Every finding on record at Roswell Center for Nursing and Healing LLC

Based on observations, staff interviews, and review of facility policy titled Instructions, the facility failed to ensure the Packaged Terminal Air Conditioner (PTAC) unit filters were maintained free of dust and debris in two rooms (rooms [ROOM NUMBERS]) of twenty-six resident rooms observed on the Sapphire Hallway. This deficient practice had the potential to affect air quality and resident comfort in those rooms. Findings include:Review of the facility's policy titled, Instructions revealed the following: Remove air filter and inspect for cleanliness. If filter is dirty, either wash or replace depending on type of filter. If clean, reinstall filter. and At a minimum, air filters are to be replaced or thoroughly cleaned depending on type of filter every three months.Observations conducted on 3/22/2026 at 2:16 PM, 3/24/2026 at 10:28 AM, and 3/25/2026 at 12:31 PM in room [ROOM NUMBER] revealed the PTAC unit filter contained visible grey, fuzzy debris accumulation. The condition remained unchanged across all three observations.Observations conducted on 3/22/2026 at 2:45 PM, 3/24/2026 at 9:59 AM, and 3/25/2026 at 12:32 PM in room [ROOM NUMBER] revealed the PTAC unit filter contained visible grey, fuzzy debris accumulation. The condition remained unchanged across all three observations.An interview and observation conducted on 3/25/2026 at 1:17 PM with the Maintenance Director (MD) revealed that he is responsible for cleaning and checking the filters monthly. He stated that, due to ongoing construction, they continue to conduct monthly checks and randomly inspect areas where work is being performed. MD stated it is the responsibility of the maintenance department to ensure filters are clean and functioning properly. MD further stated that expectations include conducting spot checks of the PTAC units. An observation of room [ROOM NUMBER] conducted on 3/25/2026 at 1:31 PM, in the presence of the MD, revealed dust accumulation on the PTAC unit filter. The MD did not dispute the finding.An interview conducted on 3/25/2026 at 3:38 PM with the Administrator stated that it is the responsibility of the maintenance department to clean the PTAC filters, which are supposed to be cleaned monthly. She stated her expectations are for preventative maintenance to be completed monthly and as needed. She stated that a potential negative outcome is the impact on residents' health and well-being.

Based on observations and staff interviews, the facility failed to audit and dispose of expired medications from one of four medication rooms and two of nine medication carts. This deficient practice had the potential to place the residents at risk for receiving expired medication. The facility census was 175. Findings include:No policy was provided by the facility for Medication storage.An observation and interview on 3/2/2026 at 10:45 am in the lower-level medication storage room revealed a lone Dulcolax suppository with an expiration date of 07/2021. LPN YY confirmed the expiration date on the suppository.An observation made on 3/26/2026 at 11:00 am of Sapphire Hall medication cart A revealed a box of hemorrhoidal suppositories with an expiration date of September 2025, which LPN YY confirmed.An observation made on 3/26/2026 at 11:10 am of Sapphire Hall medication cart A revealed a bottle of Bisacodyl stimulant laxative with an expiration date of 2/2026, a resident-specific nitroglycerin 0.4 mg tablet with an expiration date of 9/2025. All these expired medications were confirmed by the unit manager, LPN AAA.An interview with the Administrator and the Director of Nursing (DON) on 3/26/2026 at 11:36 am revealed that the expectation is that the regular charge nurse go through the medication carts and medication rooms weekly and check medication expiration dates.

Based on observations, staff interviews, record review, and facility policy review, the facility failed to ensure that medications delivered by pharmacy were properly secured. This deficient practice had the potential to cause medication diversion, medication administration errors, and adverse effects. Findings include: Review of the facility's policy titled, Medication Storage dated 12/2022 revealed, It is the policy of this facility to ensure a medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Additionally, under section, Policy Explanation and Compliance Guidelines, it revealed, 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerators, medication rooms). b. Only authorized personnel will have access to the keys to locked compartments.During an observation on the secured unit on 7/1/2025 at 6:33 AM, an unopened box of lidocaine patches and a purple pharmacy bag containing medication patches and blister packs of pills inside of it were sitting on desk at nurse's station unattended medication cart. An unknown male resident was walking up to the nurse's station when surveyors observed the unsecured medications. Approximately a minute later, Licensed Practical Nurse (LPN) 2 arrived at the nurse's station. LPN2 confirmed the medications were left unsecured and unattended.During a walk-through of the facility on 7/1/2025 from 6:30 AM - 6:53 AM, three unknown partial pills were found on the floor in the hallway on the secured unit, two additional unknown pills were found on the floor in the hallway of the adjacent unit. Two more pills were found on the floor in the hallway on a unit on the second floor. Both night shift staff and day shift staff were present due to a change of shift at 7:00 AM. Different staff members were picking the pills up off the floor stating they weren't supposed to be on the floor and not knowing where they came from or who they were for. Review of the following resident medications were found unlocked at the desk at nurse's station unattended medication cart:Review of R24's Face Sheet, located in the Resident tab of the electronic medical record (EMR) revealed R24 was admitted to the facility on [DATE] with diagnoses that included but was not limited to Alzheimer's disease, late onset and dementia.Review of R24's EMR titled quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/14/2025 revealed a Brief Interview for Mental Status (BIMS) score of six out of 15, which indicated the resident had severe cognitive impairment. Review of R24's EMR titled Physician Orders located under the Resident tab and dated 11/23/2022 indicated [R24] Exelon transdermal patch 24 hour 13.3 MG/24 HR for Alzheimer's . apply to intact skin for 24 hours, rotating site, and allow 14 days before reapplying to same sight.Review of R25's Face Sheet, located in the Resident tab of the electronic EMR revealed R25 was admitted to the facility with diagnoses that included but not limited to neurocognitive disorder with Lewy bodies and dementia with psychotic disturbance.Review of R25's EMR titled annual MDS with an ARD of 5/15/2025, revealed a BIMS score of five out of 15, which indicated the resident had severe cognitive impairment. Review of R25's EMR titled Physician Orders located under the Resident tab and dated 4/30/2025 indicated [R25] Buspar 5 MG Tablet for anxiety .give every 12 hours.'Review of R26's Face Sheet, located in the Resident tab of the electronic EMR revealed R26 was admitted to the facility with diagnoses that included but not limited to Alzheimer's disease, late onset and dementia with psychotic disturbance.Review of R26's EMR titled quarterly MDS with an ARD of 5/16/2025, revealed a BIMS score of three out of 15, which indicated the resident had severe cognitive impairment. Review of R26's EMR titled Physician Orders located under the Resident tab and dated 5/4/2025 indicated [R26] Buspar 5 MG Tablet for anxiety .give every 12 hours.Review of R27's Face Sheet, located in the Resident tab of the electronic EMR revealed R27 was admitted to the facility with diagnoses that included but not limited to Alzheimer's disease, early onset and dementia with behavioral disturbance. Review of R27's EMR titled quarterly MDS with an ARD of 6/16/2025, revealed a BIMS score of ten out of 15, which indicated the resident had moderate cognitive impairment. Review of R27's EMR titled Physician Orders located under the Resident tab and dated 5/15/2025 indicated [R27 Lovastatin 20 MG tablet for high cholesterol .give at bedtimeReview of R28's Face Sheet, located in the Resident tab of the electronic EMR revealed R28 was admitted to the facility with diagnoses that included but not limited to vascular dementia moderate, with psychotic disturbance and alcohol abuse with alcohol-induced psychotic disorder.Review of R28's EMR titled quarterly MDS with an ARD of 6/14/2025, revealed a BIMS score of ten out of 15, which indicated the resident had moderate cognitive impairment. Review of R28's EMR titled Physician Orders located under the Resident tab and dated 6/1/2025 indicated [R28] Pantoprazole delayed release 40 MG tablet .give twice daily for gastroesophageal reflux disease.Review of R29's Face Sheet, located in the Resident tab of the electronic EMR revealed R29 was admitted to the facility with diagnoses that included but not limited to Parkinson's disease without dyskinesia and vascular dementia.Review of R29's EMR titled annual MDS with an ARD of 6/19/2025, revealed a BIMS score of two out of 15, which indicated the resident had severe cognitive impairment. Review of R29's EMR titled Physician Orders located under the Resident tab and dated 5/6/2025 indicated [R29] pain relief pad Lidoderm 5% (percent) .apply to neck for twelve hours, then remove for twelve hours .Review of R30's Face Sheet, located in the Resident tab of the electronic EMR revealed R30 was admitted to the facility with diagnoses that included but not limited to bipolar disorder, current episode mixed, mild and borderline personality disorder.Review of R30's EMR titled annual MDS with an ARD of 6/15/2025, revealed a BIMS score of two out of 15, which indicated the resident had severe cognitive impairment. Review of R30's EMR titled Physician Orders located under the Resident tab and dated 6/13/2025 indicated [R30] Vraylar 3 MG capsule for bipolar disorder . give once daily in the morning.During an interview on 7/1/2025 at 6:33 AM, LPN2 stated, I don't know how long these meds have been here at the nurse's station on the desk. Somebody has to sign for them when pharmacy delivers them. I took the meds that were mine and locked them up. LPN2 looks at the stack of blister packs and realized they are for her residents and stated, These are actually mine. I don't know when they were delivered because we get deliveries multiple times, but I will go lock these up right now.During an interview on 7/3/2025 at 3:42 PM, the Administrator stated, Finding those pills on the floor was unacceptable. It's also unacceptable to leave medications unsecured and unattended. When pharmacy delivers them, the nurses should check them in, count them, and make sure they match what's supposed to be in the bag and then secure them behind a lock, and two locks if they are a narcotic. The nurses know leaving them at the nurses and then walking away is not the procedure we do.

Based on record review, resident and staff interviews, and facility policy review, the facility failed to ensure residents who were dependent on staff for activities of daily living (ADLs) received showers as scheduled and requested for one of three residents (Resident (R) 2) reviewed for ADLs out of 30 sample residents. This failure placed the residents at risk of a diminished quality of life.Findings include: Review of the facility's policy Activities of Daily Living (ADLs) dated January 2024, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing .The facility will provide a maintenance and restorative program to assist the resident in achieving and maintaining the highest practicable outcome based on the comprehensive assessment .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .The facility will maintain individual objectives of the care plan and periodic review and evaluation.Review of R2's Face Sheet, located in the resident's EMR under the Face Sheet tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, acquired absence of right leg below knee, acquired absence of left leg above knee, polyneuropathy, and chronic pain.Review of R2's five day Minimum Data Set (MDS) located in the MDS tab in the EMR with an Assessment Reference Date (ARD) of 6/5/2025, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated no cognitive impairment. According to the MDS R2 had limitation in range of motion to upper extremities on both sides. He required substantial/maximal assistance for showering/bathing. Review of R2's Care Plan in the EMR under the Care Plan tab, initiated 2/27/2024 and revised 12/12/2025, revealed R2 had a self-care deficit related to experiencing difficulty in performing tasks of daily living such as dressing, bathing, toileting .as evidenced by neuromuscular impairment. Interventions included to assist with bathing as needed.Record review of R2's April 2025 Documentation Survey Report, under the EMR Tasks tab, revealed the resident was to receive bed bath/shower every Monday and Thursday on the 3:00 PM through 11:00 PM shift. Documentation revealed the resident was not documented for bed bath nor shower on 4/15/2025, 4/18/2025, 4/22/2025, or 4/25/25 (where documentation was reserved for ADL charting). The resident was documented as refused on 4/29/2025 at 10:59 PM, without any documentation to indicate when the resident was offered a shower, why they refused, or if they were offered an alternate time. The resident did not receive showers on four of five opportunities, not including the documented refusal.Record review of R2's May 2025 Documentation Survey Report, under the EMR Tasks tab, revealed the resident was to receive bed bath/shower every Monday and Thursday on the 3:00 PM through 11 PM shift. Documentation revealed the resident was not documented for bed bath nor shower on 5/26/2025 (where documentation was reserved for ADL charting). The resident was documented as NA or Not Applicable on 5/2/2025,5/9/2025, and 5/19/2025. There was documentation to indicate why the resident was not provided with a bed bath/shower on NA days. The resident did not receive showers on four of eight opportunities.Record review of R2's June 2025 Documentation Survey Report, under the EMR Tasks tab, revealed the resident was to receive bed bath/shower every Monday and Thursday on the 3:00 PM through 11 PM shift. Documentation revealed the resident was not documented for bed bath nor shower on 6/9/2025, 6/16/2025, and 6/23/2025 (where documentation was reserved for ADL charting). The resident was documented as NA or Not Applicable on 6/12/2025 and 6/26/2025. There was documentation to indicate why the resident was not provided with a bed bath/shower on NA days. The resident did not receive showers on five of eight opportunities.During an interview on 7/2/2025 at 1:45 PM, R2 stated that the facility staff did not provide him with the showers that he was supposed to receive. He stated that the staff told him that they were short-staffed. He stated he believed the reason must be because of the lack of staff or that the staff just did not want to come back in and offer him his showers. R2 said that he had gone two weeks without showers on more than one occasion. He stated it was still a current problem, and that he did not refuse showers if they were offered to him. R2 stated that he was supposed to receive them twice a week on Mondays and Thursdays, but that did not always happen.During an interview on 7/2/2025 at 3:30 PM, Certified Nursing Aide (CNA) 1 stated that she believed residents were supposed to get three showers a week, but confirmed she was not sure. CNA1 said that the aides were assigned certain residents to shower, and that they documented on paper shower sheets and also on the kiosk, which documented the showers into the EMR. Although she stated she provided R2 showers and bed baths, she stated she was not sure how often he was provided or was offered the showers. She was not sure why the resident was documented with NA on numerous shower days, except that she was aware that it meant Not Applicable.During an interview on 7/2/2025 at 3:33 PM, Licensed Practical Nurse (LPN) 1 said that residents were offered showers twice a week. She said the aides were assigned residents. LPN1 stated that the aides would complete shower sheets, and they would also chart in the EMR. At the end of the month, she stated the shower sheets would be picked up by management. She confirmed R2 was supposed to be provided with showers by using a portable bed bath that would take him to the shower room.During an interview on 7/2/2025 at 3:38 PM, Clinical Manager (CM) 2 stated that the aides should chart on shower sheets, which would then get put into a binder. CM2 said that at the end of the month the sheets would go to management, but they were not kept permanently. She said that the shower sheets were not kept for the resident record and were currently all discarded up to and including June 2025. CM2 confirmed upon review of R2's bed bath/shower documentation in the Documentation Survey Report for April 2025, May 2025, and June 2025 that there were many gaps in the charting of twice weekly showers without explanation. She stated that this documentation was the only available charting of R2's provided showers. During an interview on 7/2/2025 at 3:50 PM, the Director of Nursing stated that residents would be provided two showers a week. She stated that the CNAs were assigned to provide the showers to the residents and would chart into the EMR, which would be noted in the Documentation Survey Report. The Director of Nursing confirmed that this charting in the EMR was the comprehensive and accurate accounting of the resident's shower documentation.During an interview on07/2/2025 at 3:55 PM, the Administrator stated that she expected the EMR documentation to be the accurate record of resident care. Upon review of the April 2025, May 2025, and June 2025 Documentation Survey Report of bed bath/showers for R2 she confirmed that the charting showed numerous gaps in the provision of twice weekly showers. She confirmed that if this was the only shower documentation, there would be a noted lack of showering for R2.

