Every finding on record at Sharon Center for Health & Rehabilitation

Based on clinical record review, facility documentation review, facility policy review, and staff interviews for one of three residents (Resident #1) reviewed for accident hazards and supervision, the facility failed to ensure adequate supervision of a resident with moderate cognitive impairment and an unsteady gait requiring walker-assisted ambulation, failed to accurately assess elopement risk despite a BIMS score of 9 indicating moderate cognitive impairment, and failed to ensure staff responded appropriately to an activated exit door alarm by searching for a resident or notifying the supervisor prior to deactivation. On 3/30/2026, Resident #1 exited the facility undetected, walked 0.3 miles on a two-way street without sidewalks or a crosswalk to the hospital emergency department, and remained unaccounted for by staff for one hour and 45 minutes. Resident #1 was on Apixaban (a blood thinner increasing the risk of serious bleeding from falls or trauma), was confirmed by the hospital to be confused and disoriented upon arrival, and was discharged with diagnoses including disorientation and at risk for elopement from a healthcare setting. The facility's elopement risk evaluation inaccurately concluded Resident #1 lacked the physical ability to leave; no written policy existed governing staff response to exit door alarms; and the staff member who responded to and deactivated the alarm did not look outside, search for residents, or notify the supervisor, an individual staff failure compounded by a systemic organizational failure. These failures placed Resident #1 and six additional residents identified by the facility as elopement risks in Immediate Jeopardy of serious harm or death, beginning 3/30/2026. The findings include: Record review identified Resident #1 was responsible for him/herself. Physician order dated 3/26/2026 directed Apixaban (Eliquis, used to prevent blood clots) 2.5 milligrams (mg) by mouth daily. The nursing admission assessment dated [DATE] identified Resident #1 required assistance for transfers, had an unsteady gait with poor trunk control, and was alert and oriented to person, place, time and situation. Elopement risk evaluation dated 3/26/2026 identified Resident #1 was not at risk for wandering/elopement. The evaluation identified Resident #1 did not have the physical ability to leave the facility, was not cognitively impaired, and did have the capacity to make informed decisions about leaving. The resident care plan (RCP) dated 3/27/2026 identified Resident #1 was at risk for falls due to an unsteady gait and required assistance for activities of daily living (ADL). Interventions directed to anticipate needs, and supervision for transfers and ambulation with a walker. An admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 9 (moderate cognitive impairment) and required partial assistance for bed mobility and transfers. APRN note dated 3/30/2026 at 5:54 AM identified a remote visit was conducted for nursing reports of moderate bright red blood noted while passing stool. No rectal bleeding, on Eliquis, likely constipation and plan monitor for bleeding. A nursing note written by RN #1, dated 3/30/2026 at 10:35 PM identified she received a call from the hospital ED at 7:50 PM that Resident #1 had walked into the ED at 6:20 PM. Resident #1 was alert and oriented to self and provided her/his current birth date. Resident #1 told the hospital that he/she lived in the elderly housing across the street but did not know the name. A facility reportable event (RE) dated 3/30/2026 at 8:28 PM identified the facility received a phone call from the ED stating Resident #1 was there and inquired if he/she was a resident at the facility. Hospital staff stated resident arrived at 6:20 PM and appeared confused, believing he/she was in Texas. Resident #1 was last seen by LPN #1 when he/she received medication at 6:08 PM (12 minutes prior to the reported hospital arrival). Surveyor observations identified the visitor parking lot was directly in front of the lobby door and led to a long driveway with a slight decline and to the street. The street was a two (2) way street, had residential homes on both sides, had no sidewalks or crosswalk, and the hospital was located directly across the street from the second house down from the facility driveway. Online directions identified the hospital was 0.3 miles away. A nursing note dated 3/31/2026 at 2:10 AM identified Resident #1 returned to the facility at 1:00 AM and was alert to self and cooperative, stated he/she was tired and going to bed. Resident #1 stated he/she just went out the front door and walked over (to the hospital) to get a checkup. Report from the hospital indicated was Resident #1 was cleared with no new orders. A wander guard was placed, and Resident #1 was reoriented and redirected several times during the shift and was placed on every 15-minute checks. Hospital discharge instructions dated 3/31/2026 at 12:33 AM identified diagnoses from visit included at risk for elopement from a healthcare setting, disorientation and history of a nephrectomy. The facility RE summary dated 4/3/2026 identified Resident #1 was last seen on 3/30/2026 at 6:05 PM (1 hour and 45 minutes prior to the call from the hospital at 7:50 PM) and had no indication of an elopement risk prior to the incident. Resident #1 left the facility without notifying staff, exited through the front lobby and activated the 15-second egress mechanism and door alarm. Resident #1 walked to the hospital located across the street, arriving at the hospital at 6:20 PM. Interview with Therapeutic Recreational Assistant ([NAME] #1) on 4/27/2026 at 11:54 AM identified she was in the unit common area near the end of the hallway by the lobby when she heard the facility front door alarm activate. [NAME] #1 stated she went to the door and immediately deactivated the alarm (only staff had the code to deactivate/silence the alarm). [NAME] #1 stated residents had a scheduled, supervised smoke break at 7:00 PM. She thought the alarm had been activated when the residents went outside for the smoke break and she did not realize the time was around 6 PM. [NAME] #1 stated she deactivated the alarm to stop the noise without looking for any residents and returned to her recreation activity. [NAME] #1 stated she did not search for any residents, and she did not notify the nurse or supervisor that the alarm had sounded. Interview with the LPN #1 on 4/27/2026 at 1:45 PM identified she was the nurse assigned to Resident #1 on 3/30/2026 and stated she administered medications to Resident #1 about 6:05 PM, and she did not hear any alarm activation. LPN #1 stated about 8 PM, RN #1 notified her that Resident #1 was missing and had walked to the hospital emergency room (across the street). Interview with RN #1 on 4/27/2026 at 12:30 PM identified she was the nursing supervisor on 3/30/2026 and received a phone call from the hospital at 7:50 PM notifying her that Resident #1 arrived at the hospital (emergency room) at 6:20 PM and was confused. Resident #1 reported he/she resided in the elderly housing across the street. RN #1 stated she notified the DON who instructed her to conduct a head count of all residents and indicated there were no other residents missing. RN #1 stated she had not heard any alarms activated, and stated that Resident #1 should not have been able to leave the facility without staff knowledge. Interview with the Director of Nursing (DON) on 4/27/2026 at 2:25 PM identified when an exit door alarms, staff are expected to respond to the door alarm, observe outside the door and inside in the vicinity of the door prior to deactivation of the alarm for any residents. The DON stated she observed the facility security video recording of the front door lobby area and identified that on 3/30/2026, Resident #1 exited the building at 6:07 PM and the alarm activated. The video then showed within seconds of the alarm sounding, [NAME] #1 responded to the alarm and deactivated the alarm. The DON stated if [NAME] #1 looked outside, she would have been able to observe Resident #1 in front of the building. The DON stated that dinner had already been served when Resident #1 left the building and was last seen by staff about 6:05 PM. The facility was notified Resident #1 was at the hospital at 7:50 PM, one (1) hour and 45 minutes later (staff were not aware Resident #1 was not in the facility for one (1) hour and 45 minutes). The DON stated the facility had six (6) additional residents identified at risk for elopement. Interview with the Administrator on 4/27/2026 at 2:15 PM identified that the front desk receptionist leaves at 6:00 PM daily and locks the front entrance door which activates the door alarm. The front door was an egress door and will open (unlock) if pushed by anyone after 15 seconds for fire safety reasons. The alarm activates if the door is opened and only staff have the code to deactivate the alarm. Resident #1 should not have been able to leave without staff knowledge, and the recreation staff should have searched for a resident outside the alarmed door after it was activated. Interview failed to identify that recreation staff should notify the supervisor of the alarm activation. The facility policy Elopement dated 2/2025 directed in part that residents will be accounted for at all times. Although requested, a policy for staff response to exit door alarms was not provided. During the on-site visit, a review of facility documentation subsequent to the incident, identified education was initiated on 3/31/2026 and directed staff to answer all door alarms by responding immediately to the alarmed door, scan the vicinity near the alarmed door for any residents, walk outside to check for any residents prior to deactivation of the alarm, and for staff to complete a bed check (resident head count) to account for residents or identify any missing resident. Elopement drills were conducted starting on 3/31/2026 on each shift to ensure appropriate response to door alarm and activation of code yellow or facility elopement procedures if resident not located. Audits were initiated on 4/2/2026 to ensure appropriate response to alarms on each shift, and a QAPI meeting was held. Review of the facility documentation identified a finding of past non-compliance effective 3/31/2026.

Based on clinical record review, facility documentation, facility policy and staff interviews for 1 of 5 residents (Resident #1) reviewed for unnecessary medications, the facility failed to review and respond to pharmacy recommendations in a timely manner. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included dementia, diabetes, and hypertension.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired, dependent on bathing, and personal hygiene. Also, identified Resident #1 required maximal assistance for toileting, dressing and partial moderate assistance for transfers. Further, identifying Resident #1 required set-up assistance for eating.A physician order dated 11/13/24 directed to administer Rexulti (an antipsychotic medication used to treat agitation associated with dementia) 0.5 milligram (mg) tablet every evening.A pharmacy medication review dated 12/6/24 recommended since Resident #1 was started on Rexulti and to add an order for orthostatic blood pressures once weekly for 4 weeks lying and standing or lying and sitting if unable to stand. Also, identifying the need for lab test of a HbA1c to be completed.The Resident Care Plan (RCP) dated 12/29/24 identified Resident #1 had psychotropic medication used with interventions that included to give medication as ordered and monitor and record for target behavior symptoms such as physical aggressiveness, resistive to care, and labs as ordered. A pharmacy medication review dated 1/26/25 noted a second request identifying Resident #1's need for lab work of a HbA1c to be completed.A pharmacy medication review dated 2/7/25 noted a third request identifying Resident #1's need for lab work of a HbA1c to be completed.Review of the clinical record identified a lab test for HbA1c was obtained on 2/21/25 (more than 2 months after the pharmacist's initial recommendation) but failed to identify orthostatic blood pressures were ever initiated.An interview on 8/29/25 at 11:55 AM with the Director of Nursing Services (DNS) identified once a pharmacist makes a recommendation, the facility should act upon it in a timely manner which would be within 30 days. Also, identifying nurse management was responsible for ensuring pharmacy recommendations were completed. Further, identifying the HbA1c was completed after 3 requests were made and the ortho static blood pressures not being completed was an oversight, updating the order on 8/29/25 in the presence of the surveyor.Review of the Pharmacy Medication Review Policy dated April 2023 identified the consultant pharmacist reviews the medication regimen of each resident at least monthly. Findings and recommendations are communicated to those with responsibility to implement the recommendations, and to answer in a timely fashion. Also, identifying the consultant pharmacist will submit their monthly recommendations reports to the DNS and follow up on the recommendation to verify that appropriate action has been taken and or responded to within a reasonable time frame.

Based on observations, facility documentation, facility policy and interviews, the facility failed to ensure that the correct portion of chicken was served, and corn bread or a similar substitute was provided per facility menu. The findings include: Observation of the lunch menu for 8/25/25 identified 4 oz of chicken and cornbread was to be served.a. Observations in the [NAME] Unit dining room on 8/25/25 at 12:15 PM noted that Resident #13 did not have any protein with his/her lunch meal. Resident #13 was asked if he/she wanted any chicken with lunch by the surveyor. Resident #13 responded that he/she would like chicken. Dietary Aid (DA) #1 responded, we don't have any more chicken. DA #1 did not offer an alternative and/or provide Resident #13 with any protein with his/her meal. Further observation on 8/25/25 at 12:30 PM in the [NAME] Wing dining room noted that 7 small chicken legs were served to residents out of the 11 residents in the [NAME] Wing dining room. Two residents were served an alternative (sandwich) and 2 residents had puree consistency meal. Resident #19 who was in the dining room commented, hey, look at this little chicken leg. Resident #19 indicated that he/she should have another chicken leg as it was not enough chicken. DA #1 indicated that there was no more chicken to serve residents. NA#1 on 8/25/25 at 12:45 PM asked Resident #19 if he/she did not get enough chicken to eat after the steam table left the dining room area. Resident #19 responded that he/she did not want any more food, just a second glass of iced tea which NA#1 provided to Resident #19. An interview with the Dietary Manager on 8/26/25 at 9:15 AM indicated that not enough chicken was thawed out to serve lunch. Therefore, she had to thaw out more chicken which were 2 oz (ounce) size chicken legs and prepare the chicken legs during the lunch meal. The chicken legs were not finished cooking until halfway through the lunch meal and brought up to the dining room by the Dietary Manager. The Dietary Manager indicated that she had instructed the dietary aides to provide the residents with 2 pieces of chicken legs. Furthermore, the Dietary Manager indicated that it was her responsibility to ensure the correct portion size of protein was provided to the residents and substitutions/alternatives were provided to residents. An interview with DA #1 on 8/26/25 at 10:16 AM indicated that she was instructed by the Dietary Manager to serve 2 pieces of chicken legs. DA #1 indicated that she did not serve 2 pieces of chicken legs because she was afraid, she would run out of chicken again. DA #1 stated that she did not express this concern to the Dietary Manager and she did not offer Resident #13 an alternative because Resident #13 was a very picky eater and sometimes did not want any meat other than chicken. Furthermore, Resident #13 will say he/she was a vegetarian at times but will eat meat. b. Observations in the [NAME] Wing dining room on 8/25/25 at 12:15 PM noted that no corn bread was provided to residents per facility lunch menu on 8/25/25 and there was no alternative/substitute for the lack of corn bread provided to the residents. An interview with the Dietary Manager on 8/25/25 at 9:15 AM indicated that she was aware that corn bread was not served for lunch as per the menu. She further indicated that although the menu had corn bread listed, it was not on the individual meal tickets for the residents. The Dietary Manager could not explain why the corn bread or an alternative was not provided but stated that she had been extremely busy in the kitchen as she had been cooking due to a staffing issue in the kitchen. An interview with DA #1 on 8/25/25 at 10:16 AM indicated that she was not sure why corn bread was not served or why an alternative was not offered. DA #1 indicated that no residents received corn bread as it was not prepared and that it was busy in the kitchen the last few days and maybe it was not ordered. An interview with the Dietitian on 8/26/25 at 12:30 PM indicated that she was made aware by the Dietary Manager of the chicken portions and no corn bread being available on 8/25/25. The Dietitian indicated that 2 pieces of chicken legs should have been provided to equal the 4 oz indicated on the menu and if the chicken was not available another protein should have been offered. Furthermore, if corn bread was unavailable a substitute should have been provided such as rolls or sliced bread.A review of the Nutritional and Culinary Policy dated 7/1/2025 directed, in part, planned menus are developed and used to provide each resident with a nourishing palatable well-balanced diet that meets daily nutritional and special dietary needs of the residents.Reasonable alternative food items that (reasonably) accommodate individual resident needs, allergies, intolerances, and preferences are available and offered to residents at each meal if the primary menu or immediate selections for a particular meal are not to the residents' liking, alternative options are appealing and of similar nutritive value.

