medications and proceeded to crush all the medications together. The pharmacy bag containing the medications was labeled as follows: .Duloxetine DR Cap 60 mg. sub for Cymbalta Dizzy/Drowsy, Do Not Crush . RN D then proceeded into Resident #20's room and administered the medications. Following the medication administration observation, Surveyor C asked RN D how she knew which medications to crush and which ones not to. RN D said they have a shift-to-shift report sheet that indicates how a Resident take their medications such as crushed, whole, with apple sauce, etc. When asked how they know if a medication can't be crushed, she said, If they get their medications crushed then all of them can be crushed. Between us and the pharmacy they make sure of that. If there is something that can't be crushed the pharmacy would call us. If it is something that can't be crushed, they would change it to liquid. When asked if she double checks if things can or cannot be crushed, RN D said, I wouldn't check each day, if it were something new, I probably would look. Surveyor C then asked about the medications that are ER (extended release), what this meant. RN D said, ER means extended release, meaning the medication is slowly released into the system. When asked what the potential problem is if an extended-release medication is released all at one, RN D said, It could result in overdose. RN D was shown the pharmacy package which contained Resident #1 and #20's medications that specifically read, Do Not Crush for medications that were crushed. RN D indicated she wasn't aware. A copy of the shift-to-shift report sheet was provided to the survey team. Review of this document revealed that Residents #1 and #20 were both noted as taking medications crushed. The medication cart contained a Nursing 2022 Drug Handbook from [NAME] Kluwer. This book was reviewed and gave the following information for Venlafaxine ER and Duloxetine DR: i. Page 1507-1508 read, Venlafaxine . Administration PO [by mouth] . For extended-release capsules and tablets, don't divide, crush, place in water, or allow patient to chew. May give pellet-filled capsules by carefully opening capsule and sprinkling the pellets on a spoonful of applesauce. Patient should swallow applesauce immediately without chewing, then follow with a glass of cool water to ensure that all pellets are swallowed . ii. Pages 479-480 read, Duloxetine hydrochloride .Administration PO, give whole; don't crush or open capsules . Review of the facility policy titled; Medication Administration was conducted. This policy read, .Crush only those meds that can be crushed. Refer to American Society of Consultant Pharmacists (ASCP) Crushed Medication list in each facility. Crushed meds can be thoroughly mixed individually with appropriate food to make swallowing easier . On 12/16/22 at 9:23 AM, a meeting was held with the Director of Nursing (DON) and corporate staff. The above observations and findings from the medication administration observation were shared. The DON was asked about extended-release medications and said, you can't crush those because they get more medication at one time if it is crushed. The facility staff were made aware of the medication error rate of 9.38%. No additional information was provided.

Based on Resident and family interviews, facility documentation review and clinical record review, the facility staff failed to provide dental services for one Resident (Resident #44) in a survey sample of 26 Residents. The findings included: For Resident #44, the facility staff failed to arrange for dental services to obtain dentures following extraction of his teeth. On 12/14/22 at 10:03 AM, during an interview with Resident #44, a nurse entered the room to provide the Resident with medication. One of the pills was chewable and Resident #44 was having difficulty chewing the pill. Resident #44 mentioned that he had his teeth removed and keeps waiting for dentures. On 12/14/22, an interview was conducted with the spouse of Resident #44. The spouse said that they have been waiting and waiting for him to get his dentures taken care of, but nothing seems to be happening. A clinical record review was conducted of Resident #44's chart. This review revealed the following: i. A progress note written by the registered dietician on 8/4/22, read, .Dental: Resident reports he has a DDS follow up appt next month to have dental extractions in prep for denture plates . ii. A care plan note written 8/25/22, read, .Resident reports inability to eat as much due to poor dentition. Dental appointment for extractions pending . iii. On 9/6/22, the nurse practitioner saw Resident #44 and her note stated, .patient attributes to poor dentition and dental pain. Dietary interventions. Dental issues. Looking for extraction and dentures. has appointment scheduled for dental follow-up some weight loss, has stabilized . iv. There was a handwritten note dated 9/13/22, from the provider who performed the extraction of 22 teeth. This noted indicated to follow up as