Based on interviews, record review, and the review of the facility policies titled Activities of Daily Living (ADL) and Assistance with Meals, the facility failed to provide supervision and assistance with Activities of Daily Living (ADL) care during meals for one of 45 residents (R) (R200) related to a diagnosis of dysphagia (difficulty swallowing). On [DATE], this failure resulted in R200's death by choking on a sandwich. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on [DATE], at 10:25 am. The noncompliance related to the IJ was identified to have existed on [DATE]. An Acceptable Removal Plan was received on [DATE]. Based on observation, record review, a review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice were removed on [DATE]. The facility remained out of compliance while the facility continued management-level staff oversight as well as continuing to develop and implement a Plan of Correction (POC). This oversight process includes an analysis of the facility staff's conformance with the facility's policies and procedures governing providing Activities of Daily Living (ADL) care and supervision with meals. Finding included: A facility policy titled, Activities of Daily Living (ADL) updated [DATE] indicated, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 4. Eating to include meals and snacks . A review of the facility policy titled Assistance with Meals issued in [DATE], revealed that Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. 3. Residents Requiring Full Assistance: Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity . Keeping interactions with other staff to a minimum while assisting residents with meals. A review of the Admission Record in the Electronic Medical Record (EMR) revealed R200 was a [AGE] year-old male admitted to the facility on [DATE] with a medical history of gastroesophageal reflux disease without esophagitis, urinary tract infection, cerebral palsy, congenital malformation syndromes predominantly involving limbs, functional quadriplegia, asthma, seizures, malaise, and mood disorder. A Speech Therapy Transitional Evaluation and Plan of Treatment Record revealed that R200 had poor visual acuity (right eye retinal detachment) and was non-verbal. A review of the Admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date of [DATE], revealed R200 had a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident was severely impaired and required total dependence with ADL care. A review of the Speech Therapy Transitional Evaluation and Plan of Treatment dated [DATE] revealed that R200 received treatment for dysphagia and oropharyngeal phase by the facility Speech and Language Pathologist (SLP). It was revealed that R200's prior level of function (PLOF) (prior to onset), Patient was previously consuming 75 - 100% of low residue diet (LRD) of regular texture solids with thin liquids, in a home environment with caregiver supervision, with history of one episode of choking on a chicken bone, per caregiver report. Baseline ([DATE]), Patient currently demonstrating oral/pharyngeal swallowing ability within functional limits for consumption of regular texture diet with thin liquids; however, the patient demonstrates the risk of choking/aspiration due to decreased visual acuity and per os (PO) (by mouth) efficiency. The assessment indicated precautions/ contraindications are as follows: nonverbal, falls, left foot wound, communicate via vocalizations/gestures/facial expressions; poor visual acuity; follow aspiration/choking precautions - upright during PO intake, set up and orient resident to items on meal tray, supervision during meals. The most recent MDS assessment dated [DATE] indicated that the resident required Setup or clean-up assistance with eating. Section K Swallowing Disorder indicated in C. Coughing or choking during meals or when swallowing medications. No. Speech Therapy (ST) notes outlined that R200 received Daily ST with a start date of [DATE] through [DATE]. A review of R200's 'ST Daily Treatment Note', dated [DATE] revealed R200 was unable to self-feed today's noon meal. The Physical Therapy review notes dated [DATE] revealed: PT required one-on-one assistance with feeding today due to the nature of the breakfast meal. A review of the physician orders with the last review date of [DATE] revealed that R200 was full-code, and had special instructions of up 90 degrees to eat sit up 30 minutes after eating alternate liquids and solids slowly . The Physician orders further included: Rehab ST orders: skilled therapy for five times a week x 12 weeks for dysphagia (start date [DATE] end date [DATE]). Aspiration Precautions Maintained: Up 90 degrees to eat sit up 30 minutes after eating alternate liquids and solids slowly every shift with the start date of [DATE]. Regular diet regular texture and regular consistency with a start date of [DATE]. During an interview on [DATE] at 7:49 pm, Certified Nursing Assistant (CNA) EE stated he was assigned to feed R200 during the 7:00 am to 7:00 pm shift on [DATE]. CNA EE stated he fed R200 breakfast around 8:00 am. He stated that lunch arrived late, and he fed R200 after 1:00 pm. CNA EE stated the dinner service was running late as well that evening. The dinner trays came to his hall between 6:40 pm and 7:00 pm. He stated as an Agency CNA, they were not paid for working past the scheduled time. CNA EE stated, R200 can't feed himself because of his condition. It's like he cannot grip a spoon to feed himself with it, so he needed to be fed by staff. CNA EE stated a female CNA (Couldn't remember her name) would help him with positioning R200 to 90 degrees for feeding. CNA EE stated, You have to be patient feeding him and watch him . make sure he swallows before giving the resident the next bite. I would give R200 a bite and intermittently give him fluids to drink in between bites. CNA EE stated he notified the night nurse that he would not have time to feed R200 after distributing trays to other residents on the floor, but he could drop off R200's tray in his room before his clock-out time of 7:00 pm. CNA EE left the facility in the resident's room at 7:05 pm. A review of posted dining times for meals delivered to R200's hall revealed that breakfast was served at 7:40 am, lunch was served at 11:40 am, and dinner was served at 4:40 pm. A review of the timesheet for [DATE] revealed that CNA HH clocked in at 6:45 pm for her 7:00 pm through 7:00 am shift. During an interview on [DATE] at 8:25 pm, CNA HH reported that she was assigned to care for R200 via assignment sheet and was assigned to feed R200 at the shift change meeting. A review of the video surveillance footage and documentation of the video footage the facility provided dated [DATE] revealed CNA EE entered R200's room with his food tray at 6:43 pm. The feeding assistance assignment was reassigned to CNA FF at 6:45 pm. Surveillance footage revealed that CNA FF entered R200's room at 7:15 pm and exited at 7:21 pm with R200's food tray. CNA FF reported that at approximately 7:15 pm, R200 was found to be unresponsive. A review of the EMR revealed that R200 had a banner alert in his chart with orders/special instructions for the following: UP 90 DEGREES TO EAT; SIT UP 30 MINUTES AFTER EATING; ALTERNATE LIQUIDS AND SOLIDS SLOWLY. It was revealed that R200 was provided with a meal, including a sandwich, to consume independently for 32 minutes without the required one-on-one supervision when eating or drinking on [DATE]. A review of R200's Care Plan revealed his care plan was not updated to include one-on-one assistance while eating and drinking as an intervention for complication risks of dysphagia. A review of the Medical Examiner's report and photos of the scene revealed a half-eaten slice of bread on R200's pillow and a half-eaten slice of bread on the floor next to the resident's bed. It was documented that the cause of death was R200 choked on a sandwich on [DATE]. During an interview on [DATE] at 9:30 am, the DON stated that she did not understand why the MDS nurse failed to include the dysphagia diagnosis on the care plan. The DON stated that the facility has had many transfers of ownership and leadership in the last year and that audit processes are not perfect right now in relation to the MDS assessments and care plans. During an interview on [DATE] at 12:05 p.m., the SLP, who is the Director of Rehabilitation, stated that s/he remembered prescribing R200 one-on-one assistance during meals to ensure that R200 was eating at a proper pace and not eating or drinking too fast. During an interview on [DATE] at 12:19 pm, the MDS Nurse, Registered Nurse (RN) NNN, stated that they do not always enter therapy diagnosis with the medical diagnosis. She confirmed that R200's medical record listed a diagnosis of oral pharyngeal impairment (dysphagia) and that R200 required a specialized diet and close supervision to prevent an incident of aspiration. She stated that she did not remember the specifics because it had been too long ago. She stated, If the doctor saw the person when they got here and he didn't include it in the diagnosis list, it may have been that he didn't feel they had dysphasia anymore. The facility implemented the following actions to remove the IJ: R200 expired at the center on ,d+[DATE]. The Regional Director of Operations (RDO) and the Administrator reviewed the dining assistance policies to ensure alliance with CMS/State regulation, on [DATE], without recommendation for changes/revisions. On [DATE], the Administrator, DON, and the Regional Director of Clinical Operation (RDCO) conducted mandatory retraining for nurses on supervision of ADL care including feeding/dining assistance assignments: nine of nine RNs; 42 of 43 LPNs; and 64 of 64 CNAs). Employees on leave of absence, vacation, agency staff, and/or new hires will be re-educated by the Staff Development Coordinator (SDC), DON, or Nursing Supervisor prior to returning to duty and will not be given an assignment until they are given additional on-site education. On [DATE], the DON and/or Administrator retrained nursing staff that ADL care/meal assistance must continue uninterrupted and cannot be halted or delayed due to a shift change. On ,d+[DATE], the Administrator and DON assessed staffing levels during meal service to ensure adequate assistance. On [DATE], an emergency Quality Assurance and Performance Improvement (QAPI) Ad Hoc meeting was conducted with the Administrator, DON, RDO, RDCO, and Medical Director to review the removal plan and root cause analysis. All corrective actions were alleged to be completed on [DATE] and the lJ was alleged to be removed on [DATE]. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: A review of the facility's census list revealed that R200 expired at the facility with an effective stop billing date of [DATE] at 8:00 pm. A review of the facility policy titled Assistance with Meals dated [DATE], revealed that the following individuals reviewed the policy for accuracy: The administrator signed on [DATE]; RDO signed on [DATE]; RDCO signed on [DATE]; the DON signed on [DATE]; and the Medical Director was documented as attending via the phone on [DATE]. A review of the facility's education/in-service record revealed the following: The presenters of in-service were the clinical leadership that was composed of the DON, Unit Manager (UM), and RDCO. The date of the education was [DATE]. The subject matter of the education was Nursing education-IJ POC and related policies. The overview of the education included a review of the comprehensive care plan policy (including development/implementation and adherence) and the ADL policy (including supervision of dependent residents during meal assistance, ADL care, and meal assistance). A review of the facility's active employee list below was the breakdown of direct care staff (CNAs) and Nurses (LPNs and RNs). During an interview on [DATE] at 2:49 pm, the count for the active employees matched the number provided by the administrator. Per the RDCO, there were several employees who were crossed off the list, and they were terminated. Additionally, there was an in-service with staff names on the list with an R next to their name indicating they had refused in-service. On [DATE] at 3:19 pm, the Administrator was asked to provide an active list of employees and include an updated list of staff that received the in-serving. On [DATE] at 9:08 pm, the Director of Regulatory Compliance (DRC) provided an updated Active Employee list. During an interview on [DATE] at 7:55 am, the Administrator revealed the list that was provided by the DRC was on the active employee list and reflected on all the staff that were interviewed. This list included both active employees and staff that were reeducated/in-serviced. Some CNAs do work multiple shifts; UMs primarily work 7:00 am through 3:00 pm with one-weekend day shift per month. The following staff were interviewed on [DATE] to [DATE] to certify the education/in-services: [DATE] at 7:42 am (CNA JJ); [DATE] at 7:45 am (CNA KK); [DATE] at 10:53 am (CNA LL); [DATE] at 11:02 am (LPN MM); [DATE] at 11:15 am (LPN NN); [DATE] at 11:23 am (CNA OO); [DATE] at 11:23 am (CNA PP); [DATE] at 11:41 am (UM/LPN QQ); [DATE] at 11:51 am (CNA RR); [DATE] at 12:01 pm (CNA SS); [DATE] at 12:09 pm (UM/LPN TT); [DATE] at 12:18 pm (CNA UU); [DATE] at 12:23 pm (CNA VV); [DATE] at 12:34 pm (CNA WW); [DATE] at 5:45 am (RN YY); [DATE] at 5:58 am (CNA ZZ); [DATE] at 6:13 am (CNA AAA); [DATE] at 6:30 am (RN BBB); [DATE] at 6:50 am (LPN CCC); [DATE] at 7:07 am (LPN DDD); [DATE] at 7:15 am (CNA EEE); and [DATE] at 7:21 am (CNA FFF). A review of the facility's education/in-service record revealed the following: The presenters of the in-service were the Clinical leadership that was composed of the (DON, UM, and RDCO). The date of the education was [DATE]. The subject matter of the education was Nursing education-IJ POC and related policies. The overview of the education included: Comprehensive care plan policy (including development/implementation and adherence); ADL policy including supervision of dependent residents during meal assistance; reeducation related to meal assistance must continue uninterrupted until individual service is complete; assistance with meals policy; assignment of assisted diners (ensure orders match tray card and care plan/Kardex). Interviews were conducted on [DATE] from 7:42 am through [DATE] with no concerns. Several interviews were conducted with nursing staff (CNAs and nurses) to determine what happens when food is delivered late. Staff confirmed that they are to finish feeding/providing assistance to residents even if that means they will be staying past their scheduled time. During an interview on [DATE] at 11:23 am, CNA OO revealed they must stay and complete feeding a resident even if meals are served late due to kitchen staff shortage. During an interview on [DATE] at 12:09 pm, UM/LPN TT stated that staff must have the resident's meal tray when they leave the rooms. They enter the room with the tray and exit the room with the tray in hand. During an interview on [DATE] at 12:34 pm, CNA WW stated one of the re-educations was to ensure the proper meal tray delivery processes. The Administrator and the DON completed a review of staffing levels to ensure adequate assistance availability during mealtimes. They had no concerns identified. A daily assignment sheet will be used to identify residents who require assistance with ADL dining to ensure staff assistance is available. The Administrator and DON reviewed the assignments sheets daily to monitor compliance. Both the Administrator and DON signed off on the acknowledgment. A review of the facility's daily assignment sheets included the following: The staff who are scheduled, residents who are identified as 'need to feed' residents identified as NPO, and snack times. Residents were identified by room and bed numbers that needed to be fed. The monthly QAPI meeting was conducted on [DATE]. The presenter/facilitator was the facility Administrator. The duration of the meeting was 30 minutes. The team members included DON, Medical Director, UM, Assistant DON, Scheduler, RDO, VP of Clinical Services, Social Service Directors, MDS, Maintenance Director, Activities Director, Business Office Manager, and the RDCO. Per the attendance sign-in sheet, the following individuals were in attendance: The administrator, RDO, RDCO, Assistant DON, DON, Director of Regulatory Compliance (RDC), Staffing Coordinator, three Unit Managers, Infection Control Preventionist, Social Services, Dietary Manager, Registered Dietician, Director of Therapy, Central Supply, Medical Records, Maintenance Director, MDS, Business Office Manager/Human Resources, Director of Housekeeping, Staff Development Coordinator, and Assistant Administrator. The meeting overview was to review the IJ concerns. A brief narrative description of the QAPI meeting was documented. An updated get-up list for nursing was created. Each root cause had its corresponding corrective action, responsible individual(s) have been identified with a timeline determined to be ongoing, All corrective actions were completed on [DATE] and the lJ was removed on [DATE]. 49472