Based on observations, interviews, review of the clinical record, and facility policy for 3 of 5 residents (Resident #1, Resident #34 and Resident #54) reviewed for infection control, the facility failed to maintain proper infection control techniques regarding social distancing (Resident #1 and Resident #34) and Enhanced Barrier Precautions (EBP) when entering a room of a resident on droplet precautions (Resident #54). The findings include: 1.Resident #1 had diagnoses that included COVID-19, dementia, and diabetes. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired, used a walker, required setup or clean-up assistance with eating, was independent with bed/chair transfers, and required supervision or touching assistance with walking. The Resident Care Plan (RCP) dated 8/23/25 identified Resident #1 was confirmed to have COVID-19 virus. Interventions included to assist Resident #1 with application of face mask as needed and place Resident #1 on contact/droplet transmission based precautions. The RCP further identified Resident #1 had potential to become physically aggressive related to dementia and poor impulse control. Interventions included to provide visual and verbal cues to alleviate anxiety and give the resident as many choices as possible about care. A physician order dated 8/23/25 directed contact/droplet isolation precautions to be maintained at all times every shift for 10 days related to diagnosis of COVID-19 positive. 2. Resident #34 had diagnoses that included dementia, diabetes, and atrial fibrillation. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #34 was cognitively intact, required setup or clean-up assistance with eating, and was independent with bed/chair transfers and walking. The Resident Care Plan (RCP) dated 6/17/25 identified Resident #34 had potential COVID-19 exposure. Interventions included daily and as needed COVID-19 screening, assist Resident #34 with application of face mask as needed, and assist Resident #34 with hand hygiene as needed. Observation on 8/26/25 at 11:57 AM in the Park area (central common area near nursing station) identified Resident #34 was sitting in a chair with his/her eyes closed, not wearing a face mask while Resident #1, a COVID positive (+) resident, sat in a recliner eating lunch with his/her face mask pulled under his/her chin while he/she ate. There were 2 floor tiles of space (each tile measured 18 inches by 18 inches) noted on the floor between Resident #34's chair and Resident #1's recliner. Observation on 8/26/25 at 12:04 PM identified while waiting for Registered Nurse (RN) #1 to come to the Park area, Resident #34 opened his/her eyes, stood up, walked into his/her room, and laid down on top of his/her bed. Interview and observation with Registered Nurse (RN) #1 on 8/26/25 at 12:07 PM identified Resident #1 sitting in a recliner 2 floor tiles away from the chair that Resident #34 had just vacated. RN #1 observed the space between the chair and agreed it was approximately 3 feet. RN #1 identified it was difficult to maintain social distancing of 6 feet with dementia residents who did not realize the need for social distancing. RN #1 stated it was difficult when a resident wanted to sit down in a chair and a COVID + resident was sitting nearby eating without a mask on. RN #1 identified a staff member should have redirected Resident #34 to sit in a location further away from Resident #1. RN #1 identified social distancing should be used with COVID-19 positive residents and Resident #34 should not have been sitting in that chair while Resident #1 was not wearing his/her mask over his/her nose and mouth. Observation on 8/26/25 at 12:10 PM identified, subsequent to surveyor inquiry, nursing staff approached Resident #1 and asked if he/she wanted to go back to his/her room to finish eating. Resident #1 declined and the nursing staff let him/her stay in the recliner eating. Observation on 8/26/25 at 12:47 PM identified, subsequent to surveyor inquiry, Resident #34 was observed sitting in the Park area, not wearing a mask, in the same chair as he/she previously sat in, the chair was noted to have been moved to a different location away from the recliner that Resident #1 sat in. There was greater than 6 feet of distance between Resident #34 and Resident #1 as they both sat in their chair/recliners. Review of Inservice Education titled: COVID-19 positive wanderers dated 8/27/25-8/29/25 identified subsequent to surveyor inquiry education was initiated for nursing staff that directed to ensure if a COVID-19 positive resident is a wanderer who does not adhere to the droplet/contact precautions, to redirect the resident to stay in their room as much as possible. The inservice directed if the resident will not stay in their room to encourage them to wear a mask. The inservice further directed to ensure residents are all socially distanced from other residents and to remove residents out of the area as able and encourage residents to wear a mask. 58 staff signatures (from all departments) were identified on the inservice sheet. Review of the Clinical Guide for Operations During COVID-19 Health Emergency policy directed, in part, face covering or mask (covering mouth and nose) should be worn in accordance with CDC guidance. The policy directed source control ( use of mask to cover mouth and nose) was recommended for individuals with suspected or confirmed COVID-19 infection. The policy directed communal activities and dining may occur while adhering to the core principles (wearing a mask to cover mouth and nose when confirmed with COVID-19 infection). The policy directed staff members should be designated on all shifts to audit staff compliance with appropriate donning and doffing of personal protective equipment and social distancing during breaks and mealtimes. The policy further identified to take measures to limit crowding in communal spaces. Review of the Quick Reference Guide policy (used by facility staff to guide on key points of main policy) directed, in part, for dining follow outbreak measures, continue to allow those residents on unaffected units that are not symptomatic to attend, physically distance, and wear a face mask. 3.Resident #54's diagnoses included positive for covid-19, extended spectrum beta lactamase (ESBL) resistance, and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #54 was cognitively intact and was dependent for bed mobility, transfers, bathing, personal hygiene and toilet use. Also, identifying Resident #54 was a set up assistant for eating. A nursing note dated 8/25/25 at 4:54 AM identified Resident #54 was placed on Covid isolation precautions. A physician's order dated 8/25/25 directed to maintain droplet/contact precautions for Covid-19 positive every shift for 10 days. The Resident Care Plan (RCP) dated 8/25/25 identified that Resident #54 was confirmed Covid-19 positive with interventions that included to assist Resident #54 with the application of applying a face mask as indicated or needed, to maintain contact/droplet precautions, and perform vital signs as needed. On 8/25/25 at 9:30 AM, observation made outside of Resident #54's room identified that Nurse Aid (NA) #2 was in Resident #54's room, wearing only a blue surgical mask, and was observed emptying the garbage. Registered Nurse (RN) #1 was also in Resident #54's room, wearing only a blue surgical mask, and was assisting Resident #54's roomate with respiratory equipment. Transmission based precaution signage was posted outside the door of Resident #54's room which directed that isolation droplet/contact precautions were in place and that staff must wear gloves, a gown, N-95 mask (not a blue surgical mask), and eye protection upon entering the room. A cart containing isolation gowns and other personal protective equipment (PPE) was observed already in place outside of Resident's 54's room. An interview on 8/25/25 at 9:35 AM with RN #1 identified she was performing morning rounds and stated she was assisting the resident by the window and not Resident #54 by the door. Also, identifying Resident #54 was on Contact/Droplet Barrier Precautions and she should be wearing full PPE which includes a N-95 mask, gown, gloves, and googles. An interview with NA #2 identified she went into Resident #54's room without full PPE, googles, gown, gloves, and N-95 should have been worn. Also, identifying she knows the policy to gown up before going in and she just followed RN #1 into the room. Review of the Viral Respiratory Pathogen Guidance Policy dated January 2025 identified the policy provides guidance on preventing, detecting, and managing the spread of respiratory viruses such as Covid. The goal was to protect both residents and healthcare providers by implementing a comprehensive approach involving vaccination, testing, treatment, and effective infection prevention and control measures. Also, identified enforce standard precautions, including appropriate use of PPE, hand hygiene, respiratory hygiene/cough etiquette principles and environmental cleaning protocols. Review of the signage provided by the facility directs staff to wear a gown, N-95, gloves, and googles. 4. Interview with the Infection Preventionist (RN #1) on 8/25/25 at 9:50 AM identified the facility's current COVID-19 outbreak began with a Nurse Aide (NA) that worked on 8/15/25 who developed COVID-19 signs and symptoms that same day and then tested for COVID-19 positive on 8/16/25. RN #1 stated the NA did not notify the facility of his positive COVID-19 test until 8/19/25, but had not worked since 8/16/25. RN #1 identified once she was aware of the NA COVID-19 positive test they began outbreak testing. RN #1 identified there were currently 4 COVID-19 positive residents on the lower level units. Interview with RN #1 on 8/29/25 at 11:10 AM identified she did not have a mechanism for tracking COVID-19 testing of residents. RN #1 identified per policy, testing for residents was completed on days 1, 3, and 5 following identification of a COVID-19 positive staff member or resident and declaration of an outbreak. RN #1 identified she did not have a spreadsheet or written documentation which tracked testing of residents and included at minimum, the name of the resident, location of resident, date of test, and results of test. RN #1 stated that the orders for COVID-19 testing were in the computer and we know who's getting tested. RN #1 identified after the initial testing of residents on days 1, 3, and 5, the facility does testing of the residents on the affected unit every 3-5 days until there are 14 days with no new positive COVID-19 results. RN #1 stated there was not a physician order for as needed (PRN) testing for those tests done every 3-5 days, because the policy only directed for testing on days 1, 3, and 5, and so she was unable to put in orders to test beyond those 3 days. RN #1 identified that the tests were completed by the charge nurses on the units and wrote the test results next to the resident name on a census report sheet. RN #1 identified this information was only located on those sheets and was not placed into a formal spreadsheet or document for use in tracking of the tested residents. RN #1 identified once the initial testing on days 1, 3, and 5 was completed, the facility did not go back to days 1, 3, and 5 testing for subsequent positive COVID-19 test results, she stated that they would just continue to test every 3-5 days until 14 days of no new positives. RN #1 identified there were currently 4 positive residents and there were a total of 9 positive staff members with one recovered and back to work. RN #1 identified 5 out of the 9 positive staff members had worked on both floors but the facility did not continue to test residents on the upper floor after the initial days 1, 3, and 5 testing because that floor had not had residents that tested positive on days 1, 3, and 5 so they were not going to be tested again unless there was a cluster of residents with signs and symptoms of COVID-19. Review of a Detailed Census Report dated 8/28/29 identified 80 resident names listed. There were 48 resident names crossed off including 1 name that was out on a medical leave of absence (MLOA). There were 33 residents with documentation next to their name that indicated neg for the result of their COVID-19 test. There was 1 resident who's name was crossed off but there was documentation saying neg next to his/her name. There were 40 residents listed from the lower level but only 32 were tested, 4 were COVID-19 positive, and 1 was on a MLOA. This leaves 3 residents on the lower level that did not receive a COVID-19 test. Review of the Clinical Guide for Operations During COVID-19 Health Emergency policy directed, in part, facilities are required to test residents and staff based on nationally accepted standards, such as CDC recommendations. The policy directed testing of staff and residents during an outbreak investigation was initiated upon identification of a single new case of COVID-19 infection in any staff or residents. The policy directed upon identification of a new COVID-19 case in the facility, document the date the case was identified, the date that other residents and staff are tested, the dates that staff and residents who tested negative are retested, and the results of all tests. The policy directed facilities may document the conducting of tests in a variety of ways, such as a log of community risk factors, schedules of completed testing, and/or staff and resident records. The policy further directed for residents the facility must documents testing results in the medical record.