needed. There was no further mention in the clinical chart with regards to any scheduled follow-up or scheduled appointments regarding dentures for Resident #44. On 12/19/22 at 2 PM, an interview was conducted with employee F, the social worker. Employee F stated that they do not have a dental provider that comes on-site, we use the [name redacted] free clinic, a packet has to be sent for them to determine if the person is eligible for free services. Employee F provided surveyor C with a list of Residents she is working to obtain dental services for. Resident #44 was not noted/listed. Surveyor C asked Employee F if the free clinic was the only way for a person to obtain dental services and she said the DON had just found another dentist that accepts Medicaid. Employee F was asked about the MAP adjustment process, which is where a patient's income can be approved to use for non-covered services. Employee F had no knowledge of this process. The facility policy regarding dental services and consulting providers was requested. No related policy was received. On 12/19/22, during the end of day meeting, the facility Administrator, Director of Nursing and Corporate staff were made aware of the above findings. On 12/19/22 at 2:31 PM, the DON stated they had made an appointment for Resident #44 for 12/27/22, to visit the free dental clinic to initiate the process for dentures. No further information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide a pneumococcal and/or influenza vaccine for 2 residents, Resident #53 and Resident #258, out of 5 residents reviewed for pneumococcal and influenza immunization. The findings include: 1. The facility staff failed to provide pneumococcal immunization for Resident #53. On 12/14/22, clinical record review was performed for Resident #53 and revealed a document entitled, Pneumococcal Vaccine Informed Consent, dated 11/8/22, signed by Resident #53, with a check mark placed next to the statement which read, The undersigned does authorize the Center to administer the pneumococcal vaccine. There was no further documentation that indicated whether or not Resident #53 had received a pneumococcal vaccine. Resident #53 was admitted to the facility on [DATE]. On 12/14/22, an interview was conducted with the facility Director of Nursing (DON), also serving as the facility's Infection Preventionist (IP), who accessed the clinical record for Resident #53 and verified the findings. The DON/IP stated, I do not know why [name redacted, Resident #53] did not receive a pneumonia vaccination, he did consent to get one, it must have been an oversight. A facility policy on pneumococcal immunization was requested and received. Review of the facility policy entitled, Influenza and Pneumococcal Immunization For Residents Policy, last date of review: 9/28/2022, read: Policy Statement .This policy was created to prevent the occurrence of influenza and pneumonia that are vaccine-preventable .Each resident will be offered .lifetime immunization against pneumococcal disease . On 12/14/22, during the end of day meeting, the Facility Administrator and the DON/IP were made aware of the findings. No additional information was provided prior to the survey Exit Conference held on 12/20/22. 2. The facility staff failed to provide influenza and pneumococcal immunization for Resident #258. On 12/14/22, clinical record review was performed for Resident #258 and revealed a document entitled, Influenza Vaccine, Pneumococcal Vaccine Informed Consent, dated 11/28/22, signed by Resident #258's Responsible Party, with a check mark placed next to the statements which read, The undersigned does authorize the Center to administer the influenza vaccine and The undersigned does authorize the Center to administer the pneumococcal vaccine. There was no further documentation that indicated whether or not Resident #258 had received either the influenza or pneumococcal vaccine. Resident #258 was admitted to the facility on [DATE]. On 12/14/22, an interview was conducted with the facility Director of Nursing (DON), also serving as the facility's Infection Preventionist (IP), who accessed the clinical record for Resident #258 and verified the findings. The DON/IP stated, I do not know why [name redacted, Resident #258] did not receive the flu or pneumonia vaccination, I see the consent to get them, it was an oversight. A facility policy on influenza and pneumococcal immunization was requested and received. Review of the facility policy entitled, Influenza and Pneumococcal Immunization For Residents Policy, last date of review: 9/28/2022, read: Policy Statement .This policy was created to prevent the occurrence of influenza and pneumonia that are vaccine-preventable .Each resident will be offered immunization against influenza .and lifetime immunization against pneumococcal disease . On 12/14/22, during the end of day meeting, the Facility Administrator and the DON/IP were made aware of the findings. No additional information was provided prior to the survey Exit Conference held on 12/20/22.