Based on interviews and record review, the facility's Administration failed to provide protective oversight of the facility ensuring that staff followed appropriate policies and procedures to prevent accidents and hazards resulting in Immediate Jeopardy for resident (R) R200 and Harm for R46, R206, and R204. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on [DATE] at 10:25 am. The noncompliance related to the IJ was identified to have existed on [DATE]. An Acceptable Removal Plan was received on [DATE]. Based on observation, record review, a review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice were removed on [DATE]. The facility remained out of compliance while the facility continued management-level staff oversight as well as continuing to develop and implement a Plan of Correction (POC). This oversight process includes an analysis of the facility staff's conformance with the facility's policies and procedures governing providing Activities of Daily Living (ADL) care and supervision with meals. Findings included: 1. On [DATE], R200 was found unresponsive in his bed after a Certified Nursing Assistant (CNA) EE dropped off the resident's food tray, leaving R200 unsupervised with food for 30 minutes. R200 expired in the facility, with the cause of death documented as choking. Cross Refer F677 2. The facility failed to develop a comprehensive care plan for R200 related to a diagnosis of dysphagia and supervision with meals. Cross Refer F656 3. Harm was identified on [DATE] when R46 sustained a fall resulting in a right femur fracture with possible patella fracture; on [DATE], R206 sustained a second-degree burn to bilateral glutes from sitting in spilled hot coffee; and on [DATE], R204 experienced pain and swelling from an infiltrated intravenous site, resulting in R204 being sent to the emergency room (ER) for treatment and observation. Cross Refer F689 and F694 During an interview and record review with the facility Director of Nursing (DON) on [DATE] at 9:30 am she did not understand why the Minimum Data Set (MDS) nurse did not include the dysphagia diagnosis in the R200's chart and care plan. When asked about who is responsible for auditing the MDS and care plans for accuracy, the DON stated the facility has had many transfers of ownership and leadership in the last year and audit processes are not perfect right now, but they are working on it. During an interview on [DATE] at 9:50 am, the DON confirmed that her expectations were that nurses were supposed to be rounding at least every couple of hours when a resident has a continuous IV. During an interview on [DATE] at 12:05 pm, the Director of Rehabilitation remembered prescribing R200 one-on-one assistance while he was eating to make sure that he was eating at a proper pace so he and not eat too fast or drink. During an interview on [DATE] at 12:19 pm, the MDS Nurse, Registered Nurse (RN) NNN, stated that they do not always enter therapy diagnosis with the medical diagnosis. She confirmed that R200's medical record listed a diagnosis of oral pharyngeal impairment (dysphagia) and that R200 required a specialized diet and close supervision to prevent an incident of aspiration. She stated that she did not remember the specifics because it had been too long ago. During an interview with the facility DON on [DATE] at 5:50 pm she stated she could not remember if R200's dysphagia or incidents related to dysphagia were discussed in Quality Assurance Performance Improvement (QAPI) meetings. The DON stated, I would have to review my QAPI notes. During an interview on [DATE] at 3:21 pm, the DON confirmed R46 required two-person assistance. The DON stated that that two people were required to transfer the resident and an in-service was also completed to ensure all staff understood that a mechanical lift required two staff to transfer a resident. The DON confirmed that the CNA does not work at the facility anymore and that she was a contract employee. The facility implemented the following actions to remove the IJ: On [DATE], a Root Cause Analysis (RCA) of the Care plans for residents with a diagnosis of dysphagia and ADL care for dependent residents who require assistance with dining system breakdown was completed by the Regional Director of Operation (RDC), Regional Director of Clinical Operations (RDCO), Administrator, and DON. Documentation of analysis was put on the RCA Tool and was included in the Ad Hoc meeting. The administrator hosted an Ad Hoc QAPI meeting on [DATE], with the Medical Director, DON, RDCO, and Director of Operations to review the center's ADL Care for Dependent Residents and Care Plan performance improvement measures outlined in this document. The Regional Director of Operations (RDO), RDCO, Medical Director, Administrator, and DON reviewed residents receiving swallow therapy in the past thirty (30) days to identify residents with a diagnosis of dysphagia to ensure that care plans were updated as appropriate, on [DATE]. Findings were shared at the next scheduled QAPI Meeting. The Administrator identified Improvement Activities and Performance Improvement Projects (PIP) based on trends and identified potential opportunities upon completion of the care plan and swallowing therapy audit reviewed on [DATE]. PIP plans and RCA documents were maintained as part of the QAPI process. A review of the residents receiving swallow therapy audit was reviewed by the IDT members on [DATE], to validate care plans were updated appropriately to identify the level of dining assistance required. The MDS Nurse (s) reviewed and updated care plans on residents identified with a diagnosis of dysphagia as of [DATE]. Recommendations were reviewed at the next scheduled regular QAPI meeting. The RDCO provided re-education on [DATE] to the Administrator and DON on the policies and procedures related to ADL Care for Dependent Residents and Comprehensive Care Plans. The DON will assign Nurse Managers daily to each unit to provide supervision during meal service for those residents diagnosed with dysphagia, including those who are non-verbal or visually impaired. The Administrator reviewed the results of the audits and shared the findings with the Ad Hoc QAPI Committee in February 2025. All corrective actions were completed on [DATE] and the IJ was removed on [DATE]. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: A review of the diagnosis report after the facility audited the residents diagnosed with dysphagia on [DATE] discovered that 30 of 45 needed updates to their care plan interventions for feeding assistance. There were 23 residents assigned meal supervision on [DATE], the assignments were revised on [DATE] to 45 residents assigned meal supervision as an intervention for their individualized risk. A review of the IJ Removal Plan showed that there were QAPI Meeting Minutes that occurred on [DATE]. The signature includes the Administrator, DON, RDO, RDCO, Dietary, Social Services, and the Medical Director. The topic included an annual survey and IJ citations that were issued. Also, performance improvement plans were included. There were two new diagnoses of dysphagia identified in the last 30-day review of the diagnosis report after the facility audited the residents diagnosed with dysphagia on [DATE] and updates to their care plans were updated as appropriate. Dated ([DATE] and [DATE]) A review of the RCA PIP template that was started on [DATE] was completed. The Root Cause and Contributing Factors included staffing challenges in the kitchen and nursing staff to prepare and deliver meals on time; updating the get-up list for nursing staff to collaborate; poor coordination and communication between dietary staff and nursing staff related to meal readiness, delivery, and resident needs; inadequate coordination of get-ups times with meal delivery schedules; meal service workflow, review serving line efficiency in the kitchen. The plan further included the root cause, the corrective action, the responsible individual/group, and the completion deadline. A review of the diagnosis report after the facility audited the residents diagnosed with dysphagia on [DATE] discovered that 30 of 45 needed updates to their care plan interventions for feeding assistance. There were 23 residents assigned meal supervision on [DATE], the assignments were revised on [DATE] to 45 residents assigned meal supervision as an intervention for their individualized risk. A review of the diagnosis report after the facility audited the residents diagnosed with dysphagia on [DATE] discovered that 30 of 45 needed updates to their care plan interventions for feeding assistance. There were 23 residents assigned meal supervision on [DATE], the assignments were revised on [DATE] to 45 residents assigned meal supervision as an intervention for their individualized risk. A review of the diagnosis report after the facility audited the residents diagnosed with dysphagia on [DATE] discovered that 30 of 45 needed updates to their care plan interventions for feeding assistance. There were 23 residents assigned meal supervision on [DATE], the assignments were revised on [DATE] to 45 residents assigned meal supervision as an intervention for their individualized risk. A review of the facility's education/in-service record revealed the following: The presenters of in-service were the Clinical leadership that was composed of the (DON, Unit Manager (UMs), and RDCO). The date of the education was [DATE]. The Administrator and the DON completed a review of staffing levels to ensure adequate assistance availability during mealtimes. They had no concerns identified. A daily assignment sheet will be used to identify residents who require assistance with ADLs, specifically dining to ensure availability of assistance, as appropriate. The Administrator and DON will review assignment sheets daily to monitor compliance. Both the Administrator and DON signed off on the acknowledgment. A review of the Facility's daily assignment sheets included the following: The staff that is scheduled, residents that are identified as 'need to feed; Residents that are NPO, Snack times; Pass Ice; residents with scheduled showers, residents who are on the get-up list and residents who have appointments/visit time his section identified the residents by room and bed number that need to be fed. NPO residents are identified. Interviews were conducted with staff to ensure that staff were in-serviced and were knowledgeable of where to retrieve assignments on a daily basis, but to additionally ensure that staff understood requirements for supervision, one-on-one assistance and tray set-up for residents. During an interview on [DATE] at 11:23 am, CNA OO revealed they must stay and complete feeding a resident even if meals are served late due to kitchen staff shortage. During an interview on [DATE] at 12:09 pm UM/ Licensed Practical Nurse (LPN) TT stated that a staff is required to have the resident's meal tray when they leave the rooms. They enter the room with the tray and exit the room with the tray in hand. During an interview on [DATE] at 12:34 pm, CNA WW stated one of the re-educations was to ensure the trays go in the resident room when they are ready to leave, and the tray goes out with the CNA when they leave the resident rooms A new Dining Time for Meal Delivered to Units was implemented during the week of [DATE]. New dining times for breakfast range from 7:30 am to 8:30 am; lunch from 11:30 am to 12:30 pm and dinner from 4:30 pm to 5:30 pm. Meal carts have been monitored since the new implementation and are ongoing and noted to have improvements. All corrective actions were completed on [DATE] and the IJ was removed on [DATE]. 49479