Based on observations, interviews and facility policy for 1 of 2 sampled residents observed with medication at the bedside (Resident #50), the facility failed to ensure Resident #50 was assessed and had a physician order to self-administer medication. The findings include: Resident #50's diagnoses included chronic obstructive pulmonary disease (COPD).A physician's order dated 3/25/24 and currently in effect directed ProAir HFA (a bronchodilator used to treat asthma) aerosol solution 108 micrograms (mcg)/act 2 puffs inhaled orally every 6 hours for shortness of breath.The Resident Care Plan (RCP) dated 1/9/25 identified that Resident #50 had an altered respiratory status/difficulty breathing related to COPD. Interventions included administering medications per the physician's order and monitoring for effectiveness/side effects.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #50 was cognitively intact and independent with bed mobility, transfers, and toileting.On 8/26/25 at 8:50 AM, observation of Resident #50's room, identified a ProAir inhaler was located on top Resident #50's nightstand, and not secured. Resident #50 was in the room and also had an ambulatory roommate. Resident #50 noted he/she kept the inhaler on the nightstand for his/her self-administration.An interview and record review (both electronic and paper versions) with Licensed Practical Nurse (LPN) #2 on 8/26/25 at 10:26 AM indicated that he/she was aware that Resident #50 kept his/her inhaler at the bedside. LPN #2 indicated that Resident #50's physician's order for his/her inhaler did not indicate self-administration or directions to keep the inhaler at his/her bedside. Further review failed to identify that Resident #50 was assessed to self-administer the inhaler. On 8/26/25 at 10:34 AM, subsequent to the surveyor's inquiry, Resident #50 was assessed for medication self-administration safely to keep his/her inhaler at the bedside. An interview with the Director of Nursing Services (DNS) on 8/26/25 at 10:40 AM indicated that she was made aware of Resident #50 having his/her inhaler at the bedside without the presence of a self-administration assessment or a physician order. The DNS indicated that the process for a resident to self-administer medications included a resident evaluation, a physician's order, the addition of self-administration to the resident's care plan, and the provision of a lockbox for the resident to store the medication at the bedside safely. The DNS indicated that for Resident #50, the process would be completed that day.Subsequent to the surveyor's inquiry on 8/26/25, a physician's order was obtained, which directed ProAir HFA Inhalation Aerosol Solution 108 mcg/act, 2 puffs inhaled orally every 6 hours for shortness of breath related to emphysema, and that Resident # 50 may keep at the bedside and self-administer.A physician order, dated 08/26/2025 at 4:00 PM, directed that for Resident #50, his/her ProAir HFA Inhalation Aerosol Solution 108 mcg/act, 2 puffs inhaled orally every 6 hours for shortness of breath related to emphysema, and that the Resident may keep at the bedside and self-administer. Review of the National Healthcare Associates, Clinical Services Self-Administration Policy, last revised October 2024, directed that to maintain the residents' right to maintain a high level of independence, residents who request to self-administer medications are permitted to do so if the center's self-evaluation had determined that the practice would be safe for the Resident and that there was a health care provider's order to self-administer medication(s)/treatments. The procedure listed, within this policy, included the need for a Self-Administration Evaluation completed by a licensed nurse to evaluate the Resident's safety and understanding of their medications, obtainment of an order from the Healthcare Provider for self-administration for the specific medication, instruction to the Resident in the process of storing medications safely including a locked box, and periodic review of the residents' ability to continue to self-administer over time.

Based on observations, review of clinical records, facility policy and interviews for 1 of 3 sampled residents reviewed for wounds, the facility failed to ensure Resident #46 was placed on the correct precautions to prevent Resident #46 from being confined to his/her room. The findings include: Resident #46's diagnoses included non-pressure chronic ulcer of right foot with unspecified severity and Type 2 diabetes. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #46 was cognitively intact and required moderate assistance of 1 staff member with activities of daily living.The Resident Care Plan (RCP) dated 7/22/25 identified Resident #46 was on Enhanced Barrier Precautions (EBP) for wounds and indwelling medical devices (intravenous catheter). Interventions included applying personal protective equipment (PPE) when providing high contact care activities.A physician's order dated 8/12/25 directed to apply Mupriocin external ointment (a topical antibiotic used to treat bacterial infections of the skin) to the right foot every shift and as needed to diabetic ulcers followed by collagen then border foam topical dressing, maintain EBP, non-weight bearing to lower extremities and light physical therapy (PT) on recumbent bike with limited pressure to forefoot or heel region. May transfer once a day with an ortho wedge shoe. A nursing note dated 8/13/25 written by the Infection Control Nurse (ICN) at 11:35 AM identified Resident #46 had a right foot wound culture report from 8/9/25 ruling out Carbapenem-resistant Enterobacterales (CRE) (an infection difficult to treat with antibiotics). Resident #46 was placed on isolation precautions pending findings by the ICN. Resident #46's RCP was updated on 8/15/25 regarding resistant bacterium but failed to reflect any updates regarding isolation precautions.In an interview with Resident #46 on 8/27/25 at 10:00 AM in his/her bedroom, Resident #46 stated he/she had just recently been removed from precautions that confined him/her to his/her bedroom. Resident #46 stated that he/she was informed that the culture to the foot did not show the infection and stated that he/she was made aware by nursing staff that the confinement to his/her room was not necessary anymore. Resident #46 also stated that he/she probably would have come out of the room during the time he/she was on isolation if he/she had been permitted to do so, and that he/she had not been able to go to the rehab gym for therapy. An interview with the ICN on 8/27/25 at 11:45 AM indicated that she placed Resident #46 on transmission based/isolation precautions for suspected CRE on 8/13/25. She indicated that the regional corporate nurse was on vacation and when she returned, she instructed her to change Resident #46 to EBP. The ICN indicated that Resident #46's drainage to the foot had always been contained with a dressing and stated that she had placed Resident #46 on isolation precautions, confinement to his/her room in error and removed the isolation precautions on 8/25/25 to EBP (12 days after initiating the isolation precautions).A review of an ICN note on 8/27/25 at 2:14 PM indicated that the right foot drainage specimen obtained from Resident #46's right foot on 8/6/25 was negative for CRE and the APRN, resident, and responsible party had been updated. An interview Physical Therapist (PT) #1 on 8/28/25 at 9:35 AM noted that Resident #46 was not permitted to have therapy in the gym from 8/13/25 through 8/25/25 and stated that Resident #46 had received therapy in his/her room. PT #1 indicated that Resident #46 was limited to his/her physical therapy due to non-weight bearing status to his/her feet and that most of his/her therapy was able to be performed in the bedroom even though Resident #46 had a physician's order for the use of the recumbent bike in the rehab gym with some limitations. An interview with the Medical Director on 8/28/25 at 10:00 AM revealed that Resident #46 was previously on isolation precautions and they were recently discontinued. He indicated that the facility follows their policy for infection precautions, and he was unsure why they had placed Resident #46 on isolation precautions for the suspected CRE if it did not follow the facility policy. An interview with the Regional Corporate Nurse and the DNS on 8/28/25 at 12:30 PM identified that it was not necessary for Resident #46 to be on isolation precautions. The Regional Corporate Nurse stated that the wound was contained so contact precautions would have been sufficient. The DNS indicated it was the responsibility of the ICN to ensure the correct precautions are put in place for residents and was unsure why she had put Resident #46 on isolation.A review of the Precautions to Prevent Infections policy dated June 2024 directed, in part, EBP which falls between Standard and Contact Precautions, and require the use of gown and gloves for certain residents during specific high contact resident care. Gown and gloves would be required for resident care activities for pan-resistant organisms and Carbapenemasse-producing Enterobacteriaceae. Residents are not restricted to their rooms or limited from participation in group activities. In general, isolated activities that are not otherwise bundled with other high contact care activities would not necessitate use of gown and gloves.

Based on observation, interviews and facility policy for 1 of 2 sampled residents (Resident #48) observed with medication at the bedside, the facility failed to ensure licensed staff followed standards of practice for medication administration and remained with the resident until medication was consumed. The findings include: Resident #48 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, hypertension, and atrial fibrillation. A physician's order date 8/14/25 directed to administer Metoprolol Tartrate 12.5 mg (milligrams) two times a day for blood pressure, Spironolactone 25 mg once a day for heart failure, Isosorbide Mononitrate ER (extended release) 30 mg one a day for blood pressure, Lorestan Potassium 25 mg two times a day for blood pressure and Aspirin 81 mg in the morning for surgical aftercare.A Resident Care Plan dated 8/17/25 did not reflect that Resident #48 may self-administer medication and/or had been assessed for self-administration of medications.The 5-day admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #48 was cognitively intact, required set-up/supervision for activities of daily living and was able to eat independently. Observation on 8/26/25 at 8:30 AM identified Resident #48 had pills in a medication cup located on his/her beside table without the presence of the nurse. Resident #48 stated he/she took the medications without the nurse present all the time and indicated that he/she was able to do so independently. An interview with Licensed Practical Nurse (LPN) #1 on 8/26/25 at 8:50 AM indicated that she had left the medications with Resident #48 and was aware that she should not have left the medications with the resident. LPN #1 stated that she had worked on the unit before and was aware that Resident #48 liked to take his/her medications independently. An interview with the DNS on 8/26/25 at 9:15 AM indicated that LPN #1 had spoken to her after the incident and was aware that medications were left with Resident #48. In addition, the DNS stated that the medications should not been left at the bedside, and it was the charge nurse's responsibility not to leave the medications with the resident. According to the 2025 Joint Commission, medication management, when giving medication to patients, it is crucial to stay with the patient to ensure safe administration. Leaving pills at the bedside or not being present during medication administration can lead to potential hazards such as choking, hoarding or other adverse outcomes.

Based on review of the clinical record, facility policy and interviews for 1 of 3 residents (Resident #10) reviewed for pressure ulcer/injury, the facility failed to obtain a timely nutritional evaluation for a resident with a new and worsening wound. The findings include: Resident #10 had diagnoses that included epilepsy (seizure disorder), dementia, and leukoencephalopathy (brain disease that damages the white matter which is responsible for communication between different brain regions).The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #10 was moderately cognitively impaired, at risk for developing pressure ulcer/injury, and was dependent for eating, bed mobility, and transfers.A physician order dated 4/1/25 directed to provide Thrive ice cream (protein rich ice cream) 2 times a day with lunch and dinner for weight loss related to variable oral intake.A Nutritional Evaluation written by Dietician #1 on 4/1/25 at 1:40 PM identified Resident #10 met 51 percent (%) to75% of his/her estimated dietary intake needs with his/her average amount of oral intake between 25-100%. The evaluation identified Resident #10 had a 7%/12 pounds (lbs.) significant weight loss in 30 days (weight 228.4 pounds (lbs.) on 3/1/25 and weight 216.4 lbs. on 4/1/25). The evaluation identified Resident #10 was at risk for malnutrition related to a non-pressure wound, mechanically altered diet, dementia, and cholecystectomy. The evaluation further identified Resident #10 was started on the Thrive ice cream at lunch and dinner related to his/her significant weight loss and oral intake.The Resident Care Plan (RCP) dated 4/8/25 identified Resident #10 was at risk for impaired nutrition. Interventions included to provide diet per physician orders with Thrive ice cream with lunch and dinner and provide feeding/dining assistance as needed. The RCP identified Resident #10 had potential for skin breakdown due to decreased mobility and history of adult failure to thrive. Interventions included to obtain a dietician evaluation and interventions as needed and provide supplements and/or vitamins as ordered. The RCP further identified Resident #10 had an actual alteration in skin integrity related to surgical incisions from a cholecystectomy. Interventions included to updated the physician with changes as needed and obtain weekly wound evaluations until healed.A Skin & Wound Evaluation by Licensed Practical Nurse (LPN) #3 on 4/19/25 at 7:41 PM identified Resident #10 had a facility acquired wound to the medial, middle, inferior, sacrum that measured 2.8 centimeters (cm) length by 1.1 cm width by not applicable (NA) depth. The evaluation failed to identify the practitioner, responsible party, or dietician had been notified.A Skin & Wound Evaluation by Registered Nurse (RN) #1 on 4/25/25 at 8:31 AM identified Resident #10 had a facility acquired Stage 2 pressure ulcer to the medial, middle, inferior, sacrum first observed on 4/19/25 that measured 2.8 cm X 1.3 cm X 0.1 cm). The evaluation identified the practitioner was notified and indicated the Medical Doctor (MD) #1 and Resident #10's representative was notified. The evaluation identified the dietician was notified.A wound progress note written by Advanced Practice Registered Nurse (APRN) #1 on 4/25/25 (6 days after the pressure ulcer was identified) at 8:52 AM identified she had seen Resident #10 for consultation for management of a new Stage 2 pressure injury to the sacrum. The note identified the wound measured 2.8 centimeters (cm) long by 1.3 cm wide by 0.1 cm deep and had 100% epithelial tissue to the wound base. The note identified the treatment for the pressure injury was to cleanse the wound followed by apply calcium alginate (highly absorbent topical wound dressing) to the base of the wound followed by cover with a dry clean dressing and change daily and/or as needed. The note further identified wound recommendations to optimize nutrition with a registered dietician consultation.A wound progress note written by APRN #1 on 5/2/25 at 8:02 AM identified she had seen Resident #10 for consultation for management of Resident #10's pressure injury to the sacrum. The note identified the pressure injury had worsened and was a Stage 3 pressure injury that measured 4.1 cm X 1.6 cm X 0.3 cm and the wound base was 75% granulated tissue and 25 % slough (dead tissue). The note further identified wound recommendations to optimize nutrition with a registered dietician consultation.Review of nursing notes and nutritional/dietary evaluations from 4/25/25 through 5/22/25 failed to identify Resident #10 was evaluated by a Dietician per APRN's recommendation on 4/25/25.A Nutritional Evaluation by Dietician #1 on 5/23/25 (30 days after the APRN's recommendation) at 2:01 PM identified Resident #10 had a significant change. The evaluation identified Resident #10 had a food intervention of Thrive ice cream 2 times a day with lunch and dinner. The evaluation identified Resident #10 met 51-75% of his/her estimated dietary intake needs with his/her average amount of oral intake at 74% of meals in the past 2 weeks. The evaluation identified Resident #10 was at risk for malnutrition related to a pressure injury, mechanically altered diet, dementia, and a cholecystectomy. The evaluation identified Resident #10 had a new pressure injury, significant weight loss and tolerated the Thrive ice cream 2 times a day with lunch and dinner with mostly 100% intake of the ice cream. The evaluation further identified Dietician #1 added to provide Ensure Plus inside Resident #10's honey thick liquids daily at breakfast, and to administer liquid protein supplement once daily.A physician order dated 5/23/25 directed to administer Ensure Plus once daily with breakfast and liquid protein supplement once daily inside honey thick liquids.A wound progress note written by APRN #1 on 5/25/25 at 9:45 PM identified she had seen Resident #10 for consultation for management of Resident #10's pressure injury to the sacrum. The note identified the pressure injury had worsened and was unstageable and measured 3.9 cm X 3.0 cm X 0.1 cm and the wound base was 100% slough.An interview with Dietician #1 on 8/28/25 at 1:54 PM identified she followed up weekly for residents with weight loss and attended the weekly risk meetings which reviewed residents with weight loss and pressure injuries. Dietician #1 identified RN #1 sent her a wound report every week via email, would review the report and adjust residents supplements as needed. Dietician #1 identified when she worked she put in wound notes weekly for new or worsening wounds, but she did not put weekly notes in for stable wounds. Dietician #1 identified she had been on vacation and also was ill from the beginning of April 2025 through the end of May 2025 and she had not been working at the time Resident #10's pressure injury was first identified. Dietician #1 identified she did not know who covered for her while she was away but identified upon her return to work at the end of May 2025 had evaluated Resident #10 on 5/23/25 and had added the Ensure and liquid protein supplements for added nutritional supplements due to Resident #10's pressure injury. Dietician #1 further identified the nursing staff could have initiated supplements for Resident #10 to address his/her new pressure injury and the nursing staff did not have to wait for her to put in dietary/supplement orders.An interview with APRN #1 on 8/29/25 at 10:51 AM identified she had seen Resident #10 on 4/25/25 for a new stage 2 pressure injury to the sacrum. APRN #1 identified she had seen Resident #10 on 5/2/25 and the pressure injury to the sacrum had worsened to a Stage 3 pressure injury. APRN #1 identified she had seen Resident #10 again on 5/23/25 and the sacral wound was unstageable and had worsened. APRN #1 identified immobility, nutrition, and resident refusals of care contributed to worsening of a wound. APRN #1 identified she recommended to optimize nutrition in her wound notes. APRN #1 further identified protein was good for wound healing and if a resident was not eating well and was nutritionally challenged he/she should be referred by the nursing staff to the dietician for a nutritional evaluation.An interview with Director of Nursing Services (DNS) on 8/29/25 at 12:10 PM identified per policy the dietician was notified of pressure ulcers which typically occurred at the weekly risk meetings. The DNS identified when Dietician #1 was on vacation or ill for an extended period she would have someone cover for her remotely. The DNS identified the covering dietician should be notified of new or worsening pressure ulcers. The DNS identified Resident #10 should have had a nutritional evaluation after identification of his/her pressure injury on 4/19/25 and before Dietician #1's evaluation on 5/23/25. The DNS was unaware who covered for Dietician #1 while she away the beginning April 2025 through the end of May 2025.Although requested the name of the covering dietician for April 2025 through May 2025 during the time of absence of Dietician #1 was not provided.Review of the Pressure Injury Nutritional Protocols policy directed, in part, a nutritional assessment was required for residents with pressure injuries. The policy directed if the resident was unable to consume adequate calorie and/or protein needs via meals/snacks, consider the addition of high-calorie, high-protein fortified foods and/or nutritional supplements. The policy further directed for stage 2 or greater pressure injuries to provide high-calorie, high-protein, arginine, zinc, and antioxidant oral nutritional supplements.