Based on observation, Resident interview, staff interview, facility documentation review and clinical record review, the facility staff failed to apply palm protectors to prevent the development of skin breakdown for one (1) Resident (Resident #31) in a survey sample of 26 Residents. The findings included: On 12/13/22 at 12:02 PM, Resident #31 was observed lying in bed. Resident #31 was noted with bilateral hand and wrist contractures and no splinting or device to prevent the development of wounds was noted. Resident #31 would not verbally respond to Surveyor C's questions. On 12/14/22 at approximately 10 AM, Resident #31 was observed lying in bed, no palm protector devices were noted. On 12/16/22 at 11:30 AM, Resident #31 was observed in bed, without a palm protector on. CNA B, who was assigned to Resident #31 was asked about splints or palm protectors and CNA B was able to find one palm protector in the chest of drawers. CNA B stated that Resident #31 will frequently refuse them. Resident #31 was asked about the palm protector and the Resident said, Please put it on. CNA B assisted Resident #31 in extension of his fingers so that Surveyor C could observe the skin integrity of the palms, the skin was noted to be intact. A review of the clinical record for Resident #31 was performed. This review revealed a physician order dated 7/19/22, that read, Hand Protectors Resident to have palm protectors to bilateral hands as tolerated two times a day. There were no nursing progress notes to indicate any Resident refusals. The ADL sheets for Resident #31 for the months of November and December were reviewed and there was no evidence of the palm protectors being refused. Review of the care plan for Resident #31 noted the following: A focus area initiated 11/10/22, with a revision on 11/12/22, that read, [Resident #31's name redacted] has actual skin impairment: PI [pressure injury] to R [right] hand . Interventions for this focus area made no mention of the palm protector. The facility Administrator was asked to provide facility policies related to assistive devices; no related policies were provided. On 12/19/22, the facility Administrator and Director of Nursing were made aware of the above findings. On 12/20/22 at 9:45 AM, the Director of Nursing provided Surveyor C with a copy of the physician order dated 7/19/22, that read, Hand Protectors: Resident to have palm protectors to bilateral hands as tolerated. Surveyor C explained she had seen this order but there was no documentation within the clinical record to indicate Resident #31 had instances of refusals. No further information was provided.

Based on observation, Resident and staff interviews, facility documentation review and clinical record review, the facility staff failed to provide vision services for 2 Residents (Resident #25 and #44) in a survey sample of 26 Residents. The findings included: 1. For Resident #25 the facility staff failed to 1) arrange for repair of the Resident's glasses which were broken and 2) failed to make an appointment for evaluation of cataract removal as recommended for over a year. On 12/14/22 at 11:32 AM, Resident #25 was visited in his room. Resident #25 presented as being alert and oriented. Surveyor C observed that Resident #25's glasses were broken. The left side stem was taped, despite the tape the stem of the glasses was hanging downside of the Resident's face/cheek and his glasses were sliding down to the tip of his nose as a result. When asked, Resident #25 reported they had been broken for a while but they were working to get him Medicaid so they can get them fixed. Resident #25 reported this has been going on for 3 months. On 12/19/22 at 2:17 PM, Resident #25 was visited again. His glasses were still noted to be broken with the left stem taped. On 12/20/22 at 9 AM, Resident #25 was observed in the dining room eating breakfast. His glasses remained broken with the stem on the left side hanging down the side of his cheek. A clinical record review was conducted of Resident #25's chart. This review revealed the following: i. On 9/13/22, a quarterly minimum data set assessment was conducted. On this assessment Resident #25 was coded as having scored 15 out of 15 on a brief interview for mental status, which indicated he was cognitively intact. This assessment also coded Resident #25 as having impaired vision and requiring the use of glasses. ii. Resident #25 was seen by an on-site eye doctor on 11/23/21, which indicated the Resident's vision was 10/10 with his glasses. The progress notes from the eye doctor read, Physician orders: Age-related nuclear cataract, bilateral- Cataracts- OU- moderate- recommend referral for cataract evaluation iii. Resident #25 was seen again by the on-site eye doctor on 6/27/22. During this visit the doctor noted Physician orders: .2. Cataracts-OU-moderate- recommend referral for cataract evaluation to: [name and phone number of provider redacted] . Plan and Treatment . Age-related nuclear cataract, bilateral- Cataracts-OU-moderate- patient was scheduled for cataract surgery but has not gone-- recommend referral for cataract evaluation. There was a nursing progress note written 6/27/22, in response to the eye doctor visit which made no mention of the