49687 Based on interviews and record review, the facility failed to develop and implement a comprehensive care plan for one of 45 residents (R200) related to a diagnosis of dysphagia (difficulty swallowing) and supervision with meals, resulting in R200's death by choking on a sandwich. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on [DATE], at 10:25 am. The noncompliance related to the IJ was identified to have existed on [DATE]. An Acceptable Removal Plan was received on [DATE]. Based on observation, record review, a review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice were removed on [DATE]. The facility remained out of compliance while the facility continued management-level staff oversight as well as continuing to develop and implement a Plan of Correction (POC). This oversight process includes an analysis of the facility staff's conformance with the facility's policies and procedures governing providing Activities of Daily Living (ADL) care and supervision with meals. Finding included: A facility policy titled, Care Plans, Comprehensive Person-Centered updated [DATE] indicated, 9. Areas of concern that are identified during the resident assessment will be evaluated for interventions are added to the care plan. 10. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, or the endpoint of an interdisciplinary process . 13. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. An Admission Record revealed R200 was a [AGE] year-old male admitted to the facility on [DATE] with a medical history of gastroesophageal reflux disease without esophagitis, urinary tract infection, site not specified, cerebral palsy, congenital malformation syndromes predominantly involving limbs, functional quadriplegia, asthma, seizures, malaise, mood disorder. A Speech Therapy Transitional Evaluation and Plan of Treatment Record revealed that R200 had poor visual acuity (right eye retinal detachment) and was non-verbal. An initial Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed R200 had a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident is severely impaired. The resident requires total dependence on all ADL care. Speech Therapy Transitional Evaluation and Plan of Treatment, dated [DATE] performed treatment for dysphagia, oropharyngeal phase by the facility Speech and Language Pathologist (SLP) revealed R200 prior level of function (PLOF) (before onset), Patient was previously consuming 75 - 100% of low residue diet (LRD) of regular texture solids with thin liquids, in a home environment with caregiver supervision, with history of one episode of choking on a chicken bone, per caregiver report. Baseline ([DATE]), Patient currently demonstrating oral/pharyngeal swallowing ability within functional limits for consumption of regular texture diet with thin liquids; however, patient demonstrates risk of choking/aspiration due to decreased visual acuity and per os (PO) (by mouth) efficiency. The assessment indicated Precautions/Contraindications are as follows: nonverbal, falls, left foot wound, communicate via vocalizations/gestures/facial expressions; poor visual acuity; follow aspiration/choking precautions - upright during PO intake, set up and orient resident to items on meal tray, supervision during meals. The most recent MDS dated [DATE] indicated in section GG the resident required Setup or clean-up assistance with eating. Section K Swallowing Disorder indicated in C. Coughing or choking during meals or when swallowing medications. No. Swallow Therapy (ST) notes outlined that R200 received Daily ST with a start date of [DATE] through [DATE]. A review of R200's 'ST Daily Treatment Note', dated [DATE] revealed R200 was unable to self-feed today's noon meal. Physical Therapy Review of Therapy notes dated [DATE] revealed: PT required one-to-one assistance with feeding today due to the nature of the breakfast meal. A review of the physician orders with the last review date of [DATE] revealed that R200 was full code, and had special instructions of up 90 degrees to eat sit up 30 minutes after eating alternate liquids and solids slowly . The Physician orders further included: Rehab ST orders: skilled therapy for 5 times a week x 12 weeks for dysphagia (start date [DATE] end date [DATE]. Aspiration Precautions Maintained: Up 90 degrees to eat sit up 30 minutes after eating alternate liquids and solids slowly every shift with the start date of [DATE]. Regular diet regular texture and regular consistency with a start date of [DATE]. On [DATE], R200's assigned feeding assistant Certified Nursing Assistant (CNA) EE received the late dinner trays for his assigned hall at approximately 6:40 pm, approximately 20 minutes before his shift ended. CNA EE notified the nurse that he would not have time to feed R200, but he could drop off R200's tray in his room before his time to clock out by 7:00 pm. Surveillance footage provided by PPP shows CNA EE entering R200's room with his food tray at 6:43 pm. The feeding assistants assignment was reassigned to CNA FF at 6:45 pm. Surveillance footage shows CNA FF initially entering R200's room at 7:15 pm and exiting at 7:21 pm with R200's food tray. CNA FF reported at approximately 7:15 pm that R200 was found to be unresponsive. The facility provided R200 a sandwich to consume for 32 minutes without the required one-to-one supervision when eating or drinking on [DATE]. R200 had a banner alert in his electronic medical records (EMR) chart with orders/special instructions for the following, UP 90 DEGREES TO EAT SIT UP 30 MINUTES AFTER EATING ALTERNATE LIQUIDS AND SOLIDS SLOWLY. A record review of R200's Care Plan revealed the facility failed to customize R200's care plan to include one-to-one assistance while eating and drinking as an intervention for complication risks of dysphagia. A record review of the Medical Examiner's report and photos of the scene (a half-eaten slice of bread on R200's pillow and a half-eaten slice of bread on the floor next to the resident's bed) revealed the cause of death was R200 choked on a sandwich. In an interview and record review with the facility DON on [DATE] at 9:30 am she did not understand why the MDS nurse did not include the dysphagia diagnosis in the R200's chart and care plan. When asked about who is responsible for auditing the MDS and care plans for accuracy, the DON stated the facility has had many transfers of ownership and leadership in the last year and audit processes are not perfect right now, but they are working on it. In an interview and record review on [DATE] at 12:05 pm with the facility SLP, Director of Rehabilitation, she remembered prescribing R200 one-on-one assistance while he was eating to make sure that he was eating at a proper pace and not eating too fast or drinking. In an interview and record review on [DATE] at 12:19 pm with MDS Nurse, Registered Nurse (RN) NNN she stated that they do not always enter therapy diagnosis with the medical diagnosis. She stated that the doctor could have changed it. When shown the medical records list a diagnosis of oral pharyngeal impairment, which is dysphagia, and the resident required a specialized diet and close supervision to prevent an incident of aspiration. She replied, I don't remember it's been too long ago but if the doctor saw the person when they got here. He didn't include it. It may have been that he didn't feel they had dysphasia anymore. The RN NNN was reminded that the evaluation was concluded the day before the R200 admission to the facility. She stated, I don't know. I don't remember. I mean it's been so long ago, and we just do hundreds and hundreds of assessments. A review of the facility's dysphagia care plan audit compared with the residents currently assigned feeding assistance during meals revealed 30 of 45 residents diagnosed with dysphagia who require assistance with meals care plans had not been reviewed/customized/ or revised for this individualized intervention for complication risks of dysphagia. Record review revealed that the facility updated the 30 dysphagia residents' care plans on [DATE] and assigned caregivers and in-serviced all active nursing staff of their responsibilities and expectations of their duties when providing the various levels of feeding assistance. The facility implemented the following actions to remove the IJ: R200 expired at the center on [DATE]. On [DATE], the policy for comprehensive care plans was reviewed and/or revised by the Administrator and Regional Director of Clinical Operations without a recommendation for revisions. On [DATE], the MDS Nurse reviewed care plans for 45 of 45 in-house residents identified with a diagnosis of dysphagia. Thirty care plans were updated to include a diagnosis of dysphagia current and active care plans for dysphagia and appropriate levels of meal supervision. On [DATE], the DON in-serviced the MDS team and licensed nurses on the Center's Comprehensive Care Plan policy and development/implementation and adherence of care plans. (RNs nine of nine equaling 100%; LPNs 42 of 43 equaling 97.7%; OVERALL 98%). Employees on leave of absence, vacation, agency staff, or new hires will be re-educated by the Staff Development Coordinator, DON, or Nursing Supervisor prior to returning to duty, and will not be given an assignment until they are given additional on-site education. On [DATE], the DON and Regional Director of Clinical Operations reviewed residents in the past thirty (30) days with a new diagnosis of dysphagia to ensure that care plans were updated as appropriate. Two (2) residents were identified with a new diagnosis of dysphagia for this review period. The Administrator reviewed the results of the audits and shared the findings with the Ad Hoc Quality Assurance Performance Improvement Committee on [DATE]. All corrective actions were completed on [DATE] and the IJ was removed on [DATE]. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: A review of the facility census list revealed that the facility stopped billing R200 on [DATE] with an action code of DE - deceased Date (Facility). A review of the Care Plans and Comprehensive Person-Centered policy statement updated in [DATE] and signed by the Administrator, DON, Regional Director of Clinical Operations, Regional Director of Operations, and Medical Director via phone on [DATE] without revisions. Review of the diagnosis report after the facility audited the residents diagnosed with dysphagia on [DATE] they discovered that 30 of 45 needed updates to their care plan interventions for feeding assistance. There were 23 residents assigned meal supervision on [DATE], the assignments were revised on [DATE] to 45 residents assigned meal supervision as an intervention for their individualized risk. On [DATE] at 9:08 pm, the facility provided via email a revised list of in-serviced staff due to recent terminations, suspensions, and agency staffing. This consisted of 43 LPNs and nine RNs. There were two new diagnoses of dysphagia identified in the last 30-day review of the diagnosis report after the facility audited the residents diagnosed with dysphagia on [DATE] and updates to their care plans were updated as appropriate. Dated ([DATE] and [DATE]) An Ad hoc meeting was held on [DATE] to address the concerns described in the IJ called on [DATE] during the annual recertification survey that began on [DATE]. Topics reviewed F677 - ADL Care Provided for Dependent Residents, F656 - Develop/Implement Comprehensive Care Plan, and F835 - Administration. The POCs and related performance improvement plans were initiated for abatement. The root causes and contributing factors were discussed. A review of the sign-in sheet for QAPI revealed that the Medical Director attended via phone. All corrective actions were determined to be completed on [DATE] and the IJ was removed on [DATE].