Top of FormBased on observations, clinical record review, review of facility documentation, review of facility policy and interviews for the only sampled resident reviewed for respiratory care (Resident #85), the facility failed to follow a physician's order for oxygen administration and failed to ensure oxygen was administered to a resident on continuous oxygen with a diagnoses of chronic obstructive pulmonary disease (COPD). The findings include: Top of FormResident #85's diagnoses included COPD, dependence on supplemental oxygen (O2), and shortness of breath (SOB). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #85 was cognitively intact and required substantial/maximal assistance with bed mobility and full assistance with toileting and transfers. The MDS also indicated Resident #85 had a diagnosis of COPD and was dependent on supplemental O2. A Resident Care Plan (RCP) dated 6/27/25 identified Resident #85 had the potential for alteration in respiratory status related to shortness of breath and COPD. Interventions included to provide O2 via nasal cannula at 1 liter and to monitor the resident for increased coughing, wheezing and SOB. Physician's orders dated 7/17/25 directed O2 at 1 liter (L) per minute every shift for SOB related to COPD and to call the physician (MD) if oxygen saturation (O2 sat) was below 90%. A physician's progress note dated 7/31/25 at 2:57 PM identified Resident #85 had an episode of hypoxia with an O2 saturation (sat) of 88 percent (%), the resident's condition was guarded. Nursing progress notes dated 8/2/25 at 3:55 PM and 8/7/25 at 2:02 PM noted Resident #65 had a suspected respiratory infection and was being administered O2 at 2 L (despite physician orders dated 7/17/25 directing O2 at 1 L per minute). An observation on 8/25/25 at 11:57 AM noted Resident #85 in bed with an oxygen concentrator at the bedside set at 2 L (despite physician orders dated 7/17/25 directing O2 at 1 L per minute). The oxygen nasal cannula was sitting to the side of the resident's nares (nasal openings) and he/she was able to put the nasal cannula back in place when asked to. Review of the Nurse Aid care card in Resident #85's room on 8/27/25 directed Oxygen Settings: O2 via nasal cannula at 1 L. Review of Resident #85's Treatment Administration Record for August 2025 on 8/27/25 directed O2 at 1 L every shift and to contact the MD if the O2 sat was below 90 %. Observation on 8/27/25 at 12:55 PM noted Resident #85 in bed without the benefit of O2 via nasal cannula in place. The O2 tubing was found disconnected from the oxygen concentrator and coiled up and sitting on top of the O2 concentrator, which was out of reach of the resident. The oxygen concentrator was operating, was set at 2 L (despite physician orders dated 7/17/25 directing O2 at 1 L per minute), was to the far right of the resident and placed against the wall behind the resident. Resident #85 was unable to indicate how oxygen ended up off of him/her and out of reach or for how long it had been that way. Observation and interview with Registered Nurse (RN) #3 on 8/27/25 at 12:57 PM identified she was not aware Resident #85 did not have O2 on/in place or that it was out of reach of the resident. RN #3 indicated she was last in the resident's room around 10:00 AM during medication pass. RN #3 proceeded to reconnect the O2 tubing to the oxygen concentrator and placed the O2 on the resident via nasal cannula at 2 L. An O2 saturation reading taken on room air was 82% and it increased to 94% after the O2 was placed back on the resident. RN #3 identified she was unsure how the oxygen tubing had ended up behind and out of reach of the resident and indicated the resident required continuous oxygen. RN #3 further identified although Resident #85 sometimes removed the nasal cannula from his/her nares, the resident would not have been able to physically place the O2 tubing how it was found (disconnected, out of reach, and behind the resident) because he/she was unable to move around a lot. Interview and observation with Nurse Aide (NA) #3 on 8/27/25 at 12:57 PM identified she was assigned to Resident #85 and was last in the resident's room around 11:15 AM when she provided incontinent care to the resident. NA #3 was unsure how the oxygen tubing ended up behind and out of reach of the resident but indicated the resident required continuous oxygen. NA #3 further identified that although Resident #85 sometimes removed the nasal cannula from his/her nares, the resident would not have been able to physically place the O2 tubing how it was found (disconnected, out of reach, and behind the resident) because he/she was unable to move around a lot. An additional interview and review of the clinical record with RN #3 on 8/27/25 at 1:38 PM identified she had reviewed Resident #85's oxygen orders and noted the resident was supposed to be placed on O2 at 1 L (not 2 L) and she had made a mistake. RN #3 indicated Resident #85's medical doctor (MD) was very particular and did not want the resident's O2 to go above 1 L. She was unsure why the O2 concentrator had been set at 2 L or for how long it was like that. RN #3 identified Resident #85's MD was called to notify him of the resident's hypoxia (low O2 sat) due to a lack of oxygen administration and the incorrect setting of the oxygen concentrator and she was awaiting a call back. RN #3 further indicated although Resident #85 was often cyanotic (lacking oxygen) with his/her lips appearing bluish at times, he/she was receiving O2 at 1 L with an oxygen saturation of 91% at this time. A nursing progress note dated 8/27/25 at 2:03 PM identified Resident #85 was observed without O2 in place via NC and the oxygen tubing was found on top of the oxygen concentrator machine. The progress note indicated Resident #85's O2 sat was 82% on room air and O2 at 2 L was administered via NC with an increase in the O2 sat to 91-93% noted. The progress note further identified the residents O2 was lowered to 1 L with an O2 sat of 92% and a call was placed to the MD. A nursing progress note dated 8/27/25 at 2:31 PM identified RN # 3 had received a call back from the physician and he was notified of the resident's hypoxia due to a lack of oxygen administration and the incorrect setting of the resident's oxygen concentrator. Subsequent to surveyor inquiry, a physician's order was obtained on 8/27/25 which directed DO NOT increase O2 via NC (nasal cannula) past 1L (liter) under any circumstance. Interview with the DNS on 8/28/25 at 12:45 PM identified Resident #85 should have had his oxygen in place and the nursing staff should have been checking the resident regularly and on rounds. The DNS indicated Resident #85's oxygen tubing should not have been disconnected from the concentrator and out of reach of the resident because the resident would become hypoxic if he/she did not have continuous oxygen on. The DNS identified that although Resident #85 would sometimes remove the oxygen tubing from his/her nares, the resident would not have been able to place it out of reach or disconnect it from the concentrator and it was up to the nursing staff to monitor and check on the resident more frequently. The DNS further indicated Resident #85 should have been on the correct O2 setting of 1L and not 2L before and after oxygen need to be put back on the resident and RN #3 should have reviewed the oxygen order first. Review of the facility policy, Oxygen Therapy, undated, directed to verify the physicians order to determine liter flow and type of O2 delivery device, adjust the O2 flow meter to the prescribed flow and to [NAME] the flow of O2 at the patient end of the delivery device. The policy further directed for COPD patients, that every patient needed to be assessed individually to determine their own oxygen requirement.

Based on review of personnel files and staff interviews for 3 of 3 employee files reviewed (Nurse Aide (NA) #4, NA #5, and NA #6), the facility failed to ensure the required annual performance evaluations were completed. The findings include:: 1. NA #4's date of hire was 8/27/13. The last performance evaluation identified in the employee's personnel file was dated 10/20/20. Although requested, the facility could not provide an updated annual evaluation for NA #4 for 2021 and 2022. Additional review with human resources identified that no additional evaluations were available. Upon review of NA #4's record with the DNS, she identified that this NA was now a Licensed Practical Nurse (LPN) as of 2022. Additionally, there were no employee yearly evaluations for 2023, 2024, and 2025. Review of the facility time clock documentation for August 2025 for NA #4/LPN identified she currently works in the facility (on 8/6/25, 8/7/25, 8/9/25, 8/10/25, 8/13/25, 8/14/25, 8/15/25, 8/20/25, 8/21/25, 8/23/25, 8/24/25, 8/27/25, and 8/28/25). 2. NA #5's date of hire was 11/30/09. The last yearly performance evaluation in the employee's personnel file was dated 5/5/23. Although requested, the facility could not provide any additional annual evaluations for NA #5 for 2024 or 2025. Review of the facility time punch documentation for August 2025 for NA #5 identified that she currently works in the facility (on 8/3/25, 8/4/25, 8/5/25, 8/11/25, 8/18/25, 8/19/25, 8/25/25, 8/26/25, and was scheduled for 8/30/25). 3. NA #6's date of hire was 6/22/23. There were no yearly performance evaluations available in the personnel file for NA #6. Although requested, the facility could not provide any annual evaluations for NA #6. Review of the facility time punch documentation for August 2025 for NA #5 identified she currently works in the facility (on 8/6/25, 8/7/25, 8/8/25, 8/6/25, 8/11/25, 8/12/25, 8/14/25, 8/15/25, 8/16/25, 8/17/25, 8/19/25, 8/20/25, 8/21/25, 8/22/25, 8/23/25, 8/24/25, 8/25/25, 8/26/25, 8/28/25, and 8/29/25). An interview and review of facility documentation with the Director of Human Resources on 8/29/25 at 12:27 PM identified that performance evaluations should be in the employee's personnel file, and that she was aware that evaluations had fallen behind under the prior facility owner, that a new form was implemented for evaluations under the new facility owner, and that evaluations were being caught up currently, but were still not up to date for all employees. Additional interviews with the Facility Administrator on 8/29/25 at 12:58 PM identified that performance evaluations would be in the employee's personnel file and that he was aware that the evaluations had not been completed for all employees since the change in ownership. The Administrator further identified that evaluations were triggered for department head completion by HR, that he would expect completion annually, and that these were potentially missed during the transition of ownership. An interview with the DNS on 8/29/25 at 13:00 PM indicated that human resources (HR) would have tracked and informed her when the performance evaluations were due, and it would have been her responsibility to get them completed, either by herself or a designee, for NA#4, NA #5, and NA #6. She further identified that she would expect that evaluations were completed annually for all staff. Although requested, a facility policy on performance evaluations was not available.