recommendation for cataract evaluation . iv. On 10/19/22, Resident #25 was again seen by the on-site eye doctor. This visit again recommended a referral for cataract evaluation. This visit note also indicated, hyperopia/presbyopia- ordered new progressive addition glasses. There was no further information within the clinical chart as to the status of the glasses that had been ordered on 10/19/22, nor the status of or that an appointment for evaluation of his cataracts had been made. On 12/19/22 at 2 PM, an interview was conducted with Employee F, the social worker. The social worker confirmed that an eye doctor comes on-site but stated she is fairly new to this facility and just knows he is scheduled to return in January. The facility policy regarding consulting providers and physician orders was requested. The facility staff provided a document titled, JOB AID - MANAGING PROVIDER ORDERS. This document read, Procedure for Transcribing Physician Orders 1. Review the order for clarity and completeness. If the order is not clear or complete, contact the physician giving the order and obtain clarification. Discontinue the original order and write a new order that is clear and complete General Principles and Guidelines: Review the Pending and Queued Orders tabs of the EMR at least twice per shift to ensure that all orders have been transcribed/activated and the necessary actions for implementation have been done . On 12/19/22, during an end of day meeting held with the facility Administrator, Director of Nursing and Corporate staff, they were made aware of the above concerns. On 12/20/22 at 9:44 AM, the Director of Nursing (DON) met with Surveyor C and provided a copy of a progress note written 12/20/22. The DON said, we called this morning and made him an appointment and [Employee F's name redacted] is working on his glasses. The progress note indicated that Resident #25 had an appointment scheduled for 5/17/23 for follow-up regarding cataracts. On 12/20/22 at 10:50 AM, Surveyor C was provided a document and the DON stated they had been able to obtain Resident #25 an appointment for 1/12/22. The Corporate staff also stated they had ordered Resident #25 a pair of glasses from Amazon earlier that morning. No further information was provided. 2. For Resident #44, the facility staff failed to arrange for evaluation of cataracts as per recommendations from the eye doctor. On 12/14/22, an interview was conducted with Resident #44. Resident #44 mentioned that he has been waiting to get his eyes fixed for some time. On 12/14/22, an interview was conducted with the spouse of Resident #44. The spouse said that they have been waiting and waiting for him to get his cataracts taken care of, but nothing seems to be happening. A clinical record review was conducted of Resident #44's chart. This review revealed Resident #44 was seen by an on-site eye doctor on 11/23/21 and again on 6/27/22. Each of the progress notes from the eye doctor read, Physician orders: 1. Cataracts- OU-moderate/progressive- recommend referral for cataract evaluation to: [office name and phone number redacted] . A care plan note dated 8/4/22, read, .Ophthalmology appointment for cataract surgery remains pending . The attending physician of Resident #44 saw him on 10/7/22, and made the following note, .He also has had decline in his vision and optometry here has identified cataracts affecting both eyes. He would like to proceed with ophthalmology consult for cataract surgery .Have referred him to Ophthalmology to assess his candidacy for cataract surgery. In terms of preop evaluation will wait for ophthalmology opinion. Although he has multiple medical conditions and place him at high risk of major surgery a minor procedure like cataract surgery should be tolerated fairly well. Also, would like to get echocardiogram prior to doing assessment of risk of surgery. His EKG will be of little help for risk assessment of surgery given that he has a paced rhythm . There was no evidence within the clinical record of any upcoming appointment for cataract evaluation. The facility policy regarding vision services, consulting providers and physician orders was requested. The facility staff provided a document titled, JOB AID - MANAGING PROVIDER ORDERS. This document read, Procedure for Transcribing Physician Orders: 1. Review the order for clarity and completeness. If the order is not clear or complete, contact the physician giving the order and obtain clarification. Discontinue the original order and write a new order that is clear and complete General Principles and Guidelines: Review the Pending and Queued Orders tabs of the EMR at least twice per shift to ensure that all orders have been transcribed/activated and the necessary actions for implementation have been done . On 12/19/22, during an end of day meeting the facility Administrator and Director of Nursing were made aware of the above concerns with regards to the lack of follow-up for evaluation of cataract removal. On 12/20/22 at 9:43 AM, the DON provided a progress note that was written 12/19/22, and indicated it was a late entry for 10/14/22. It read that Resident #44 had an appointment on 3/24/23 for evaluation for cataract surgery. No further information was provided.