49472 Based on interviews, record review, and review of the facility policy titled Infusion Therapy, the facility failed to monitor one of 19 sampled residents (R) (R204) for complications related to intravenous (IV) therapy, resulting in infiltration of the IV. Harm was identified to have occurred on 8/27/2024 when this failure caused R204 to experience pain and swelling, resulting in R204 being sent to the emergency room (ER) for treatment and observation per family request. Findings included: A review of the undated facility policy titled, Infusion Therapy, revealed that the facility . will have qualified nursing staff present on all shifts to manage the care of patients receiving infusion therapy or maintain access devices. Additional training will be provided as needed for specific therapies. A review of the Admission Record revealed R204 was an [AGE] year-old female admitted to the facility on [DATE] with a medical history of normal pressure hydrocephalus, essential hypertension, cerebrospinal fluid drainage device, adult failure to thrive, hyperlipidemia, hypomagnesemia, hypokalemia, anxiety disorder, paroxysmal atrial fibrillation, polyneuropathy, muscle weakness. A review of the admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 8/29/2024, revealed R200 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was mildly impaired and that the resident requires substantial assistance with all Activities of Daily Living (ADL) care. A review of the care plan dated 7/14/2024 revealed that R204 was at risk for dehydration or potential fluid deficit related to poor intake. Interventions included that directed staff was to encourage resident to drink fluids of choice, ensure access to cold water whenever possible, monitor vital signs as ordered and as needed (PRN), notify physician (MD) of significant abnormalities, observe/report PRN any signs/symptoms of dehydration, decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes (initiated 7/15/2024), obtain and monitor lab/diagnostic work as ordered, report results to MD and followup as indicated (initiated 7/15/2024). A review of the physician orders dated 8/26/2024 revealed that R204 was ordered Dextrose 5 1/2 normal saline at 60 ml hour x 2-liter one time only for Nausea and Vomiting until 8/26/2024 at 11:59 pm. A review of the Infection Note on 8/26/2024 at 6:16 pm by the Assistant Director of Nursing (DON)/Infection Prevention Coordinator (IPC) revealed that R204 had recently been readmitted with diagnoses of acute metabolic encephalopathy, altered mental status, recurrent urinary tract infection (UTI), failure to thrive, and was currently being treated for pneumonia, on antibiotics Cefpodoxime 10 milliliters (ml) every 12 hours x 5 days. A line is inserted for IV fluids. A review of the nursing assignments revealed that Licensed Practical Nurse (LPN) DD was assigned to manage R204's IV therapy on the 7:00 pm through 7:00 am shift. Per the DON, LPN DD also attended an in-service for IV Management prior to her shift. A review of R204's vitals taken by LPN DD on 8/26/2024 at 9:30 pm revealed that her blood pressure was 140/73 mmHg; lying left arm. (Note: LPN DD took blood pressure on the same arm the IV was implanted. Potential complications: The application of a blood pressure cuff on an arm with an IV can cause blood to flow back into the IV line, potentially disrupting the infusion or creating clots). LPN DD documented a pain score for R204 as 0 out of 10. During an interview on 1/29/2025 at 9:50 am, the DON confirmed that her expectations were that nurses were supposed to be rounding at least every couple of hours when a resident has a continuous IV. A review of the 24-hour nurse logs and progress notes revealed no evidence that LPN DD monitored or documented R204's infusion rate amounts every two hours throughout the 7:00 pm through 7:00 am shift. A review of the police investigation report revealed that a family member called the emergency line on 8/27/2024 at 2:52 am with complaints that R204 was in pain and her nursing call light was being ignored at the facility. A review of the Health Status Note dated 8/27/2024 at 2:50 am and documented by LPN DD on the status of R204's IV revealed, (R204's) IV site to right (left) arm noted swollen, IV fluids stopped, arm elevated on pillow. Provider made aware. No orders to transfer to the hospital for further evaluation and treat. A review of the Physician's orders dated 8/26/2024 at 11:59 pm called for the IV to be discontinued. A review of Health Status Note dated 8/27/2024 at 3:30 am, revealed that LPN DD documented the status of the R204's IV revealed, R204 transported via stretcher x 2 EMT personnel to preferred hospital. No complaints, no distress noted. LPN DD did not respond to attempts to be interviewed via phone or while on-site at the facility about the incident. LPN DD later resigned from employment at the facility. A review of the police report dated 8/27/2024 revealed that Paramedic RRR and EMT SSS arrived and were shocked by how much the arm had swollen. Paramedic RRR stated that the IV gauge used was the smallest possible, normally used on infants and that caregivers should have noticed that it was blown immediately. Paramedic RRR stated that it was extremely out of the ordinary given that it would have taken several hours for the arm to swell to the level that it had. During an interview on 1/24/2025 at 10:42 am, LPN III, the night shift supervisor on 8/27/2024, stated that nurses are on two-hour rotations where they check on each patient in their care. LPN III stated, The Police Department was already walking through the building when I got up there, and they did call EMS. You know, I can't answer for what LPN DD did, you will have to ask her. A review of emergency room records dated 8/27/2024 revealed that R204 arrived with weakness, IV infiltration, left arm pain, and left arm swelling. R204 was administered hydrocodone dash acetaminophen (Norco 10 milligrams - 325 milligrams oral tablet) for pain, Clonidine 0.1 milligrams, and ondansetron (Zofran) 4 milligrams. R204's ultrasound result of the left arm was negative for blot clots. R204 was later discharged from the hospital on 8/27/2024 and admitted back to the facility.

Based on resident and staff interviews, record review, and review of the facility's policy titled Incidents and Accidents, the facility failed to provide adequate supervision to prevent accidents for two of four sampled residents (R) (R46 and R206) reviewed for accidents hazards. Harm was identified to have occurred (1) on 9/25/2023 when R46 sustained a fall resulting in a right femur fracture with possible patella fracture, and (2) on 6/4/2023 when R206 sustained a second-degree burn to bilateral glutes from sitting in spilled hot coffee. Findings included: 1. A review of the Electronic Medical Record (EMR) revealed that R46 was admitted to the facility on [DATE] with multiple diagnoses including multiple sclerosis, insomnia, restless legs syndrome, dependence on a wheelchair, overactive bladder, other muscle spasms, major depressive disorder, bipolar disorder, hyperlipidemia, and urinary tract infection. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that R46 had a Brief Interview for Mental Status (BIMS) score of 15, indicating R46 was cognitively intact. A review of the R46's quarterly MDS assessment dated [DATE] revealed that for transfers, R46 required extensive assistance with two persons' physical assistance. A review of R46's nursing progress note dated 9/25/2023 revealed that R46 was telling the officer that she had fallen earlier in the day and injured her knee. It was noted that the resident stated, I have complained of pain all day. The day shift nurse was passing along to (the writer) while doing room-to-room walking report that the resident had been lowered to the floor earlier on the day shift due to losing her balance with the Certified Nursing Assistant (CNA) and was lowered the resident to the floor. A review of R46's hospital record dated 9/25/2023 revealed R46's X-ray of the right knee with findings to include an acute intra-articular fracture of the distal femur with apparent extension to the patellofemoral joint. A review of the facility's policy titled Incidents and Accidents revised January 2024 revealed that an 'Accident' refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. During an interview on 1/15/2025 at 1:56 pm, R46 revealed that she was dropped by a CNA during a transfer and broke he right leg. R46 explained that she told the CNA there should be two staff transferring her however, the CNA didn't ask for assistance from another staff. During an interview on 2/19/2025 at 3:21 pm, the DON confirmed R46 required two-person assistance. The DON continued that the facility had included the intervention of a mechanical lift in the incident report to ensure that two people were required to transfer the resident and an in-service was also completed to ensure all staff understood that a mechanical lift required two staff to transfer a resident. The DON confirmed that the CNA does not work at the facility anymore and that she was a contract employee. 2. A review of the EMR revealed that R206 was admitted to the facility on [DATE] with multiple diagnoses including dementia, encephalopathy, hypertension, chronic kidney disease, unspecified abnormalities of gait and mobility, anemia, and acute kidney failure. A review of the Admission MDS assessment dated [DATE] revealed that R206 had a BIMS score of 13, indicating R206 was cognitively intact. A review of R206's progress notes dated 6/4/2023 revealed that the CNA notified the nurse that R206 was complaining of pain in the buttocks area; the nurse assessed R206's buttocks and noticed skin breakdown; and a skin protectant was applied. Later, R206 came to the nurse asking for help with his leg where he had spilled coffee. It was noted that R206 specifically told the nurse he spilled coffee on the left side of his leg. The nurse assisted R206 to his room and assessed the resident's left side. The nurse observed burns and blisters on the left side of his leg. A review of R206's progress notes dated 6/5/2023 revealed that the Unit Manager requested for the resident's buttock to be assessed related to coffee burn. The buttocks assessment noted the resident had three burn wounds. When the resident was asked how he burned himself he stated, I spilled the damn hot coffee . and it hurts. The wound measurements were documented as: Right buttock, 17.0 x 6.5 x 0.1 cm, 100% Dermis, no exudate; Left buttock, 16.5 x 26.5 x 0.1 cm, 90% Dermis & 10% Skin, no exudate; Left hip, 8.0 x 7.0 x 0.1 cm, 100% Dermis, no exudate. A review of the EMR revealed that R206 was sent to the nearest hospital on 6/5/2023 to be treated for the coffee burn and did not return to the facility. A review of the EMR revealed that R206 sustained second-degree burns to the bilateral buttock and the left hip and that R206 refused to return to the facility. During an interview on 1/27/2025 at 11:35 am, the Dietary Manager stated that the hydration cart is provided during the meal service and confirmed that the temperature of the coffee is not monitored. During an interview on 2/6/2025 at 3:10 pm, the Dietary Manager stated she heard about the resident who sustained the coffee burn. According to the Dietary Manager, two dietary aides were giving the resident coffee in his mug straight from the coffee machine. The Dietary Manager continued that the Director of Regulatory Compliance (DRC) notified the kitchen staff to start taking the temperature of the coffee on 2/5/2025. During an observation on 2/6/2025 at 3:12 pm, the temperature of the coffee for breakfast and lunch on 2/6/2025 was not taken. During an interview on 2/12/2025 at 10:33 am, Former Administrator CC revealed that R206 had received coffee from an agency aide. R206 then complained to staff he had spilled the hot coffee on himself, and it was burning. The CNA reported the concerns to the nurse who was also an agency nurse. The Former Administrator CC stated that he found out about the incident approximately 24 hours later and that the staff was reeducated. The corrective action included that the dietary manager should monitor the temperature of the coffee and that it should be documented before serving the residents. The Former Administrator CC further added that the other corrective action was that the kitchen staff would pour the coffee in the facility's cups, not in residents' mugs.

Based on observations, interviews, and a review of the facility's policy titled, Call Lights: Accessibility and Timely Response, the facility failed to ensure that the call light communication system was functioning adequately on one of five units (Jasmine Unit) to allow residents to call for staff assistance. Findings included: A review of the facility's policy titled, Call Lights: Accessibility and Timely Response, revised [DATE] Under Policy Explanation and Compliance number 1. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring residents access to the call light. 8. Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied . A review of the Electronic Medical Record (EMR) revealed R160 was originally admitted to the facility on [DATE] with multiple diagnoses including lymphedema, essential (primary) hypertension, poly osteoarthritis, hyperlipidemia, morbid obesity, and chronic sinusitis. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that R160 had a Brief Interview for Mental Status (BIMS) score of 15, indicating R160 was cognitively intact. During an interview on [DATE] at 11:20 am, R160 revealed that none of the call lights work on the [NAME] Unit. R160 continued that the call light had been out of order since the weekend. R160 was asked how she would get help from staff since the call lights were not functioning, R160 revealed that she would wait till someone walks down the hall and then yell for help. R160 was asked to press the call light, but the call light did not light up. During observations on the [NAME] Unit, the following was observed: Observation on [DATE] at 11:45 am, room [ROOM NUMBER]A's call device was not working. Observation on [DATE] at 11:46 am, room [ROOM NUMBER]B's call light was not working. Observation on [DATE] at 12:50 pm, Licensed Practical Nurse (LPN) XX was observed passing out bells and placing them in various rooms on the [NAME] unit as the call light functionality testing ensued. Observation on [DATE] at 12:55 pm, room [ROOM NUMBER]A's call light was not functioning. Observation on [DATE] at 1:49 pm, room [ROOM NUMBER]A's call device was not working. Observation on [DATE] at 12:31 pm, room [ROOM NUMBER]A's call light was not working. During an interview on [DATE] at 12:31 pm, the Maintenance Assistant revealed, It needed a new battery. Observation on [DATE] at 12:33 pm, room [ROOM NUMBER]B's Call light was not working. In an Interview on [DATE] at 12:33 pm, the Maintenance Assistant revealed, This may need a new light bulb. Observation on [DATE] at 12:37 pm, room [ROOM NUMBER]B's call light was not working Observation on Room [DATE] at 12:37 pm, room [ROOM NUMBER]C's call light was still not working In an Interview on [DATE] at 12:38 pm, the Maintenance Assistant revealed that these call lights may need a light bulb change. Observation on [DATE] at 3:05 pm, room [ROOM NUMBER]B's call light was not working. Observation on [DATE] at 3:28 pm, the Maintenance Assistant was outside room [ROOM NUMBER]B's, working on the call light. During an interview on [DATE] at 1:05 pm, LPN XX revealed she saw that the call lights were not working so she decided to go get the bells for the residents. When asked if LPN XX was aware the call devices were not working, LPN XX stated no. She confirmed that it wasn't until the surveyor was going to each room to check the lights that she noticed they were not working. On [DATE] at 12:29 PM, the Maintenance Assistant accompanied the surveyor to the [NAME] Unit to test the call devices' functionality. During an interview on [DATE] at 12:29 pm, the Maintenance Assistant revealed they check the call light functionality once to twice a week. The Maintenance Assistant continued that sometimes it just needs to be a new light bulb, or the call light needs to be reset. During an interview on [DATE] at 3:55 pm, the Maintenance Director (MD) stated since the new operating company, they don't test the call lights weekly they test them once a month.