Based on observations, interviews, review of controlled substance (narcotic) records, and facility policy, the facility failed to ensure the completion of the controlled medication count by licensed staff. The findings include: An interview and review of the 1st floor narcotic logbook located on the medication cart with the Nursing Supervisor/Registered Nurse (RN) #2 on 8/27/25 at 9:30 AM, noted 8 out of 78 missing signatures on the Narcotic Change of Shift Audit for August 2025. RN #2 identified signatures should have been completed by two nurses at each shift change for confirmation and reconciliation of the count of narcotics available in the medication cart.An interview and review of the 2nd floor narcotic logbook, located on the medication cart, with the Director of Nursing Services (DNS) on 8/28/25 at 12:20 PM, identified that the narcotic logbook was missing 7 out of 82 expected signatures on the Narcotic Change of Shift Audit for August 2025. The DNS indicated these signatures should be completed by two nurses at each shift change for confirmation and reconciliation of the count of narcotics available.An 8/28/25 review of the Clinical Services: Bi-Monthly Narcotic Drug Audit Forms with the DNS at 12:30 PM indicated that numerous audits identified under the item reviewed 'All change of shift narcotic count sheets are signed (no empty spaces)' that this item was not met month-over-month and documented as not met as far back as January 2025.An 8/28/25 review of the Clinical Services: Bi-Monthly Narcotic Drug Audit Forms for the prior six months, identified that in 2025: 9 of 9 audits conducted in March 2025, 2 of 11 audits conducted in April 2025, 8 of 10 audits conducted in May 2025, and 4 of 4 conducted in August 2025 indicated that there were empty spaces on the Narcotic Change of Shift Audit sheets, where a nursing signature should have been.On 8/29/25 at 11:32 AM, a review and interview with the DNS of the Narcotic Change of Shift Audit logs from March 2025 through August 2025 identified that: in March 2025, the upper level South Narcotic Change of Shift Audit log was missing no signatures, the upper level [NAME] Narcotic Change of Shift Audit log was missing 5 of 93 signatures, the lower level South Narcotic Change of Shift Audit log was missing 7 of 93 signatures, and the lower level [NAME] Narcotic Change of Shift Audit log was missing 8 of 93 signatures; in April 2025, the upper level South Narcotic Change of Shift Audit log was missing 1 of 90 signatures, the upper level [NAME] Narcotic Change of Shift Audit log was missing 4 of 90 signatures, lower level [NAME] Narcotic Change of Shift Audit log was missing 3 of 90 signatures, and the lower level South Narcotic Change of Shift Audit log was missing 13 of 90 signatures; in May 2025, the upper level South Narcotic Change of Shift Audit log was missing 3 of 93 signatures, the upper level [NAME] Narcotic Change of Shift Audit log was missing 6 of 93 signatures, lower level [NAME] Narcotic Change of Shift Audit log was missing 14 of 93 signatures, and the lower level South Narcotic Change of Shift Audit log was missing 13 of 93 signatures; in June 2025, lower level [NAME] Narcotic Change of Shift Audit log was missing 11 of 93 signatures and the lower level South Narcotic Change of Shift Audit log was missing 12 of 93 signatures; in July 2025, the upper level South Narcotic Change of Shift Audit log was missing 8 of 93 signatures, the upper level [NAME] Narcotic Change of Shift Audit log was missing 15 of 93 signatures, lower level [NAME] Narcotic Change of Shift Audit log was missing 6 of 93 signatures, and the lower level South Narcotic Change of Shift Audit log was missing 15 of 93 signatures; in August 2025, the upper level South Narcotic Change of Shift Audit log was missing 8 of 83 signatures and the lower level South Narcotic Change of Shift Audit log was missing 8 of 83 signatures.An interview on 8/29/25 at 11:32 AM with the DNS and the Regional Director of Clinical Operations (RN #4) revealed that clinical staff received orientation about the proper completion of Narcotic Change of Shift Audit logs during their clinical orientation, and that the expectation was that staff provide peer-to-peer review of this practice at each shift change, as needed. Additionally, the DNS and RN #4 identified that two nurses, the nurse coming onto the shift and the nurse leaving from the prior shift, were responsible for completing their signatures on the Narcotic Change of Shift Audit form documenting a dual count of the narcotics available at each medication cart; that a review of these documents for completion was the responsibility of the DNS, however this was delegated to any registered nurse as needed and that these reviews were completed no less than twice per month. The DNS and RN #4 indicated that when a gap in documentation completion was identified, the nurse responsible would be contacted to complete the task in real-time, whenever possible, or at home if they were not present at the time of identification. The DNS and RN #4 indicated that when the same nurse was not completing the required signatures, the pattern would be discussed during Quality Assurance and Performance Improvement Committee (QAPI) meetings to identify and correct the root cause, up to and including re-education of the individual, monitoring of completion efforts, and progressive discipline when necessary.Although requested, a facility policy on documentation of narcotic counts at change of shift on the Narcotic Change of Shift Audit was not available. RN #4 indicated that this process is part of nurses' clinical orientation training.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for abuse, the facility failed to ensure a resident was treated in a respectful and dignified manner. The findings include: Resident #1 had diagnoses that included anxiety, tobacco use, and moderate dementia with psychotic disturbance. The quarterly MDS dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) indicative of intact cognition, without the presence of behaviors, continent of bowel and bladder, independent with ADLs and ambulation. The care plan dated 12/10/24 identified Resident #1 is a current smoker with interventions that directed cigarettes and/or lighting material to be given by nursing at the designated times. The physician's orders dated 12/19/24 directed Resident #1 is permitted to smoke during designated smoking times only. Review of the facility's reportable event form dated 1/17/25 at 7:35 P.M. identified NA #1, LPN #2, LPN #3, NA #1, and NA #4 reported that when Resident #1 approached the nurse's station to ask LPN #1 a question LPN #1 in a raised voice used inappropriate language towards Resident #1. The facility's reportable event identified Resident #1 had no apparent injuries, no signs or symptoms of distress, and emotional support was provided. LPN #1 was sent home and suspended pending investigation. A nurse's note dated 1/17/25 at 11:17 P.M. written by RN #1 identified she was notified when Resident #1 approached the nurse station to ask when they were taking the residents out to smoke staff observed LPN #1 responding to Resident #1 using inappropriate language in a raised voice. RN #1 indicated Resident #1 walked away and went to h/her room. RN #1 indicated emotional support to Resident #1, Resident #1 was asked if h/she felt safe, and Resident #1 stated h/she feels safe at this time. RN #1 identified she notified the DNS, MD, and the police. RN #1 indicated she left a message for psych and Resident #1's POA. The facility's summary dated 1/23/25 identified LPN #1 had recently completed abuse training education which included prevention on 1/13/25. Social services interviewed other residents that residents on the floor and no other concerns or incidents were identified. After a thorough investigation including staff and resident interviews, the facility concluded that LPN #1 did speak to Resident #1 in an inappropriate manner which included a raised voice and LPN #1 used the word damn. LPN #1 was placed on leave pending the outcome of the investigation and LPN #1's employment has since been terminated. Interview with Resident #1 on 2/7/25 at 11:00 A.M. identified on 1/17/25 at approximately 7:15 P.M. when h/she asked LPN #1 when smoke break was LPN #1 with a raised voice stated It is none of my business I don't give a damn I am not taking you out it's not my job. Resident #1 identified when LPN #1 raised her voice h/she started walking away and went in h/her room. Resident #1 identified h/she did not feel embarrassed, humiliated, threatened and h/she felt safe. Resident #1 identified following the incident on 1/17/25 LPN #1 was sent home, and Resident #1 never saw LPN #1 again. Interview with LPN #3 on 2/7/24 at 11:15 A.M. identified on 1/17/25 at approximately 7:15 P.M. when she was at the nurse's cart in the west hallway, she heard LPN #1 yelling from the nurse's station It is not my damn job LPN #3 identified she walked over to the nurse's station observed LPN #1 standing at the nurse's station and Resident #1 was walking into h/her room. LPN #1 indicated Resident #1 replied 'I am okay I feel safe.' LPN #3 asked Resident #1 what happened Resident #1 reported h/she wasn't getting anywhere with LPN #1 so h/she was going back to h/her room. LPN #3 identified she notified the DNS and RN #1, and LPN #1 was sent home. Interview with NA #1 on 2/7/25 at 12:10 P.M. identified on 1/17/25 at approximately 7:15 P.M. she heard LPN #1 yelling speaking loudly to Resident #1 Go ask the nurse aides they have the answers it's not my damn job. NA #1 identified Resident #1 reported he had just asked LPN #1 to call downstairs to find out if his buddy was going to go on smoke break and Resident #1 said h/she was okay. Interview with the DNS on 2/7/25 at 1:30 P.M. identified on 1/17/25 at approximately 7:30 P.M. LPN #3 and RN #1 notified him that Resident #1 went to the nurse's station to ask LPN #1 who was taking them out for smoke break and LPN #1 raised her voice and used profanity towards Resident #1. The DNS identified he directed RN #1 to remove send LPN #1 home pending who was suspended pending outcome of the investigation. The DNS indicated an investigation was conducted that included interviews with staff and residents on LPN #1's assignment, staff statements were obtained, and an interview with Resident #1 was completed. The DNS identified based on the investigation on 1/17/25 when Resident #1 asked LPN #1 who was taking them out for smoke break LPN #1 said It is not my damn job it's none of my business I am not taking you out. The DNS identified LPN #1 was terminated because she did not treat Resident #1 in a respectful and dignified manner. The DNS identified his expectations are staff always treat all residents with respect and dignity. Review of the facility policy for Resident Rights directed residents have the right to be treated with consideration, respect, and full recognition of their dignity and individuality.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of two residents (Resident #2) reviewed for quality of care, the facility failed to honor a resident's advance directives following a change in condition. The findings include: Resident #2's diagnoses included dementia with psychotic disturbances, atrial fibrillation, and malignant neoplasm of prostate. Record review identified Person #1 was Resident #2's court appointed Conservator (COP) for health care decisions. Physician orders dated [DATE] directed Resident #1's code status was a full code. Resident #1 to receive CPR (cardiopulmonary resuscitation). The Resident Care Plan (RCP) dated [DATE] identified Resident #2 had an established advance directive and wished to receive CPR (cardiopulmonary resuscitation). Interventions directed to review advance directives with resident and/or healthcare decision maker quarterly, and support the resident's decision for CPR. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had significantly impaired cognition. A social services note, written by SW #2, dated [DATE] at 1:07 PM identified SW #2 spoke to Person #1/COP to review Resident #2's advance directives and review the care plan (a 72-hour meet and greet admission form). The note indicated Person #1/COP directed Resident #2's advance directives/code status would be DNR/DNI (do not resuscitate/do not intubate). Review of the Advanced Directives Declaration Code Status form dated [DATE] identified Resident #2 was deemed as a DNR/DNI, with verbal consent from Person #1, dated [DATE]. The physician's signature area had an unidentifiable signature, with the date of [DATE], and a time noted of 5:55 PM. Review of the facility and clinical documentation failed to reflect the change was made in the clinical record to reflect Resident #2's updated code status as DNR/DNI in accordance with the POA direction on [DATE]. A social services note, written by SW #2, dated [DATE] (7 days after the COP directed DNR) at 1:10 PM identified a team meeting was held to discuss Resident #2 care plans. Resident #2 was unable to participate due to cognitive status, and a voicemail was left for Person #1. Advanced directives were reviewed during the meeting and the note indicated Resident #2 was currently a full code/CPR. The incident report dated [DATE] at 5:15 PM identified Resident #2 was found lying on the floor unresponsive at 5:15 PM unresponsive to all verbal and tactile stimuli. No pulse, respirations or blood pressure were detected. Resident #2 remained on the floor and emergency medical services (EMS) were called at 5:16 PM by the charge nurse. A code was called, an AED (automated external defibrillator) brought to the scene, and CPR was initiated at 5:20 PM. The AED was placed at 5:21 PM, EMS arrived at 5:30 PM and took over for CPR. When the nurse began to print paperwork for EMS, he/she found a signed DNR/DNI paperwork (located in a different section of the chart). The RN returned to room and notified EMS of DNR/DNI status. EMS contacted the physician who pronounced Resident #2 to be deceased at 5:59 PM. Interview with RN #1 on [DATE] at 1:05 PM identified he was the RN Supervisor on [DATE] during the 7AM to 3 PM shift (when SW #2 obtained the change in code status from Person #1). RN #1 identified he was not notified by SW #2 regarding the change in advance directives for Resident #2. If he was notified, he would have obtained physician orders and updated the clinical record. Although attempted, interview with RN #2 was unable to be obtained. Interview with SW #2 on [DATE] at 1:20 PM identified she spoke with Person #1 on [DATE], and Person #1 directed to change Resident #2's code status from a full code to DNR/DNI. SW #2 was unable to confirm who she updated on the nursing team of the new advance directives, but indicated it was whichever staff member was on the unit at that time. SW #2 identified she did not report the change to any other staff member, aside from the unidentified person on the unit. SW #2 identified when a resident changes their advance directive, the staff are expected to update the documentation and notify the nursing staff to ensure an order gets placed. SW #2 was unable to explain why her note on [DATE] (7 days after the change) did not reflect Resident #2's accurate code status. SW #2 stated it was most likely an error on her part. Interview with Administrator #2/Regional Director of Operations on [DATE] at 2:00 PM identified that although facility ownership changed after this incident event (during [DATE]), interview failed to identify why the record was not updated to reflect the accurate code status. A facility policy regarding entering code status orders in the clinical records was not provided for surveyor review. Interview and facility documentation review with the Administrator on [DATE] at 10:53 AM identified although staff education was initiated on [DATE] regarding code status documentation in the clinical record, and audits were initiated with a QAPI meeting on [DATE], review failed to identify the education included SW #2. The Administrator stated SW #2 should have received education. Based on review of facility documentation, past non-compliance was unable to be identified due to SW #2 was not included in the education.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of two residents (Resident #1) reviewed for quality of care, the facility failed to monitor the resident's behaviors for a resident receiving antipsychotic medications. The findings include: Resident #1's diagnoses included dementia with behavioral disturbances, major depressive disorder, post-traumatic stress disorder, and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 as alert and oriented, and received antipsychotic medications on a routine basis in the prior seven (7) days. The Resident Care Plan (RCP) dated 1/9/2024 identified Resident #1 had the potential to be verbally abusive due to dementia. Interventions directed to monitor behaviors. Physician orders dated 1/23/2024 directed to administer Quetiapine Fumarate (anti-psychotic) 50 milligrams (mg) at 9:00 AM and 100 mg at 8:00 PM, for dementia with behavioral disturbances. Review of the Pharmacy Drug Regimen Review - Physician Referral dated 1/25/2024 identified Resident #1 was on Quetiapine (Seroquel - antipsychotic) for behaviors associated with dementia and recommended a workup to assess resident behaviors. Review of the Pharmacy Drug Regimen Review - Nursing Referral dated 4/12/2024 identified to provide target behaviors monitoring for the psychotropic medications that Resident #1 is taking. Please make sure the target behavior is specific. Review of clinical and facility documentation failed to reflect Resident #1 had target behaviors monitored during the timeframe of 1/23 through 7/18/2024. Physician order dated 7/19/2024 directed to monitor behaviors of labile mood, sad, crying, tearful, paranoid, accusatory, verbally aggressive, and suicidal/homicidal ideations. Interview with Pharmacist #1 on 8/20/2024 at 1:30 PM identified the facility were given notifications (from the pharmacist) in January and April 2024 directing to add target behaviors due to Resident #1 receiving Seroquel and psychotropic medications. Interview with APRN #1 on 08/20/2024 at 9:30 AM identified it was her expectation that the nursing staff monitor target behaviors for Resident #1 and was unaware the facility was not monitoring behaviors prior to 7/19/2024. APRN #1 indicated target behaviors should be monitored every shift and reported to herself if there is any significant change or increased frequency. Review of the Clinical Services Psychotropic Medications Policy dated 5/2023 identified when psychoactive medications are prescribed, a specific condition or targeted behavior that warrants the use of the psychoactive medications shall be documented in the clinical record: a. The healthcare provider progress notes. b. The healthcare provider order sheet. c. Behavior monitoring flowsheet.