Based on observation, staff interview and clinical record review the facility staff failed to provide assistance to a Resident who was dependent upon staff assistance with activities of daily living for one Resident (Resident #29) in a survey sample of 26 Residents. The findings included: For Resident #29, the facility staff failed to assist the Resident when she requested a shower. On 12/13/22 at 3:25 PM, Surveyor C observed Resident #29 in the hallway at the nursing station and asked if she could be showered. Resident #29 stated, I haven't had a shower since Monday before last and my body stinks. CNA C was at the nursing station and responded to Resident #29 by saying, I'm here tomorrow on women's day and will try to get you in there then. Today is men's day and you don't want to be in there with stinky men. Resident #29 responded, At this point I don't really care. CNA C said, I promise I will try to get you in there first thing tomorrow, I promise. Review of Resident #29's clinical record revealed a care plan initiated 12/6/22, that indicated the Resident required staff assistance with ADL's (activities of daily living). One of the associated interventions read, Staff to assist with ADLs as needed and document amount of assistance required per protocol. Resident #29 had a quarterly minimum data set assessment completed, which had an assessment reference date of 8/29/22. This assessment indicated Resident #29 had a brief interview for mental status score of 15, indicating she was cognitively intact. This same assessment noted Resident #29 as requiring physical help of staff for bathing. Review of the ADL record for December revealed Resident #29 had most recently received a bath on 12/7/22, prior to her request on 12/13/22. This document noted a refusal on 12/9/22. On 12/20/22, Surveyor C shared concern with regards to baths/showers for Residents with the facility Administration. No further information was provided.

Based on Resident and staff interviews, facility documentation review and clinical record review, the facility staff failed to notify the doctor and Resident representative timely of a Resident change in condition for 1 Resident (Resident #51) in a survey sample of 26 Residents. The findings included: For Resident #51, who reported visual hallucinations, the facility staff failed to notify the doctor and resident representative until the following day. On 12/13/22 at 12:23 PM, Resident #51 reported to Surveyor C that she is having visual hallucinations. Resident #51 presented to be alert, oriented and an accurate historian. Resident #51 said that the hallucinations started over the weekend and they are really bad. Resident #51 described that she is seeing building and people but can't touch them. The Resident denied any auditory hallucinations and reports she notified the nurse. On 12/13/22 at approximately 12:30 PM, Surveyor C went to LPN B, who was the assigned nurse for Resident #51, and made her aware that Resident #51 was reporting visual hallucinations. LPN B stated that she was aware and said, She had COVID about 3 weeks ago and this is something we have been dealing with off and on since then, some days are worse than others. We are going to make the Dr. aware so they can keep an eye on her. Her vital signs are stable, her appetite is good, she still gets up and walks around in her room. We remind her to drink fluids, even though she has it there she doesn't always remember to drink them. On 12/14/22 at 10:42 AM, Resident #51 was observed sitting at nursing station. Surveyor C approached the Resident and asked how she was feeling. Resident #51 reported that she was still hallucinating and said, it has never been this bad for this long, it is 24/7, I see the people but can't touch them and know they are a spirit, I am waiting for them to decide what they are going to do. Review of the clinical record for Resident #51 revealed a behavior note: written 12/13/22 at 13:10 by LPN B. The note read, Resident reported to writer that she is having hallucinations, that are very strong like she has her sight back. Resident proceeded to tell writer while administering medication, that she seen 2 dogs sitting beside me, even though she knows there is nothing there. Resident stated these hallucinations having been happing since the weekend. Assured resident that writer would flag doctor, also advised resident to take in more water to increase hydration. There was no indication that the doctor was made aware of the reported hallucinations until 12/14/22. The doctor saw Resident #51 on 12/14/22 and ordered lab work. The resident representative was notified on 12/14/22 and visited the Resident after being notified. There was an entry into the clinical record of Resident #51 on 12/9/22, by Employee