Based on observations, staff interviews, record reviews, and review of the facility's policies titled Handwashing/Hand Hygiene and Activities of Daily Living (ADLs), the facility failed to follow infection control protocols related to hand hygiene during ADL care for four of five residents (R) (R91, R9, R83, R16) reviewed for incontinent care. Findings included: A review of the facility's undated policy titled, Handwashing/Hand Hygiene, dated section Policy Interpretation and Implementation under number 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Number 7. Use an alcohol-based hand rub containing at least 62% alcohol; alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: H. Before moving from a contaminated body site to a clean body site during resident care. A review of the policy titled, Activities of Daily Living (ADLs), revised August 2023 revealed that a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, groom, and personal and oral hygiene. 1. A review of the Electronic Medical Record (EMR) revealed that R91 was admitted into the facility on [DATE] with diagnoses of but not limited to cutaneous abscess of the chest wall, anoxic brain damage, and chronic obstructive pulmonary disease. A review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed that R91 presented with a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate impairment. The MDS also indicated R91 had impairment to bilateral lower extremities and required assistance with ADLs. During an interview on 2/10/2025 at 10:40 am, Licensed Practical Nurse (LPN) LPN III revealed two Certified Nursing Assistants (CNAs) CNA RR and CNA KKK would provide incontinent care for R91. During an observation on 2/10/2025 at 10:59 am, incontinence care for R91 revealed CNA RR provided incontinent care for R91 while CNA KKK positioned R91 in place. CNA RR completed the incontinent care without washing hands or using hand sanitizer between dirty and clean. CNA RR provided incontinent care, removed the soiled brief, and cleaned R91's peri area. CNA RR neglected to wash hands or use hand sanitizer before applying the barrier cream and clean brief to R91. During an interview on 2/10/2025 at 11:08 am, LPN III revealed the CNAs should have washed or sanitized their hands after cleansing R91 and before applying barrier cream and the clean brief. During an interview on 2/10/2025 at 11:10 am, CNA RR revealed the only time the hands should be washed was before and after incontinent care. CNA RR stated she did not wash or sanitize her hands after cleansing R91 and before applying barrier cream and a clean brief. A record review of R91's care plan revealed that R91 was at risk for skin breakdown related to decreased mobility and incontinence. The care plan interventions included but were not limited to providing residents with incontinence care after incontinence episodes, and applying moisture barrier as needed (PRN). R91's care plan also revealed that R91 was at risk for urinary tract infection (UTI) due to incontinence of the bladder and bowel. The interventions included but were not limited to increased fluid intake and observation of the color and characteristics of urine. 2. A review of the EMR revealed R9 was originally admitted to the facility on [DATE] with multiple diagnoses including cerebral infarction due to thrombosis of left anterior cerebral, hypertension, gastroesophageal reflux disease, cerebral infarction, hemiplegia, and hemiparesis following cerebral infarction affecting right dominant side and dementia. A review of the Quarterly MDS assessment dated [DATE] revealed that R68 had a BIMS score of 99, indicating R9 is severely cognitively impaired. During an observation on 2/17/2025 at 4:44 am, CNA MMM entered R9's room to provide incontinent care. CNA MMM completed the incontinent care without washing hands or using hand sanitizer between handling dirty and clean wipes and between handling dirty and clean briefs. Additionally, CNA MMM neglected to wash hands or use hand sanitizer before applying the barrier cream and clean brief to R9. 3. A review of the EMR revealed R83 was originally admitted to the facility on [DATE] with multiple diagnoses including end-stage renal disease, anemia, heart failure, hypertension, Gastro-Esophageal Reflux Disease, sleep apnea, muscle weakness, and bilateral primary osteoarthritis of the knee. A review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed that R83 had a Brief Interview for Mental Status (BIMS) score of 15, indicating R83 is cognitively intact. In an observation on 2/17/2025 from 5:04 am to 5:20 am, CNA MMM completed the incontinent for R83. R83 had a bowel movement, and the CNA MMM did not change the gloves after wiping the resident and putting on new clean briefs. 4. A review of the EMR revealed R16 was originally admitted to the facility on [DATE] with multiple diagnoses including, Type II diabetes with hyperglycemia, End stage renal disease, hypertension, insomnia, sleep apnea, chronic obstructive pulmonary disease, neuromuscular dysfunction of bladder, and left and right above knee amputee. A review of the Annual MDS assessment dated [DATE] revealed that R16 had a BIMS score of 15, indicating R16 is cognitively intact. An observation on 2/17/2025 at 6:25 am, CNA MMM enters R16's room to provide incontinent care. CNA MMM provided incontinent care and applied Vaseline to R16's peri area with the same contaminated gloves. During an Interview on 2/17/2025 at 7:05 am CNA MMM revealed she was not washing or sanitizing her hands in between taking off the dirty briefs and putting on the new one. CNA stated, I'm going to tell the truth and shame the devil. She didn't change gloves and sanitize between the dirty and clean briefs. During an Interview on 2/17/2025 at 8:25 am, the Director of Nursing (DON) revealed the staff should be changing gloves in between changing a resident's diaper. A new set of gloves should be worn after the resident is wiped down after having a bowel movement. The last In-service about incontinent care was done a week ago. The DON stated another Inservice will be done. 49687

Based on observations, staff interviews, and a review of the facility's policy titled, Disposal of Garbage Refuse, the facility failed to ensure areas around the garbage dumpsters were kept free from dirt and debris. In addition, the facility failed to ensure the sliding door was kept closed when not in use. The facility census was 189 residents. Findings included: A review of the facility's policy titled Disposal of Garbage Refuse, revised April 2024, documented that Surrounding area should be kept clean so that accumulation of debris and insect/rodent attraction are minimized. During an initial tour of the kitchen accompanied by the facility's Dietary Manager (DM) on 1/13/2025 at 9:44 am, it was revealed that there was one garbage dumpster. The garbage dumpster had a lid that was left open while not in use and there was debris underneath the dumpster and an open blue trash can. During an Interview on 1/13/2025 at 9:44 am, the DM revealed that the garbage dumpster was used by the whole facility. She stated that she had brought concerns to the housekeeping manager about the cleanliness of the dumpster's surrounding areas was a concern. She confirmed that there was debris underneath the dumpster and an open blue trash can. She confirmed that she did not know where the debris and trashcan came from.

Based on staff and resident interviews, record review, and review of the facility policy titled, Activities, the facility failed to ensure an ongoing program of activities based on preferences for one of one resident (R) (R59) reviewed for activities. The resident was not provided with person-centered activities that would meet their individual needs and preferences. Findings included: A review of the policy titled Activities revised January 2024, the policy revealed that each resident's interest and needs will be assessed on a routine basis. The assessment shall include but is not limited to: Activity assessment to include resident's interests, preferences, and needed adaptation. A review of the Electronic Medical Record (EMR) revealed that R59 was originally admitted to the facility on [DATE] with multiple diagnoses including, Peripheral Vascular Disease, Hypertension, Hypothyroidism, Cerebral Infarction, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Anorexia, Dysphagia and Gout. A review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed that R59 had a Brief Interview for Mental Status (BIMS) score of 10, indicating R59 had moderate cognitive impairment. During an interview on 1/13/2025 at 12:58 pm, R59 revealed she would like to be outside in the summer and winter, loves to read, and would like books to read. R59 went to her dresser behind her; however, there were no books. A review of R59's Activities Care Plan, dated 1/21/2025 revealed R59's goal was to attend/participate in activities of choice 3-5 times weekly by next review date. Additionally, R59's preferred activities included watching TV and reading books. During an interview on 2/13/2025 at 12:28 pm, the Interim Activities Director (IAD) revealed that R59 had shown an interest in religious services and had received a Bible. The IAD added that the facility has someone come every Friday to read to the residents. The IAD also offers the residents books, paper, and magazines. The IAD has a 1:1 list that she utilizes for residents who require or prefer 1:1 activity. A review of the list of residents that require 1:1 activity provided by the IAD revealed that R59 is on the list. During an interview on 2/18/2025 at 10:25 am, R59 stated she still hasn't received any books to read. She has a reader but no books. R59 also noted that the IAD will visit with her sometimes but maybe someone else must tell her to bring her some books. During an interview on 2/18/2025 at 11:39 am, the IAD and the surveyor went to the R59's room to ascertain the request for books. It was determined that the R59 owns a tablet, and she needed to have books downloaded to it. The IAD stated this was the first time she had heard about this from the R59. When asked what the IAD does during the 1:1 activity visit, IAD stated she just visits and talks to the residents on the list.

Based on resident and staff interviews, and record review the facility failed to ensure the advanced directive was documented accurately throughout the Electronic Medical Record (EMR) for one of 43 residents (R) (R68) reviewed for advanced directives. Findings included: A review of the EMR revealed R68 was originally admitted to the facility on [DATE] with multiple diagnoses including hypertension, presence of a cardiac pacemaker, seizures, intraocular lens, polyneuropathy, depressive disorder, poly osteoarthritis, Alzheimer's disease, vascular dementia, alternating exotropia, cerebral infarction due to unspecified occlusion or stenosis of other cerebral arteries, dysphasia following cerebral infarction, chronic kidney disease, and encounter for palliative care. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that R68 had a Brief Interview for Mental Status (BIMS) score of 12, indicating R68 had moderate cognitive impairment. A review of the EMR dashboard revealed: Code Status: (Advance Directives) DNR (Do Not Resuscitate), FULL CODE. A review of R68's Physician Orders documented a Full Code status with a revision date of [DATE] and was documented as active. Further review of the Physician Orders revealed a DNR status with a revision date of [DATE] also documented as active. A review of R68's Care Plan initiated on [DATE] documented, I am DNR status per me and my family wishes. A review of the Physician Order for Life-sustaining Treatment (POLST) form dated [DATE] revealed R68's code status as Allow Natural Death - Do Not Attempt Resuscitation. The POLST code was signed by R68, the Medical Director, and an additional facility physician. During an interview on [DATE] at 11:36 am, Licensed Practical Nurse (LPN) XX revealed that to find the code status of a resident; if it's during medication pass LPN XX stated the code status of that resident would appear right under the resident's picture under their dashboard of the resident's profile. Another place the staff could find the code status is under the resident's orders. LPN XX had never seen a resident coded for both DNR and Full code simultaneously. LPN XX revealed that she initially just noticed the full code status on R68's dashboard so she would have treated R68 as a Full Code. LPN XX will talk to her manager right away. During an interview on [DATE] at 12:09 pm, Unit Manager/LPN LLL revealed she updated the code status based on the residents most recent orders. During an interview on [DATE] at 12:38 pm the Director of Nursing (DON) revealed that they have new owners so the switchover may have caused a glitch in the system. Upon admission, all residents are coded as full code until the POLST form is completed. Residents' families are also notified about coding appropriately. The DON is unsure how both DNR and full code could have been reflected on the code status at the same time. During an interview on [DATE] at 2:46 pm, R68 revealed no one spoke to her today about her code status. R68 was asked if she knew what her code status was, and R68 stated no. When asked if something was to happen to her and CPR needed to be done would she want them to do that, R68 stated yes, she would.

Based on observations, interviews, record review, and a review of the facility policy titled, Menu Policy, the facility failed to offer one of 19 sampled residents (R) (R5) a diet that suits her pescatarian diet (a diet that includes plant-based foods and fish and other seafood) preferences. Findings included: A review of the facility's undated policy titled, Menu Policy revealed that menus are developed and prepared to meet resident choices including religious, cultural, and ethnic needs while following established national guidelines for nutritional adequacy. Menu items and available snacks reflect the religious, cultural, and ethnic preferences of the residents. A review of the Admission Record revealed R5 was an [AGE] year-old female that was admitted to the facility on [DATE] with diagnosis of parkinsonism, anemia, essential hypertension, type 2 diabetes, hyperlipidemia, dementia, anxiety disorder, major depressive disorder, coronary artery disease, acute kidney failure, bipolar disorder, obsessive-compulsive disorder, suicidal ideations, paraplegia, gastroesophageal reflux disease, rheumatoid arthritis, pruritus, and glaucoma. A review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed that R5 presented with a Brief Interview for Mental Status (BIMS) score of 12, indicating mild to moderate cognitive impairment and that R5 required supervision with eating. A review of the Care Plan for R5 dated 2/12/2025 revealed resident R5 was at nutritional risk related to having a fair appetite, history of weight fluctuations, history of poor appetite, history of wounds, edentulous, vegetarian preference (fish ok), and mechanically altered diet. Interventions to care include administering medications as ordered, observing/reporting any signs/symptoms of dysphagia, observing/reporting to the medical doctor (MD) signs/symptoms of malnutrition, emaciation (cachexia), muscle wasting, significant weight loss: 3 pounds in one week, >5% in one month, >7.5% in three months, >10% in six months, obtain lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Provide and serve supplements as ordered. Provide and serve diet as ordered. Registered Dietician (RD) to evaluate and make diet change recommendations as needed (PRN). Observation During an interview with R5 on 1/14/2025 at 10:46 am it was noted R5 had some hearing impairment. She stated that she was unhappy with her food choices. She does not eat meat, pork, beef, or chicken. She prefers fish, cottage cheese, peas, and potato salad. She would like fish to be a daily option. During an interview and observation on 2/12/2025 at 12:52 pm during lunch observation R5 expressed she did not like the food, she ate the mixed vegetables and pudding dessert. R5 stated, The vegetables were too hard, I could not eat them. She requested to speak with the dietitian about her food preferences. Observation of R5's plate had roasted zucchini and carrots (firm texture), mixed vegetables (yellow carrots, orange carrots, green beans, onions, green and red bell peppers) (mostly eaten), and uneaten rice. R5 is prescribed a mechanical soft diet with regular liquids. During an interview and observation on 2/12/2025 at 1:30 pm, Kitchen Manager UUU assessed R5's lunch plate and meal ticket to confirm the accuracy of a vegetarian mechanical soft diet. She admitted that the zucchini and carrots were undercooked, and the rice had hard bits in it; too hard for the resident to consume. A review of the facility's October 2024 through February 2025 posted monthly menu revealed fish being offered only four times for four meals of the month. R5's pescatarian diet requires a fish option for all three meals of the day, daily. During an interview on 2/12/2025 at 5:37 pm, the Registered Dietician (RD) stated that she would observe food preparation in the kitchen and assess R5 at dinner service, as R5's quarterly assessment was due that day. She stated that R5 could have fish daily. A review of the updated care plan dated 2/12/2025 revealed no dietary interventions to provide R5 with fish daily. During an interview and observation on 2/13/2025 at 3:18 pm with UUU, the Kitchen Manager stated that the nurses are supposed to inform them of what the resident wanted to eat. She confirmed they do have alternates and that every nursing station had a menu, and the nurses were responsible for making sure the residents who were bedbound chose the meal. The only fish I have access to are tuna, flounder, breaded cod, and catfish nuggets. I won't buy the catfish nuggets that are trash fish covered in batter. Especially if you're not cutting the filets yourself. But I can't order regular catfish, it's not on my order guide. We have restricted order guides.