Based on observations of the noon meal, clinical record review, review of facility policy and staff interviews, the facility failed to ensure food was served in a manner that contained nutritive value, flavor and was not burned and for (Resident #34), the facility failed to ensure ice cream was not served in a softened form. The findings included: 1. During the noon meal a lunch test tray was ordered from the kitchen on 8/21/23 which consisted of breaded chicken with a side of potatoes and mixed vegetables. The meal served was warm, the chicken and potatoes were flavorful, however the vegetables were overcooked with some of the broccoli and green bean pieces burned. Interview with the Director of Dietary Services (DDS) on 8/22/23 at 11:55 AM indicated the steamer which was used to cook vegetables has been broken for five to six months, forcing staff to cook vegetables in the oven with some water in a pan. The DDS further indicated quality of the food served has diminished due to the alternate cooking method used. A lunch test tray was obtained from the steam table on 8/22/23 at 12:20 PM consisting of meatloaf, green beans, and potato croquettes. The temperature of each item was measured after leaving the warmer and steam table and identified the following: meatloaf temperature of 164.8 degrees, green bean temperature of 133.7 degrees and potato croquette temperature at 121.0 degrees. Interview with the Director of Dietary Services (DDS) on 8/22/234 at 12:23 PM identified all food served from the steam table should be held at 140 degrees and that the chaffing dishes would remain warmer if left covered, until ready to serve. The DDS also identified the convection oven and stove shut off in the middle of the cooking process and that one of four stove burners and two ovens were broken. The DDS indicated the appliances were too old to repair and that corporate had approved the purchase of new appliances to replace the broken appliances, but facility have not received the funds yet. Although requested, the facility failed to provide a policy related to food quality. 2. Interview with Resident #34 on 8/18/23 at 10:57 AM identified ice cream on the meal tray arrived melted on several occasions. On 8/21/23 at 11:45 AM, a test tray was conducted which included scalloped potatoes, fried chicken legs, vegetables, and ice cream. The ice cream arrived in the original disposable packaging and had been delivered on top of the warm meal. Upon opening the ice cream cup, it was noted that the inner portion was frozen, and the outer edges were melted. On 8/22/23 at 12:00 PM, an interview with Dietary Aide (DA) #1 indicated ice cream was brought from the kitchen on a tray and then placed in a refrigerator located in the dining room. The ice cream was then removed from the refrigerator and placed with resident meals on a cart for delivery to resident rooms. Upon further inquiry, DA #1 indicated that the refrigerator that was used was only a refrigerator and not a freezer. At 12:10 PM, Resident #34's meal was delivered to the room, and the ice cream cup was noted to be on top of the warm food and soft. On 8/22/23 at 12:30 PM, an interview with the Director of Dietary indicated that ice cream was delivered after the meals in a prior process but that this process had been changed at the start of the COVID-19 pandemic. Additionally, the Director of Dietary indicated that ice was previously placed on top of the ice cream, but the kitchen's ice machine had been broken for two weeks before the current survey. 48880

Based on observations, facility policy, facility documentation, and interviews, the facility failed to contain food items appropriately in the dry storage room, to discard expired foods, to maintain their three-day emergency supply per menu and to complete daily temperature log sheets. The findings included: 1 a. During a tour of the kitchen with the Dietary Manager on [DATE] from 10:00 AM to 11:30 AM identified the following: .The small dry storage room located in the kitchen contained an expired jar of Admiration Maraschino Cherries ([DATE]), a container of Kikkoman Teriyaki Marinade and Sauce and a container of Kikkoman Less Sodium Soy Sauce that were opened and not refrigerated, expired vanilla pudding packets ([DATE]), expired chocolate pudding packets ([DATE]), expired butterscotch pudding and pie filling packets ([DATE]), expired gelatin dessert packets ([DATE]) and expired red assorted gelatin packets ([DATE]), an undated bag of cornflake cereal, an opened, undated, and open bag of croutons, a dented can of Northeast red and green pepper strips, and an opened bag of Par Excellence Whole Grain [NAME] Rice #25. b. Further observation on [DATE] identified the refrigerator contained expired diet Jell-O ([DATE]), pre-sliced salami, ham, and bologna ([DATE]), an expired gallon of Ken's Buttermilk Ranch dressing ([DATE]), and an expired gallon of 1% Hood Milk ([DATE]). c. Observation on [DATE] of the facility Three-Day Emergency Food supply identified a damaged can of pears, supply of spinach (1 case), two expired cases of instant oatmeal, and a supply of soup and applesauce (a 3-day supply of each) which was not adequate for Three Day Emergency Food supply. Interview with the Dietary Manager on [DATE] at 11:00 AM identified that all refrigerated, individual serving food items should be discarded 3 days after the preparation date, expired foods should be discarded by the expiration date listed on the container and foods requiring refrigeration after opening should be refrigerated. The Dietary Manager further identified all dry storage items should be discarded by date listed on the container, all undated, unopened dry storage items should be dated or discarded, opened dry storage food items should be contained and dated, and the Three-Day Emergency Food supply should be maintained and on premises. 2. A review of daily refrigerator temperature log sheets (staff, dietary, resident and resident/dietary) identified 27 missing entries from [DATE] and 3 for [DATE]. Review of the daily temperature log sheets (including food temperatures, refrigerator temperatures, dishwasher temperatures and chemical ware washing Ph levels) for [DATE] identified several days of missed dish machine temperature entries, several days of missed Ph log entries for manual ware washing, three days of missing breakfast temperature entries, six days of missing lunch temperature entries, 4 days of missing dinner temperature entries and three days of missing daily temperature log sheets for ([DATE], [DATE] and [DATE]). Review of [DATE] daily temperature log sheets (including food temperatures, refrigerator temperatures, dishwasher temperatures and chemical ware washing Ph levels) identified several days of missed dish machine temperature entries, several days of missed Ph log entries for manual ware washing, 1 missed day of breakfast temperature entries, three days of missing lunch temperature entries, five days of missing dinner temperature entries, and five days of missing daily temperature log sheets for ([DATE], [DATE], [DATE], [DATE] and [DATE]). The [DATE] daily temperature log sheets (including food temperatures, refrigerator temperatures, dishwasher temperatures and chemical ware washing Ph levels) identified eight missed Ph log entries for manual ware washing, one dish machine temperature entry, and nine days of missing daily temperature log sheets ([DATE], [DATE] through [DATE]). Interview with the Dietary Manager on [DATE] at 1:23 PM identified several days of missed entries on the daily temperature log sheets. Although, the Dietary Manager indicated kitchen staff were in-service on [DATE] regarding the missed temperature log entries and re-educated on the process and expectation, thirteen days of missed temperature log sheets were not completed. The Dietary Manager indicated the cooks were responsible for completing the daily temperature log sheets and the policy directed the temperature log sheets to be completed daily. Review of the Logging Food Temperature policy directed food temperatures would be taken with a monitoring device for each item and every consistency and that temperatures would be recorded on the temperature monitoring log sheet. Review of the Manual Ware Washing policy directed to log the Ph level of chemical sanitizer used onto the daily temperature log sheet. Review of the Food policy directed to monitor refrigeration temperatures regularly, to maintain logs of all refrigeration temperatures, and random testing of food temperatures would be done regularly, and logs would be maintained of all food temperatures.

Based on clinical record review, observations, review of facility policy and procedures and staff interview for 1 out of 3 sampled residents (Residents # 21) who required assistance with care, the facility failed to ensure that signs were not posted in resident's rooms that contained personal and confidential information regarding the resident's plan of care and treatment regimen within eyesight of public view. The findings include: Resident # 21's diagnoses included cerebral infraction with hemiplegia and hemiparesis, dysphagia, heart failure and osteoarthritis. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 21 had severe cognitive impairment and required extensive assistance with bed mobility, dressing, eating and personal hygiene. The Resident Care Plan (RCP ) dated 6/22/23 identified Resident #21 with Activity of Daily Living (ADL) deficit. Interventions directed to encourage self-performance, praise all attempts, allow sufficient time for task completion, and assist as needed. Observations on 8/17/23 at 11:14 AM and 8/18/23 at 2:34 PM identified signs posted above Resident #21 bed that contained information regarding the residents out of bed to adaptive wheelchair scheduled time and directions for no blood pressure and no blood draw on left hand. The posted signs also noted directions to the staff to place the resident's teeth in because the resident communicated better with them in and directions to place items on the residents left side due to the resident not being able to use her/his right side. Interview and clinical record review with the Director of Nursing Services (DNS) on 8/18/23 at 2:56 PM identified that personal care instructions posted on the wall above the head of bed should be facing the wall or be placed inside the resident's closet. The DNS further identified the signs with Resident # 21's personal information will be removed immediately. Interview with Person #1 on 8/21/23 at 6:25 PM identified signs posted above Resident #21's head of bed containing information about the resident's care and needs have been there for months. Person #1 further identified the facility did not speak to him/her regarding posted signs and he/she thought the facility placed the signs to help staff to remember how to care for the resident. Although requested, a facility policy regarding access to health information and/or privacy practices were not provided. Review of Residents' [NAME] of Rights given onsite identified the resident has the right to privacy in accommodations, in receiving personal and medical care and treatment, in visits and in meetings with family and resident groups. However, the facility was not required to provide the resident with a private room.

Based on clinical record reviews, review of facility documentation, facility policy and staff interviews for 1 of 2 sampled residents (Resident #11) who was reviewed for Accidents/Falls, the facility failed to follow physician's orders and for 1 sampled resident (Resident #473) receiving antiviral medication to treat COVID-19, the facility failed to ensure that verbal medication order was transcribed to a written order in the resident's clinical record per facility policy and to meet professional standards. The findings included: 1. Resident #11's diagnoses included dementia, history of falling, unsteadiness on feet, and muscle weakness. A physician's order dated 4/1/2023 directed to check for placement of pressure alarm and function of bathroom alarm at shift changes every shift. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #11 was severely cognitively impaired and required extensive assistance with bed mobility, transfers, and toilet use. The Resident Care Plan dated 8/16/23 identified an ADL deficit related to impaired cognition, noncompliance, and decreased mobility, and risk of falls secondary to cognitive impairment, shuffled gait, and noncompliance with safety measures. Interventions directed to apply an alarm at bathroom the door and directed the nurses to check placement and function of pressure and bathroom alarm at shift changes and to clip the resident's alarm to lower part of bedframe and not side rail. An interview and clinical record review with the DNS on 8/23/23 at 12:30 PM identified a physician's order for nurses to check for placement of the pressure alarm and function of the bathroom alarm at shift changes each shift. However, the DNS indicated the order was erroneously entered on 4/1/23. The staff failed to transmit the physician's order to the Treatment Administration Record (TAR) therefore daily checks each shift was not completed from 4/1/23 to 5/15/23. Review of the physician's orders - transcription policy directed to carefully transcribe orders as written to Medication Administration Record (MAR) and/(TAR). 2. Resident #473's diagnoses included COVID-19, atrial fibrillation, congestive heart failure, chronic ischemic heart disease, chronic kidney disease, diabetes mellitus, and hypertension. The Admission assessment dated [DATE] identified Resident #473 was alert and oriented to person, place, and time, and required assistance with transfer, bed mobility and ambulation. The nurse's note dated 8/16/23 identified Resident #473's COVID-19 swab results were positive. The Resident Care Plan dated 8/16/23 identified Resident #473 had actual COVID-19 infection. Interventions directed to provide transmission-based precautions as ordered and directed a follow up with the Medical Doctor (MD) / Advanced Practice Registered Nurse (APRN) as indicated. A physician's order dated 8/16/23 directed to administer Paxlovid (antiviral medications to treat COVID-19) 150/100 oral tablet therapy pack 10 x 150 mg and 10 x 100 mg (Nirmatrelvir-Ritonavir) to give 2 tablets by mouth two times a day for 10 administrations. Further review identified physician's orders which directed to decrease Apixaban (anticoagulant medications) 5 mg one tablet by mouth two times a day to 0.5 tablet and to hold Atorvastatin (to treat high cholesterol and triglyceride) from 8/16/23 to 8/26/23. The Reportable Even Form dated 8/17/23 identified on 8/16/23 at 9:00 PM Resident #473 was given morning dose and evening dose (two doses equal to 200 mg) of Ritonavir 100 mg instead evening dose of Nirmatrelvir 150 mg and Ritonavir 100 mg. The nurse's note dated 8/17/23 identified during morning medication pass Licensed Practical Nurse (LPN #4) and APRN #1 noted the resident received wrong dose of Paxlovid on 8/16/23 during evening shift. The APRN immediately assessed the resident. The APRN #1's note dated 8/17/23 identified Resident #473 was started on renal dose of Paxlovid, but due to medication administration error last night, the resident received two doses of Ritonavir, and none of Nirmatrelvir. The resident was washing up in the bathroom and reported feeling better. Further review of the APRN's #1 note identified Paxlovid would be held that morning (8/17/23) and resumed that night, and Apixaban will be also held that morning (8/17/23). Review of physician's orders identified order for Paxlovid with added note on 8/17/23 directing staff to note dosage on package, 2 tablets labeled morning dose and 2 tablets labeled evening dose. A physician's order dated 8/17/23 directed to discontinue Paxlovid and on 8/18/23 the physician's order directed to administer Molnupiravir (antiviral medications to treat COVID-19) oral capsule 200 mg by mouth two times a day for 10 administrations. Interview with APRN #1 on 8/22/23 at 10:34 AM identified Ritonavir and Nirmatrelvir (Paxlovid) were prescribed to treat COVID-19 and were ordered to be given together to enhance effectiveness. Paxlovid may cause overdose of other medications that otherwise would not happen, that is why he ordered to decrease Apixaban doses and to hold Atorvastatin medication. The resident's order included renal dose of Paxlovid which was a lower dose and administering double dose of Ritonavir might cause overdose of other medications and/or other concerns. APRN #1 further identified he would have expected to be called to clarify any questions regarding medication orders prior to medication administration to prevent medication errors. APRN #1 identified that after assessing the resident and reviewing the clinical record he felt that it was not safe to resume Paxlovid and ordered Molnupiravil to be administered instead to ensure prevention of drug interactions. Further interview with APRN #1 identified on 8/17/23 when he went to LPN #4 to verify if Paxlovid was started the day before, they both realized there was a medication error and APRN #1 gave a verbal order to hold morning dose of Paxlovid at that time. It was a significant medication error, and he was concerned about the possible effect of overdose on the resident. He was trying to determine what was the safest way to continue the resident's treatment for COVID-19 and forgot to write the order in the resident's clinical record. LPN #4 already carried out the order and held the morning dose of Paxlovid as she was directed. Interview with LPN #4 on 8/23/23 at 10:31 AM identified APRN #1 usually writes orders in the resident's clinical record himself. LPN #4 further identified that she implemented the verbal order to hold the morning dose of Paxlovid and continued to give other residents their morning medications and did not check if the verbal order was written on 8/17/23. Interview with DNS on 8/23/23 at 11:25 AM identified expectations were for nurses when taking verbal orders from APRN or MD to enter the orders into electronic resident's clinical record in facility computer system. The RN supervisors would monitor and ensure that orders were entered by the APRN or MD and not just written in the progress notes. Further interview with the DNS identified medication orders or change in medication orders must have a written physicians order to avoid any possible miscommunication and/or medications error. APRN #1 gave a verbal order to hold Paxlovid and nurse followed that order, but no order was written. Review of facility Verbal/Telephone Orders policy ---- directed in part to reduce errors associated with misinterpreted verbal or telephone communications of medication orders or test results verbal orders and test results will be immediately written down by the recipient, read back by the recipient, and confirmed or corrected by the prescriber. The order must be written before it is read back. The policy further directed recipients of verbal orders to sign, date, time, and note the order at the time it is written on the order sheet or documented in the computer system.