F, the social worker. The entry indicated that a brief interview for mental status (BIMS) was conducted, and Resident #51 scored 15 out of 15, which indicated she was cognitively intact. On 12/15/22 at 6:15 PM, Resident #51 was visited in her room. She reported that the facility staff took blood and urine, the urine test didn't take so they are going to get another one. I know they [hallucinations] aren't real but sometimes I don't know if I'm dreaming or hallucinating. On 12/15/22 at 6:23 PM, an interview was conducted with LPN B. LPN B was asked to discuss when the medical providers (doctor and nurse practitioner) visit the facility and how the staff communicate with them. LPN B explained that the doctor comes on Tuesday and Fridays and the nurse practitioner comes on Mondays and Thursdays. LPN B stated if they are not in the facility where staff can tell them of anything, we have their direct cell phone numbers and we can call them or message them via PCC [electronic health record system]. They are good about responding. LPN B went on to say that she always notifies the Resident's family member and then writes a progress note that everyone was notified. During the above conversation/interview with LPN B, LPN B access the electronic health record system and displayed to Surveyor C how she can use the system to send a message to the provider. A record of the conversation is maintained in the system for a period of time. LPN B then accessed Resident #51's chart and was asked to show/display the communication with the provider. There were no communications noted for Resident #51. LPN B then said, We got orders Tuesday and her labs were drawn yesterday, we are waiting on the cultures and urine results. Further review of the clinical record revealed that the order for labs was not received until Wednesday, 12/14/22. There was no indication that the doctor or nurse practitioner had been notified of Resident #51's report of hallucinations until 12/14/22. On 12/15/22, during an end of day meeting with the facility Director of Nursing (DON) and Corporate Staff, the DON was asked to explain how and when facility staff are to communicate Resident changes to the medical provider. The DON said, If it is urgent, we call the provider and if it is after hours, we call the on-call provider. We can also communicate via PCC and send messages to them. The DON was asked if the messages in PCC are part of the clinical record and she indicated they are not, they are only visible for 7-14 days. The DON said that when the nurse practitioner comes, she gives a detailed report on the Residents and reports any changes. When asked what she had reported to the nurse practitioner on 12/13/22, the DON stated one Resident, which was not Resident #51. The DON accessed the messages to the provider in the electronic health record system for Resident #51 and noted there were not any notes to the provider present. When asked about the timing of notifying the doctor of a Resident's change in condition she reported that it should be reported immediately. The DON also logged into the hospital-based record system, which is where their labs are processed and was able to access labs for Resident #51. Surveyor C was provided a copy. Review of the lab reports revealed the labs had been collected/drawn from the Resident on 12/15/22 at 6:44 AM. On 12/19/22, a review of Resident #51's clinical record revealed that on 12/15/22 at 15:45, the doctor had called the facility and ordered to decrease the Resident's Synthroid medication dose in response to the TSH (Thyroid Stimulating Hormone) lab results. On 12/19/22, the facility Administrator was asked to provide the survey team with the facility policy with regards to notification of doctor of Resident's change in condition. The Administrator indicated the facility uses the INTERACT Process and provided documents describing this process. The document titled, INTERACT Process was reviewed and it read, A. Change in Resident condition noted. B. Observer alerts LPN/RN using the Early Warning Stop and Watch Tool . C. LPN Observation/RN Evaluation. The nurse observes and evaluates reported change from the Stop and Watch .D. MD/NP/PA Notification- SBAR Form and Progress Notes. Fill out the SBAR Change in Condition form accurately and completely, as necessary. Call the provider. Document progress notes in the back of the SBAR form . Review of the clinical record of Resident #51 again on 12/19/22, revealed there was no SBAR form to indicate the provider and resident representative were notified of the change in condition on 12/13/22. On 12/19/22 at 4:32 PM, the facility Administration and Corporate Staff were made aware of the above findings. No further information was provided prior to the conclusion of the survey.