Based on observation, staff interviews, and review of the Housekeeper/Room Attendant Job Description, the facility failed to maintain clean resident rooms on three of four units (Magnolia Way Unit, Jasmine Place Unit, and Emerald Court Unit). Findings included: A review of the undated job description for the Housekeeper/Room Attendant revealed: Essential Functions: The Housekeeper is the focal point of our environmental service staff. He/she is responsible for the cleaning and sanitation of the facility on a daily basis. During an observation of room [ROOM NUMBER]B on the Magnolia Way Unit on 3/7/23 at 4:43 p.m., revealed a layer of dust on the bed rails. During an observation of room [ROOM NUMBER] on the Jasmine Place Unit on 3/7/23 at 4:47 p.m., revealed spillage on the heating/air unit. During an observation in room [ROOM NUMBER] on the Emerald Court Unit on 3/8/23 at 1:20 p.m., the floor was dirty with debris and stains, particularly along the baseboards behind the beds, and call light and bed cords from the unoccupied bed were strewn on the floor. In an interview with Unit Clerk (UC) FF on 3/8/23 at 1:30 p.m., she stated the resident rooms on the Emerald Court Unit were not cleaned daily. She stated there was at least one housekeeper on the unit on the day shift on a daily basis but even when there were two housekeepers, they did not clean all the resident rooms or clean them thoroughly. In an interview with the Licensed Practical Nurse (LPN) HH on 3/8/23 at 11:00 a.m., she stated she had only been with the facility for a short time, but she had challenges with housekeeping from the start on the Emerald Court Unit. She stated the housekeepers don't clean all the rooms on the unit every day. She stated she even cleaned some rooms herself when she first started, including cleaning horrible debris in the closets. She stated her residents deserved better service and she was committed to seeing that they received it. In an observation/interview with the Housekeeping Supervisor on 3/9/23 at 4:00 p.m., he confirmed room the observations in rooms 47B, 68, and 106. He confirmed all the rooms on the Emerald Court Unit on the lower level were not cleaned daily due to his inability to staff the housekeeping team as he would like.

Based on observations, interviews, record review, and review of policy titled Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in the Facility, the facility failed to (1) provide proper source control as evidenced by not providing receptacles for containing doffed personal protective equipment (PPE) for seven of nine residents (R)( R#113, R#75, R#165, R#91, R#69, R#169, and R#126) residents on transmission based precautions (TBP); (2) properly managing COVID-19 positive residents by cohorting with COVID-19 negative (but exposed) residents without proper symptom monitoring for seven of nine residents (R) (R#113, R#75, R#165, R#91, R#69, R#169, and R#126) in isolation for TBP; and (3) properly have a water management program that would monitor measures in place for preventing growth of Legionella and other opportunistic waterborne pathogens. Findings included: 1. During the initial screening of R#113 and R#75, it was observed on 3/7/23 at 10:30 a.m., the surveyor donned PPE to enter the residents room. The signage noted that the residents were in isolation for TBP. Resident #130 was laying in the bed and stated that she did not feel good, she was sick and had cramps in her legs. Resident #75 was laying in the bed, had no difficulties noted and had no complaints. She stated that she had been in isolation for what seemed like three weeks. After the screening of these two residents was completed, the surveyor went to doff the used PPE and observed that there was no trash can or bin by or around the door to discard used PPE. During an interview with the Infection Preventionist (IP) on 3/7/23 at 3:00 p.m., he stated that R#165 tested positive for COVID-19 on 2/23/23; R#91 and R#69 had both tested negative for COVID-19 on 2/23/23. Resident #69 tested positive for COVID-19 on 2/27/23 and R#91 had remained negative for COVID-19. He further confirmed that there was no bin in the residents rooms for doffed PPE and the door to the room was open and should be closed. He stated that there was bin in the room last week, and that someone must have removed it. On 3/7/23 at 3:10 p.m., R#169 and R#126 were in a shared room. There was signage observed on the door for droplet and contact isolation. The IP confirmed that R#126 had tested positive for extended-spectrum beta-lactamases (ESBL) in his urine and was on contact for that. When asked why the droplet precautions sign was used, he revealed that it was not needed, and it should have been taken down. It was also confirmed that the were no bin at the door for the doffing of PPE. On 3/7/23 at 3:15 p.m., R#113 and R#75 were in a shared room. It was confirmed by the IP that there was no bin next to door for the doffing of PPE, and that R#113 had tested positive for COVID-19 and was on isolation for TBP. It was also revealed that the R#75 tested positive for COVID-19 on 2/23/23, and resident in R#113 tested positive for COVID-19 on 2/27/23. On 3/7/23 at 3:25 p.m. an interview was conducted with Licensed Practical Nurse (LPN) # GG. She revealed that there was no bin of any kind in R#113 and R#75's room. She stated that after providing direct care to those residents, she would remove the PPE and place it in a bag, then leave the room and place the bagged PPE into the trash in the soiled utility room. She also verified that the door to R#165 and R#91, another TBP room, was open and should be closed. On 3/7/23 at 3:37 p.m., an interview was conducted with Certified Nursing Assistant (CNA) BB. She stated that there was no bin in R#113 and R#75's room and that when she would doff PPE, she would remove and place in a bag. Then she would take the bag to the trash in the soiled utility room. During an interview with the Environmental Services Department Manager (EVS) on 3/8/23 at 2:00 p.m., he revealed that he was not notified that there were bins needed for the TBP rooms. He stated that he would put a plan in place to allow for communication between EVS and the IP to provide the needed equipment. 2. During an interview with the IP on 3/8/23 at 10:30 a.m., he provided the facility's Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in the Facility, which was last revised on 10/3/22. It is recommended that for COVID-19 Positive Residents: ideally, residents shall be placed in a single -person room and a dedicated bathroom, i. If a limited single room are available or if numerous residents are simultaneously identified to have known SARS-CoV-2 exposures or symptoms for COVID-19, residents should remain in their current location. ii. If cohorting, residents with the same respiratory pathogen should be housed in the same room, if feasible. It also recommends that door shall remain closed to reduce transmission. During an observation on 3/9/23 at 4:00 p.m., it was observed that R#130 and R#43 had a shared room. During an interview with R#130 at that time, she stated that she has had COPD (chronic obstructive pulmonary disease) and emphysema for several years and always has a cough. She stated she coughed up some phlegm about a week ago, but she feels fine and has no fever or feelings of nausea, headache, or shortness of breath (SOB). During an interview with R#43 at that time, she stated she had a headache that has been on and off for the last day. She confirmed that she did not have a cough, no SOB, no fever, and no feelings of nausea. A review of New COVID-19 Positive Resident list of 2023 revealed that R#130 tested positive for COVID-19 on 2/23/23.There is no information in the record to indicate if the resident had symptoms prior to testing positive for COVID-19. A review of the clinical record revealed that R#43, tested positive for COVID-19 on 2/27/23.There is no information in the record to indicate if resident had symptoms prior to testing positive for COVID-19. During an observation on 3/9/23 at 4:10 p.m., it was observed that R#165, R#91, and R#69 had a shared room. During an interview with R#165 at that time, she stated that she was sick a while ago but now she is better. Resident's #91 and R#69 were also observation at this time and they both voiced no concerns. A review of the clinical record revealed that R#165 tested positive for COVID-19 on 2/23/23. There is no information in the record to indicate if resident had symptoms prior to testing positive for COVID-19. A review of the clinical record revealed that R#169 tested positive for COVID-19 on 2/27/23. There is no information in the record to indicate if resident had symptoms prior to testing positive for COVID-19. A review of the clinical record revealed that R#91 tested negative for COVID-19 on 1/23/23 and 2/27/23. During an observation on 3/7/23 at 10:35 a.m., it was observed that R#113 and R#75 had a shared room. During an interview with R#113 at this time, she stated that she didn't feel good. She was emotional and tearing up. She stated that she had muscle pain. A review of the clinical record revealed that there was no information to indicated that resident had any symptoms or was experiencing symptoms since testing positive. During an interview with R#75 on 3/9/23 at 4:05 p.m. she stated that she had a cough when she tested positive for COVID-19. There is no information in the record to indicate if resident had symptoms prior to testing positive for COVID-19. During an interview with LPN GG on 3/9/23 at 3:50 p.m., they revealed that once a resident has tested COVID-19 positive at any point in the past, then nurses no longer check vital signs or symptoms. During an interview with the IP on 3/9/23 at 4:03 p.m., he revealed that COVID-19 symptom monitoring should be completed and documented on all residents. During an interview with the Assistant Director of Nursing (ADON) on 3/9/23 at 5:30 p.m. she stated that all residents are supposed to be monitored for symptoms each shift and that it is the responsibility of the nurses to make sure they are monitoring residents for symptoms. She stated that when she was the Director of Nursing (DON), they conducted an audit but could not remember exactly when, to make sure that symptom monitoring was on the EMAR. She then stated that now, once a resident tests COVID positive, symptoms are monitored and the nurse only has to chart in progress notes if symptoms are present. The facility provided an attendance record of an in-service (not dated) with the subject noted as COVID Symptoms. It was noted that symptoms should be monitored while a resident is COVID positive or exposed for worsening symptoms. 3. An interview with the Maintenance Director on 3/9/23 at 2:15 p.m. was conducted he revealed that the facility does not test for Legionella and has not for two or three years. He stated that he flushes the hot water lines once a month, and it was last completed on 3/1/23. The Water Management Program was requested several times from the facility, and it was never provided.

Based on observation, interviews, and review of the undated facility policies titled Ice Machine Sanitation Policy and Dietary Cleaning Policy, the facility failed to maintain the dry storage room in the kitchen and the basement ice maker in a sanitary manner. The facility census was 196 residents. Findings included: A review of the facility policy titled Dietary Cleaning Policy revealed under Policy: Cleaning duties are to be performed on a daily [basis]; Manager will perform daily walk-through of the kitchen. A review of the undated facility policy titled, Ice Machine Sanitation Policy, documented the Procedure for Large Ice Bin Kitchen Machines as a monthly cleaning procedure. During an observation of the kitchen with the Certified Food Manager (CFM) on 3/7/23 at 9:35 a.m., revealed a large amount of a light brown substance on the floor underneath one of the metal racks in the dry storage area. The CFM could not distinguish what the substance was. He stated each staff member was responsible for cleaning up their own mess. The basement ice maker revealed a black substance across the lower portion of the ice chute through which ice is deposited into the bin. The CFM stated he had only been employed at the facility for three weeks and did not know when the ice maker was last cleaned. He stated the ice maker in the kitchen was not in use and had been serviced by an outside company twice already but was still not functioning properly. He stated he was not sure if housekeeping or maintenance was responsible for cleaning the ice maker, but he would attend to it right away. During an interview with the CFM on 3/8/23 at 10:10 a.m., he stated the maintenance staff was responsible for cleaning the ice maker monthly. In an interview with the Maintenance Director on 3/9/23 at 1:40 p.m., he confirmed the Maintenance Department was responsible for monthly cleaning of the large ice makers in the kitchen and basement.

Based on clinical record review, staff interviews, review of the facility's policy Advanced Directives the facility failed to ensure that the Do Not Resuscitate document was signed by a concurring physician for one of 63 sampled residents (R) (R#55). Findings included: A review of the policy titled Advanced Directives revised date December 2016 revealed: The Director of Nursing Services (DON) of designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. The Attending Physician will not be required to write orders to which he or she has an ethical or conscientious objection. A review of the electronic medical record (EMR) for R#55 revealed she was admitted to the facility on [DATE] with diagnoses that included but not limited to Alzheimer's, hypertension, osteoarthritis, low back pain, anemia, and abnormal glucose. Review of the minimum data set (MDS) assessment revealed R#55 had a Brief Interview for Mental Status (BIMS) of 00, which indicates resident has severe cognitive impairment. A review of the EMR revealed the resident's responsible party signed a document titled .Code Status on 10/5/22 and the physician's signature was dated 10/5/22 and there was not a concurring physician signature indicated on the form. The line labeled 'Reason patient is unable to sign' was written 'poor medical conditions.' A review of the physician's order dated 1/11/23 revealed an order for do not resuscitate (DNR). During an interview with Social Worker (SW) on 3/8/23 at 2:00 p.m. she stated that she has heard conflicting reports of physicians needing two signatures on DNR's. She stated the verbiage behind the report stated it wasn't necessary. The SW stated she would bring us the updated POLST/DNR for the resident, however no additional documentation was presented by the SW. During an interview with administrator on 3/9/23 at 10:43 a.m., it was revealed that she knew that for any resident with dementia there should be two physicians signature for the DNR document. She stated she did not see any other documentation for the resident's DNR in her electronic medical record.