Based on clinical record review, review of facility documentation and staff interviews for 1 sampled resident (Resident #473) receiving antiviral medication to treat COVID-19, the facility failed to administer medications as ordered by the physician. The findings include: Resident #473's diagnoses included COVID-19, atrial fibrillation, congestive heart failure, chronic ischemic heart disease, chronic kidney disease, diabetes mellitus, and hypertension. The Admission assessment dated [DATE] identified Resident #473 was alert and oriented to person, place, and time, and required assistance with transfer, bed mobility and ambulation. The nurse's note dated 8/16/23 identified Resident #473's COVID-19 swab results were positive. The Resident Care Plan dated 8/16/23 identified Resident #473 had actual COVID-19 infection. Interventions directed to provide transmission-based precautions as ordered and directed a follow up with the Medical Doctor (MD) / Advanced Practice Registered Nurse (APRN) as indicated. A physician's order dated 8/16/23 directed to administer Paxlovid (antiviral medications to treat COVID-19) 150/100 oral tablet therapy pack 10 x 150 mg and 10 x 100 mg (Nirmatrelvir-Ritonavir) to give 2 tablets by mouth two times a day for 10 administrations. Further review identified physician's orders which directed to decrease Apixaban (anticoagulant medications) 5 mg one tablet by mouth two times a day to 0.5 tablet and to hold Atorvastatin (to treat high cholesterol and triglyceride) from 8/16/23 to 8/26/23. The Reportable Even Form dated 8/17/23 identified on 8/16/23 at 9:00 PM Resident #473 was given morning dose and evening dose (two doses equal to 200 mg) of Ritonavir 100 mg instead evening dose of Nirmatrelvir 150 mg and Ritonavir 100 mg. The nurse's note dated 8/17/23 identified during morning medication pass Licensed Practical Nurse (LPN #4) and APRN #1 noted the resident received wrong dose of Paxlovid on 8/16/23 during evening shift. The APRN immediately assessed the resident. The APRN #1's note dated 8/17/23 identified Resident #473 was started on renal dose of Paxlovid, but due to medication administration error last night, the resident received two doses of Ritonavir, and none of Nirmatrelvir. The resident was washing up in the bathroom and reported feeling better. Further review of the APRN's #1 note identified Paxlovid would be held that morning (8/17/23) and resumed that night, and Apixaban will be also held that morning (8/17/23). Review of physician's orders identified order for Paxlovid with added note on 8/17/23 directing staff to note dosage on package, 2 tablets labeled morning dose and 2 tablets labeled evening dose. A physician's order dated 8/17/23 directed to discontinue Paxlovid and on 8/18/23 the physician's order directed to administer Molnupiravir (antiviral medications to treat COVID-19) oral capsule 200 mg by mouth two times a day for 10 administrations. A review of Resident # 473's clinical record and facility documentation with DNS on 8/21/23 at 3:15 PM identified during the investigation of the medication administration error Registered Nurse (RN #2) identified that although she questioned the order and was confused regarding the medication order, packaging, and dose to be administered, she failed to call the physician and/or the pharmacy to clarify the order. RN #2 failed to follow the physician's order when she took two tablets of Ritonavir 100 mg from the blister pack that included one out of two tablets (Nirmatrelvir-Ritonavir) from morning dose and one out of two tablets (Nirmatrelvir-Ritonavir) from evening dose and administered to the resident. Following the medication error administration, on 8/17/23 the DNS added a clarification note to the Paxlovid medication order directing staff to note dosage on package, 2 tablets (Nirmatrelvir-Ritonavir) labeled morning dose and 2 tablets (Nirmatrelvir-Ritonavir) labeled evening dose. DNS further indicated to prevent future medication errors, the facility started performance improvement plan which included staff in services and weekly audits. Attempts to interview RN #2 during the survey were unsuccessful. Interview with APRN #1 on 8/22/23 at 10:34 AM identified Ritonavir and Nirmatrelvir (Paxlovid) were prescribed to treat COVID-19 and were ordered to be given together to enhance effectiveness. Paxlovid may cause overdose of other medications that otherwise would not happen, that is why he ordered to decrease Apixaban doses and to hold Atorvastatin medication. The resident's order included renal dose of Paxlovid which was a lower dose and administering double dose of Ritonavir might cause overdose of other medications and/or other concerns. APRN #1 further identified he would have expected to be called to clarify any questions regarding medication orders prior to medication administration to prevent medication errors. APRN #1 identified that after assessing the resident and reviewing the clinical record he felt that it was not safe to resume Paxlovid and ordered Molnupiravil to be administered instead to ensure prevention of drug interactions. Interview with Pharmacist #2 on 8/23/23 at 11:10 AM identified that for Paxlovid to be effective to treat COVID-19, both tablets Ritonavir and Nirmatrelvir must be administered. Further interview identified that if a resident had decreased kidney function and in error higher dose than ordered of Ritonavir was administered, the resident's kidney function should be monitored. Review of facility Medication Administration and Documentation Policy directed in part, licensed nurse assures the 5 rights: compares the medication name, strength, route and dosage schedule on the medication administration record against the prescription label. Always checks three times prior to administration of medication. 47491

Based on clinical record reviews, observations, facility documentation, facility policy and interviews for 1 of 7 sampled residents (Resident #624) reviewed for accidents and education regarding water temperature monitoring in resident rooms, and for 1 of 3 residents reviewed for smoking (Resident #37), the facility failed to ensure a portable oxygen delivery device was secured to the adaptive equipment used for ambulation to prevent an accident with a injury, failed to ensure staff was educated regarding acceptable water temperature levels in resident rooms and how to proceed if temperatures were out of normal range, failed ensure a smoking receptacle was within reach and failed to attempt to provide assistance with re-applying a smoking apron during a smoking session. The findings included: 1. Resident #624's diagnoses included malignant neoplasm of the lung, chronic obstructive pulmonary disease, and dementia. The admission Minimum Data Set assessment dated [DATE] identified Resident #624 had some short- and long-term memory recall deficits and required supervision when ambulating with the assist of a walker or wheelchair while in the corridor. The Resident Care Plan dated 7/21/22 identified Resident #624 had an activity of daily living deficit related to cognitive loss and a potential for alteration in respiratory status related to chronic obstructive pulmonary disease and malignant neoplasm. Interventions directed to provide assistance and cueing to maximize current level of function and provide oxygen as ordered. The nurse's note dated 10/16/22 at 12:30 PM identified Resident #624 knocked over the oxygen tank while transferring and the tank landed on Resident #624's left foot. The note indicated Resident #624 stated the foot hurts a little, the skin was intact with no visible bruising or discoloration, Resident #624 denied pain while weight bearing, range of motion to the left foot within normal limits, vital signs were stable, and the physician and responsible party were made aware. The nurse's note dated 10/17/22 at 10:59 AM identified Resident #624 continued with complaints of discomfort to the left foot during the shift, the Advanced Practice Registered Nurse, APRN #1, evaluated Resident #624 and ordered an x-ray of the left foot. The note indicated the x-ray results identified an acute fracture, APRN #1 was updated, an open toed postop rigid soled shoe was ordered with no need to see orthopedics and a call was placed to the responsible party who was updated. An x-ray dated 10/17/22 identified an acute appearing fracture of the first distal phalanx (toe) of the left foot. The Facility Reported Incident form dated 10/17/22 at 12:30 PM identified the portable oxygen tank fell and landed on Resident #624's left great toe resulting in a fracture. The report indicated the oxygen tank was placed on the seat of the walker while the nurse was trying to put the nasal cannula on Resident #624. The facility Reported Event Summary dated 10/21/22 identified Resident #624 walked out of his/her room without oxygen on, the charge nurse ran in Resident #624's room to grab the portable (oxygen) tank, placed it on the seat of the walker and applied the nasal cannula. Resident #624 then moved his/her walker and the tank fell on the left foot. The summary noted initially there were no complaints of pain, the following day Resident #624 was seen by APRN #1 after complaints of foot pain and an x-ray was ordered which revealed a first digit phalanx fracture. The summary identified Resident #624 was given an opened toed shoe for the left foot, was pain free and has had no change in ambulation status, the care plan was updated to include ensuring the oxygen tank was secured on the walker before placing the nasal cannula on Resident #624. An interview with the Director of Nursing (DON) on 8/22/23 at 11:21 AM identified he was the assigned Nursing Supervisor working the 3:00-11 PM shift on 10/16/22. The DON indicated he assessed Resident #624 after it was reported by the charge nurse the portable oxygen tank had dropped on Resident #624's foot while attempting to connect the nasal cannula. The DON identified it would have been his expectation that the portable oxygen tank be secured first before applying oxygen. An interview with the 3-11 PM charge nurse, Licensed Practical Nurse (LPN) #9, on 8/22/23 at 12:08 PM identified the portable oxygen tank was usually clipped to Resident #624's walker when in use. LPN #9 identified she was attempting to set up Resident #624's oxygen tubing and placed the tank on the seat of the walker without first securing it to the walker, Resident #624 was standing beside the walker when the tank slipped and fell on to Resident #624's foot. LPN #9 indicated she should have secured the portable oxygen tank to the walker prior to attempting to connect the tubing. An interview with Person #3, Operations Manager for the Oxygen vendor contracted with the facility identified the portable oxygen tank should be secured so it did not fall over. Although a facility policy for securing portable oxygen and manufactures guidelines was requested for the use of portable oxygen, none was provided. 2. On 8/17/2023 at 12:00 PM water temperatures were identified to be elevated above 120 degrees Fahrenheit (F.) in residents' rooms. The elevated water temperatures above 120 F were reported to Building Fire and Safety (BFSI) who worked with the facility Maintenance Director to conduct an audit of all resident rooms. The mixing valve was adjusted immediately, and the water temperatures came down to normal limits. (Below 120 degrees F.) The Maintenance Director indicated the temperatures would be monitored overnight. On 8/18/2023 at 11:15 AM a review of facility documentation of water temperature logs and interview with the Maintenance Director identified elevated water temperatures (highest 128.3 degrees F.) overnight in all the rooms at 1:00 AM and back to normal (below 120 degrees F.) at the 4:00 AM temperature check. Review of the facility water temperature log identified no instructions given to the staff on what expected normal water temperature ranges or instructions of what to do if the temperatures were not within normal range. The Maintenance Director indicated that s/he gave the nursing supervisor RN #6, the thermometers, and the log to complete but s/he provided no instructions how to proceed if the water temperature were found out of range. The Maintenance Director indicated that s/he would revise the log today to include guidelines and instructions on how to proceed if temperatures were found to be out of normal range including who to contact. 8/18/2023 at 2:40 PM a telephone call was placed to RN #6 without success. On 8/21/2023 at 10:00 AM a review of the revised facility temperature logs used for 8/19, 8/20, and 8/21/2023 and interview with the Administrator, indicated the Maintenance Director and himself were notified of the elevated temperatures that occurred overnight on 8/20/23 and 8/21/2023 and the Maintenance Director came into the facility both days and on 8/20/2023 staff was in serviced regarding the use of hot and cold water when providing care. Staff were also directed to accompany confused residents to and from the bathrooms and at 7:30 PM. The Administrator further indicated s/he called the management company requesting someone come out to service the mixing valve due to a sustained hot water level on the unit. The vendor onsite rebuilt the mixing valve and indicated s/he would be replacing it momentarily. The Administrator further indicated that the water temperatures would continue to be monitored twice daily for 3 days. 8/21/2023 2:40 PM an interview with RN #6 Indicated she was given a sheet of paper from the Maintenance Director who adjusted the paper to add room numbers and times. RN#6 further indicated s/he was working a double shift 3:00 PM until 7:00 AM and was asked to take the temperatures of the water in the resident bathrooms at the times indicated on the log, write the findings on the sheet and in the morning and to place the completed sheet into the Maintenance Directors mailbox. RN #6 indicated that on 8/18/2023 she was not provided instruction on what temperatures to expect or who to call but on 8/19/2023 she was provided a new form and received in-servicing on water temperature range on the new form and if it was out of range, then s/he was instructed to take a picture of the thermometer and text the Administrator and the Maintenance Director. RN #6 indicated each supervisor was to teach the next supervisor coming on the shift how to follow the procedure and further indicated that on 8/20/23 there were elevated temperatures, and the Maintenance Director came in. RN #6 also indicated that staff were instructed to provide supervision to the residents who needed to use the bathrooms and that since staff completed 15-minute checks they were able to anticipate needs of residents therefore no attempts were made by residents to go into the bathrooms independent. 3. Resident #37 was admitted to the facility on [DATE] with diagnoses that included Type 2 diabetes, dementia and chronic obstructive pulmonary disease., The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #37 was cognitively intact and required set up assistance only for bed mobility, transfers, dressing, eating and personal hygiene. The MDS further identified Resident #37 was a tobacco user. A Resident Care Plan dated 8/21/23 identified Resident #37 had a smoking history. Interventions included to instruct Resident #37 on the facilities smoking policy, education of resident of the importance of using the smoking apron during smoking sessions, ensure the safety of the resident during smoking, assist resident as necessary to ensure maximum safety. A Smoking Evaluation completed on 7/19/23 identified Resident #37 required the use of a smoking apron for safety during a smoking session. a. Observation of the smoking session on 8/22/23 at 1:04 PM identified 3 residents (Resident #10, Resident #31 and Resident #37) attended the smoking session along with the Recreation Director. The Recreation Director was observed to apply a smoking apron on Resident #37 but failed to secure the apron around Resident #37's back of the neck. The Recreation Director supplied a cigarette to Resident #37 and lit the cigarette for him/her. Resident #37 requested a second cigarette at 1:15 PM, and was noted that the smoking apron was only covering his/her pelvis and right leg, the upper chest and left leg were exposed. Further observation on 8/22/23 at 1:28 PM noted Resident #37's smoking apron had shifted down further. Resident #37 self removed the smoking apron while continuing to smoke 3 more puffs of the cigarette at 1:29 PM, without intervention or assistance to re-apply the apron from the Recreation Director. b. Resident #37 was noted to flick the ashes of the lit cigarette into the air numerous times related to not having a smoking receptacle within his/her reach. Resident #31 and Resident #10 both had smoking receptacles within their reach. When Resident #37 was finished with his/her first cigarette, the Recreation Director had to push one of the two smoking receptacles closer to Resident #37 because it was out of reach. Resident #37 continued to flick the second cigarette in the air not using the smoking receptacle which had been pushed away from Resident #37 by the Recreation Director and pushed closer to Resident #31. The Recreation Director again moved the smoking receptacle closer to Resident #37 to dispose of his/her cigarette. Interview with the Recreation Director on 8/22/23 at 1:45 PM identified the smoking apron was not placed correctly on Resident #37 as there was a clip with a quick release that was to be worn around the resident's neck that she did not secure. The Recreation Director further stated that Resident #37 does not want to wear the smoking apron and did not think of securing/fastening the apron or re-adjusting the apron once it fell to Resident #37's pelvis. The Recreation Director further identified the facility only had 2 smoking receptacles and needed 3 but did not notify anyone. Interview with RN #1 on 8/23/23 at 10:25 AM identified Resident #37 required a smoking apron because he/she flicks ashes on his/her clothing. Interview with RN #5 on 8/23/23 at 11:00 AM identified that she had performed the smoking evaluation on Resident #37, and she implemented the smoking apron, stating the smoking apron was used for safety reasons and that Resident #37 was not using the smoking receptacle as advised. Review of the facility Smoking Policy directed residents who smoke will be evaluated for their ability to smoke safely upon admission/quarterly and as indicated by any significant change in condition, to ensure that they continue to be capable of smoking and use smoking materials without presenting a danger to themselves of others. The need for assistive device and/or safety devices will be identified and noted in the residents individualized care plan. 46046 48950