Based on observation, staff interview, and facility documentation review the facility staff failed to maintain a comfortable and homelike environment for 1 Resident (Resident #31) in a survey sample of 26 Residents. The findings included: For Resident #31, the facility staff failed to maintain a comfortable and homelike environment by not repairing the baseboard in the room that was pulled away from the wall. On 12/13/22 at 12:03 PM, during tour, Surveyor C observed Resident #31's room. It was noted that on the left side of the Resident, along the entire wall the cove base molding was peeling away from the wall exposing unfinished sheetrock that was not painted and in poor condition. Resident #31 was asked about it and how long it had been that way, but he didn't respond. On 12/15/22 at 11:30 AM, an interview was conducted with CNA B, who was assigned to Resident #31. CNA B was asked about the baseboard molding, and she said it had been that way a while. She couldn't define a while but said she had let maintenance know. On 12/15/22 at 12:35 PM, an interview was conducted with Employee H, the maintenance director. Employee H provided the survey team with his maintenance work order log, which was a paper form located at the nursing station where staff would indicate any repairs that were needed and in turn maintenance would log/indicate when the work was completed. This log was reviewed for the past 3 months with no notation of Resident #31's room. Employee H reported that he makes rounds within the facility daily to identify maintenance concerns or things that need repair in addition to the maintenance work order. Employee H also reported that the facility is in the process of doing some renovations/refurbishing of Resident rooms. He was able to recall the rooms that have been completed, none of which included Resident #31's room. When asked if there is a plan or system for which rooms would be scheduled next, Employee H indicated that he did not have a list and only knew that one specific room had been identified and the contractor made aware of, which was not Resident #31's room. Each day from 12/15/22-12/16/22, the baseboard molding was noted to have not been repaired. On 12/16/22, some of the molding had completely unadhered from the wall and was laying in the floor. On 12/19/22 at 11:38 AM, Resident #31's room was observed. The base board molding was observed to be taped to the wall using duct tape. On 12/19/22 at 2:10 PM, Employee H, the maintenance director reported the CNA told me she had knocked down the baseboard last week [referring to Resident #31's room]. I was putting it up with liquid nails but ran out. [Administrator's name redacted] has the credit card we use to make purchases so I will go this evening to get it. On 12/19/22, during the end of day meeting, the facility Administrator, Director of Nursing and corporate staff were made aware of the above findings. The facility policy regarding Resident Rights was requested and received. Review of the facility provided document read, Resident's Rights and Responsibilities .Safe Environment: The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely . On 12/20/22, the facility Administrator stated they did not have a specific written policy with regards to facility maintenance, preventative maintenance program or maintenance work orders, following the request for such policies. The Administrator did provide an excerpt from the facility employee orientation training program that read, Promptly Report anything abnormal in the resident's room or unit such as: Burned out entrance or room lights (missing strings on lights, Inspection stickers missing from electrical equipment (all new admissions can't use electrical equipment until checked by maintenance., Loose or broken furniture (beds, over bed tables, chairs, side rails, bed locks), Wet or cracked ceiling tiles, Call bell system down (shower area, resident rooms), Call bells missing or pull string in bathroom, Loose grab bars, Leaks (faucets or commodes), Refrigerator temperatures > 41 degrees Fahrenheit, Holes in the walls . No additional information was provided.