Based on observations, interviews, record reviews and policy reviews, the facility failed to implement interventions in place for oxygen use, COVID-19 symptom, and vital sign monitoring for one of 63 sampled residents (R) (R#99). Findings included: A review of the electronic medical record for resident R#99, revealed that resident was admitted on [DATE], with diagnoses that included but are not limited to the following: dysphagia following cerebral infarction, cerebral infarction due to unspecified occlusion or stenosis, type 2 diabetes, epilepsy, gastrostomy tube, hypertension, anxiety, aphasia, and gastroparesis. A review of care plan for R#99 dated 7/10/20, and was revised on 2/21/23, the resident tested positive for COVID-19 on 2/20/23. The interventions in place include the following: 1). Follow protocol for COVID-19 screening and precautions, 2). Monitor temperature and signs and symptoms of respiratory issues daily, 3). Oxygen as ordered. A review of physician orders for R#99, as of 3/9/23, revealed that oxygen was ordered as follows: oxygen six liters to keep oxygen above 92% (percent). There were no orders for oxygen saturation checks. During an interview with the Registered Respiratory Therapist, on 3/9/23 at 5:35 p.m., revealed that she was not aware that R#99 needed oxygen therapy. During an interview with the registered nurse/Assistant Director of Nursing at 5:40 p.m. on 3/9/23, revealed that the resident had a change in condition on 2/16/23, where she had symptoms that included a low oxygen saturation. The physician was notified, and the nurse was given an order for oxygen and a chest x-ray. A review of the change of condition report dated on 2/16/23, revealed that resident had an oxygen saturation of 79%, (normal should be greater than 90%), and a temperature of 102.4 (Fahrenheit), a heart rate of 114 (beats per minute) and a decrease in the level of consciousness, that was noted to be different for this resident. A review of the Care Plan Policy, with a revision date of 12/12/17, revealed that each resident will have a plan of care to identify problems, needs, and strengths that will identify how the facility staff will provide services to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being. A review of the electronic medication administration record revealed that that there were no signs and symptoms, and no record of vital signs being recorded that would include oxygen saturation. A review of progress notes revealed that vital signs were not being recorded. During an observation of the resident occurred on 3/7/23 at 11:20 a.m., R #99 was noted to have no oxygen in place. No signs of distress noted. On 3/8/23 at 11:55 a.m., the resident was observed to have no oxygen on, and no signs of distress noted. A review of the policy titled Oxygen Administration, revealed that the purpose of the procedure is to provide guidelines for safe oxygen administration. It also states that in preparation of oxygen administration, the staff person is to verify that there is a physician's order for this procedure. Review of the orders or the facility protocol for oxygen administration should also be completed.

Based on medical record review, Resident Occurrence Report Review, facility staff Witness Statement review, and staff interview, the facility failed to immediately consult with the physician, and notify the family, of a fall and ongoing complaints of pain for one (1) resident ("A"), on the total survey sample of nine (9) residents, after Resident "A" expressed pain after having sustained a fall which resulted in a fracture. This delay in physician consultation resulted in a delay in obtaining the necessary care and treatment for [REDACTED]. Findings include: Cross refer to F309 for more information regarding Resident "A". Review of a Resident Occurrence Report Result report which referenced Resident "A" revealed that on 05/06/2011, the resident had attempted to get up from a wheelchair and fallen, with moderate pain noted. A 05/07/2011 written Witness Statement of Restorative Aide "CC" documented that on 05/06/2011, he had seen Resident "A" in the hallway on the floor on her side. During a 12/08/2011, 9:30 a.m. interview, Administrative Nurse "GG" stated that during investigation, Aide "CC" stated he had observed Resident "A" between 5:45 p.m. and 6:08 p.m., when he clocked out. In a 05/16/2011 written Witness Statement, Certified Nursing Assistant (CNA) "EE" documented that on 05/06/2011, between 5:00 p.m. and 6:00 p.m., she had witnessed Resident "A" complaining of pain while being taken to the dining room. During the 12/08/2011, 9:30 a.m. interview, Administrative Nurse "GG" stated that dinner had been served on 05/06/2011 at approximately 6:20 p.m., and that according to information obtained from Nurse "BB", Resident "A" had been transported back to the nurse's station at approximately 6:45 p.m. A family member arrived at approximately 7:15 p.m., and the resident continued to complain of pain, but Nurse "BB" stated that although Nurse "AA" told her of the resident's earlier fall at that time, Nurse "AA" acknowledged that he had not consulted with the physician. Nurse "AA" then placed a call to the physician, who did not initially answer, and it was only after the family member reported the resident's continued complaints of pain that a second call was placed to the physician, and that the family member was informed of the resident's fall. A Nurse's Note of 05/06/2011, written by Nurse "BB", again documented the resident's complaint of pain, and that at 8:00 p.m., the physician was notified of the resident's complaint of pain. This Note documented that the physician ordered Tylenol 325 milligrams and [MEDICATION NAME] 50 milligrams for pain, and X-rays of the resident's bilateral hips. This Note further documented that at 10:00 p.m. on 05/06/2011, the facility was notified that the X-ray had revealed an acute displaced subcapital [MEDICAL CONDITION]'s right hip. Based on the above, the facility failed to consult with the physician regarding the resident's fall and continued complaints of pain from approximately 6:00 p.m. on 05/06/2011, when the fall occurred, until 8:00 p.m., resulting in an approximate two (2) hour delay in physician consultation. The facility also failed to notify the family member of the fall until approximately 8:00 p.m.

Based on medical record review, Resident Occurrence Report Review, facility staff Witness Statement review, staff interview, and family interview, the facility failed to prohibit neglect, related to the provision of care after a fall resulting in a fracture, for one (1) resident ("A"), on the total survey sample of nine (9) residents. This resulted in a delay in obtaining timely pain relief and treatment for [REDACTED]. Findings include: Cross refer to F157 and F309 for additional information regarding Resident "A". Review of a Resident Occurrence Report Result form which referenced Resident "A", and completed by Nurse "AA", revealed that on 05/06/2011, the resident had attempted to get up from the wheelchair and had fallen, and that upon assessment, moderate pain had been noted when the resident stood up. However, further record review revealed no evidence to indicate that the resident received any treatment for [REDACTED]. In a 05/16/2011 written Witness Statement of Certified Nursing Assistant (CNA) "EE", CNA "EE" documented that on 05/06/2011, she had witnessed Resident "A" being taken to the dining room yelling that she was in "so much pain" and stating "my hip". However, although this observation was after the resident's fall, and although the resident continued to complain of significant pain, there was no evidence to indicate that the resident had received any treatment for [REDACTED]. A May 2011 Medication Record for Resident "A" revealed an entry, timed at 7:30 p.m. on 05/06/2011, which documented the administration of a 325 milligram dose of Tylenol by Nurse "AA". However, during a 12/08/2011, 1:39 p.m. family interview, this family member stated that Nurse "AA" had brought Resident "A" pain medication at around 7:30 p.m. on 05/06/2011 because the family member had requested something for the resident's pain. A Nurse's Note of 05/06/2011, written by Nurse "BB", documented Resident "A"'s continued complaint of pain on her right side, and documented that at 8:00 p.m., the physician was finally notified of the resident's complaints of pain and that orders for the medications Tylenol 325 milligrams and [MEDICATION NAME] 50 milligrams were obtained for pain. This Note further documented that at 10:00 p.m., the facility was notified that an X-ray had revealed an acute displaced subcapital [MEDICAL CONDITION]'s right hip.

Based on medical record review, Resident Occurrence Report Review, facility staff Witness Statement review, staff interview, and family interview, the facility failed to adequately monitor the status, and obtain timely treatment for [REDACTED]. which resulted in a fracture. This resulted in a delay in obtaining timely and necessary treatment for [REDACTED]. Findings include: Review of a Resident Occurrence Report Result form which referenced Resident "A" revealed that on 05/06/2011, the resident had attempted to get up from the wheelchair and had fallen. This report documented that upon assessment, moderate pain had been noted when the resident stood up. In a 05/07/2011 written Witness Statement of Restorative Aide "CC", this aide documented that on 05/06/2011, as he was in the hallway passing the nurse's station, he had seen Resident "A" on the floor on her side, and had assisted Nurse "AA" and Nurse "DD" to help the resident up. During a 12/08/2011, 9:30 a.m. interview with Administrative Nurse "GG", Nurse "GG" stated that during the facility's investigation into the resident's fall, Aide "CC" had stated he had observed Resident "A" on the floor in the hallway between 5:45 p.m. and when he clocked out at 6:08 p.m. In a 05/16/2011 written Witness Statement of Certified Nursing Assistant (CNA) "EE", CNA "EE" documented that on 05/06/2011, between 5:00 p.m. and 6:00 p.m., she had witnessed Resident "A" being taken to the dining room, and that the resident was yelling she was in "so much pain", and was stating "my hip". During the 12/08/2011, 9:30 a.m. interview with Administrative Nurse "GG" referenced above, Nurse "GG" stated the facility's investigation had revealed that dinner had been served in the dining room on 05/06/2011 at approximately 6:20 p.m., and acknowledged that CNA "EE" had witnessed Resident "A" being taken to the dining room on 05/06/2011 after the resident had fallen at the nurse's station. Nurse "GG" stated that, according to information obtained from Nurse "BB" during the investigation, the resident had then been transported back down the hallway to the nurse's station after dinner at approximately 6:45 p.m., and that Resident "A" was sitting in front of the nurse's station when a family member arrived at approximately 7:15 p.m. The resident complained of pain to the family member as the family member was taking the resident to her room. Nurse "BB" stated, during the facility's investigation, that Nurse "AA" told Nurse "BB" at that time that Resident "A" had fallen earlier, and when asked by Nurse "BB" if he had contacted the physician regarding the fall, Nurse "AA" stated he had not notified the physician at that time. Nurse "BB", after being informed of the fall, instructed Nurse "AA" to call the doctor at that time. Nurse "AA" placed a call to the physician, who did not initially answer the call. Nurse "AA" then went to the resident's room, but it was not until after the family member reported the resident's continued complaints of pain in the hip that a second call was placed to the physician to obtain treatment orders. A Nurse's Note of 05/06/2011, written by Nurse "BB", also documented Resident "A"'s complaint of pain on her right side, and that at 8:00 p.m., the physician was notified of the resident's complaint of pain. This Note documented that the physician ordered Tylenol 325 milligrams every six (6) hours as needed, [MEDICATION NAME] 50 milligrams twice daily for 7 days, and X-rays of the resident's bilateral hips to be done that day. This Note further documented that at 10:00 p.m. on 05/06/2011, the facility was notified that the X-ray had revealed an acute displaced subcapital [MEDICAL CONDITION]'s right hip. This Note documented that at 10:30 the physician was notified of the X-ray results and ordered to send the resident to the hospital for evaluation. Based on the above, the facility failed to notify the physician of the resident's fall and continued complaints of pain, in order to obtain the appropriate treatment orders, from approximately 6:00 p.m. on 05/06/2011 when the fall occurred, until 8:00 p.m., after the resident complained of pain to the family. This resulted in an approximate two (2) hour delay in obtaining the necessary treatment for [REDACTED]. During this delay in the provision of treatment, the resident continued to express complaints of significant pain. Additionally, a Nursing Narrative Notes entry of 05/06/2011, timed at 8:15 p.m., documented the resident's earlier fall, and documented that when evaluated for range of motion and pain, pain had been noted when the resident tried to get up and take a step. However, further record review, to include review of the Nurse's Notes, revealed no evidence to indicate that Nurse "AA", who had initially assessed Resident "A" upon her fall at approximately 6:00 p.m., Nurse "BB", who had at approximately 7:15 p.m. been informed of the resident's earlier fall, or any other facility staff had performed additional monitoring or assessment of the resident's condition after she sustained the fall and complained of pain, until a Nurse's Notes entry of 05/06/2011 documented that at 12:05 a.m. (on 05/07/2011) the ambulance arrived to transport the resident to the hospital for evaluation. In addition, a May 2011 Medication Record for Resident "A" revealed an entry, timed at 7:30 p.m. on 05/06/2011, which documented the administration of a 325 milligram dose of Tylenol by Nurse "AA". However, further record review revealed no evidence to indicate that facility staff performed any additional assessment of the resident's pain after 7:30 p.m., until the time of the resident's hospital transfer referenced above. During a 12/08/2011, 1:39 p.m. family interview, this family member stated that Nurse "AA" had brought the resident's pain medication at around 7:30 p.m. on 05/06/2011 because she had requested something for the resident's pain. However, the family member further stated that no facility staff member came to assess the resident's pain, obtain vital signs, or perform additional assessment for the remainder of the evening of 05/06/2011.