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1), reviewed for accidents, the facility failed to ensure staff completed a comprehensive physical assessment to include vital signs, full neurological assessment, and range of motion of all extremities timely after Resident #1 had an unwitnessed fall that resulted in a significant injury. The failures resulted in a finding of Immediate Jeopardy. The findings include: Resident #1 was admitted to the facility with diagnoses that included stroke with left sided weakness, unsteadiness on feet, dementia, significant coronary artery disease and chronic kidney disease. A physician order dated [DATE] to provide Resident #1 with Aspirin (used as blood thinner) Enteric Coated delayed release 81 milligrams (mg) daily and Ticagrelor tablet (antiplatelet blood thinner) 90 mg twice a day, and Tylenol 325 mg, three tablets every six (6) hours as needed for pain. An admission minimum data set (MDS) assessment dated [DATE] identified that Resident #1 had sever cognitive impairment, required extensive assistance of two (2) staff for bed mobility, transfers, and toilet use, was continent of bowel and bladder and utilized a walker for mobility. The Resident Care Plan (RCP) dated [DATE] identified Resident #1 was at risk for falls due to new admission, cognitive impairment and genialized weakness, and potential alteration in bladder. Interventions directed to instruct to ask for assistance prior to attempting to transfer or ambulate, observe for non-verbal cues of need for bathroom and to assist to the bathroom as needed. A nursing note dated [DATE] at 8:13 AM identified notified at approximately 6:20 AM that Resident #1 had fallen to the floor while attempting to independently transfer out of a recliner to a wheelchair to use the bathroom. Resident #1 was observed lying on her/his left side with the left arm under/behind him/her. The note further indicated blood was flowing from Resident #1's nose with blood pooling on the floor. When moving Resident #1 to a seated position, Resident #1 complained of left arm pain, pain in the 3rd, 4th and 5th fingers of the right hand, and pain to the left side of her/his head. A bruise was noted on Resident #1's left cheekbone and left temporal area. Resident #1 was assisted into a wheelchair, toileted, and was noted to be verbal, communitive, and alert and was placed in front of the nurse's station for monitoring. Resident #1 complained of a headache (rated as 10 out of 10 on a pain scale) and Tylenol 975 mg was administered for pain. The note further indicated 911 was activated per physician's direction, and Resident #1's mental status changed: Resident #1 became sleepier, had difficulty speaking and was unable to state place of orientation. Resident #1 then had bloody, almost projectile vomiting three (3) or four (4) times with loss of consciousness at 6:55 AM (35 minutes after the fall) and was unresponsive to verbal and painful stimuli. Vital signs were obtained at that time: pulse 80, pulse oximetry (blood oxygen level) 92 to 95 percent, non-labored respirations, finger stick (blood glucose) was 183. Blood pressure was noted as unobtainable by RN and LPN, and Emergency Medical Services (EMS) arrived at approximately 7:00 AM. Review of the Medication Administration Record (MAR) Resident #1 received Tylenol 975 mg at 6:37 AM on [DATE] (17 minutes after the fall was reported). A facility incident report dated [DATE] at 7:46 AM identified the DNS was notified of Resident #1's fall on [DATE] at 6:35 AM (15 minutes after the fall) and Resident #1's physician was notified at 6:49 AM (29 minutes after the fall). Additional medical record review failed to identify vital signs, neurological assessment, or a complete body assessment including range of motion was completed after Resident #1's fall. Review failed to identify an assessment, to include vital signs and neurological assessment, was completed after Resident #1 complained of a headache with pain 10 out of 10 on a pain scale 17 minutes after the fall. Review of the EMS run sheet identified EMS arrived at 7:08 AM. Resident #1 was unconscious, had intermittent large breaths followed by shallow breaths, and was non-responsive to pain or verbal stimuli. Review of Hospital #1's emergency room documentation dated [DATE] at 8:15 AM identified Resident #1 arrived at 7:15 AM and was unresponsive on arrival. Resident #1 had fixed and dilated pupils, blood oozing from the right nostril, was unresponsive to painful stimuli, was breathing without assistance and was immediately intubated for airway protection. CT of the head and chest results identified pulmonary edema, and a left subdural hematoma with significant associated mass effect measuring up to approximately 4.1 centimeters (cm) and a significant rightward subfalcine herniate with the left lateral ventricle displaced approximately 2.2. cm to the right, and the lateral and third ventricle were compressed, and possible continuing active bleeding. Resident #1 was transferred in guarded condition to another hospital for additional treatment. Review of Hospital #2's discharge summary dated [DATE] at 11:51 PM identified Resident #1 was admitted from another hospital where intubation for airway protection was provided and imaging demonstrated a significant subdural hematoma with midline shift and herniation of the brainstem, etiology traumatic with dual antiplatelet therapy. Pupils were midsized and fixed and Resident #1 was admitted for emergent craniectomy and clot evacuation however became hemodynamically unstable. Resident #1 was actively herniating and was in active cardiac arrest undergoing Cardiopulmonary Resuscitation (CPR) upon arrival to the emergency department. Discussions with family and change of care goals to Do Not Resuscitate. Resident #1 was extubated at 10:01 PM and expired at 10:20 PM. Interview with NA #1 on [DATE] at 11:35 AM identified that she responded to Resident #1's fall with RN #1 on [DATE] at 6:20 AM and observed Resident #1 was face down, head turned slightly, left arm behind Resident #1 and was bleeding heavy from the nose. Resident #1 indicated he/she was trying to go to the bathroom and RN #1 directed her to assist Resident #1 to the bathroom. NA #1 and NA #2 assisted Resident #1 to the bathroom and then placed Resident #1 in a chair by the nurse's station. Interview with RN #1 on [DATE] at 12:15 PM identified she was Resident #1's nurse (and the nursing supervisor) during the 11 PM to 7 AM shift on [DATE] when she was notified Resident #1 was on the floor. She observed Resident #1 was alert and oriented with a pillow under his/her head, and no complaints of dizziness. Resident #1 complained of head and arm pain, and pain in the 3rd, 4th and 5th fingers of his/her right hand. Resident #1's nose was bleeding heavily and Resident #1 had a bruise to the left check and a small bruise to the left temple. RN #1 identified that although she checked Resident #1's upper extremity range of motion, she did not complete vital signs or full neurological signs or range of motion of the lower extremities. Resident #1 complained of a headache, 10 out of 10 (on a pain scale of 1 to 10) and she administered Tylenol as per physician's standing order for pain as needed. RN #1 indicated although Resident #1 had bruises, complained of a headache and his/her nose was bleeding, complete neurological signs were not needed because Resident #1 was alert and talking after the fall, and she did not observe Resident #1 to have any changes when Resident #1 was ambulated. Further, after she administered Tylenol for the headache, RN #1 did not obtain vital signs or neurological assessments because Resident #1's mental status had not changed; Resident #1 was conversant and at baseline consciousness. After Resident #1 was placed at the nurse's station, RN #1 proceeded to call the DNS, and the DNS directed her to call the physician. RN #1 then called the physician who directed her to call 911, and she then called 911. RN #1 indicated Resident #1 began vomiting and she could not recall if she called 911 before or after the vomiting began. Resident #1 became unresponsive at approximately 6:54 AM, she obtained a pulse, respirations and pulse oximetry, but was unable to obtain a blood pressure, and she placed a second call to 911 to update them on Resident #1's change in condition. Although RN #1 indicated she should have obtained vital signs at the time of Resident #1's fall, RN #1 continued to indicate that she did not need to obtain neurological signs after Resident #1's fall; she identified they were not indicated. Interview with the DNS on [DATE] at 2:00 PM identified he would expect a complete assessment of a resident after a fall; the assessment should include vital signs, neurological signs (including level of consciousness, pupil checks and hand grasps) and range of motion of all extremities. The DNS indicated he was not aware vital signs, neurological signs, and range of motion of all extremities were not completed after the fall and they should all have been performed immediately after the fall, and assessments should have continued until Resident #1 was transferred to the hospital. The DNS further identified staff education was not provided for licensed staff after the incident regarding performing assessments, timely notification to the physician after unwitnessed falls, and timely notification of EMS. Interview with LPN #1 on [DATE] at 3:00 PM identified on [DATE] he arrived to work at around 6:30 AM and RN #1 reported Resident #1 had a fall and 911 had been called. LPN #1 indicated prior to his punching in, at an unidentified time, RN #1 informed him that she was unable to obtain Resident #1's blood pressure and directed him to attempt to obtain a blood pressure. LPN #1 attempted and was unable to obtain a blood pressure, and he left to punch and return to his routine work, leaving RN #1 with Resident #1. Interview with Ambulance Dispatcher #1 on [DATE] at 10:30 AM identified that the facility called 911 twice on [DATE]. The first call was received at 6:53 AM (33 minutes after Resident #1's fall) and the second call was received at 6:58 AM (38 minutes after the fall). The facility failed to complete vital signs, full neurological assessments, and a full range of motion assessment timely after Resident #1 had an unwitnessed fall on [DATE] at 6:20 AM with injuries, and after a change in neurological status (headache, bleeding nose, and facial bruising) with subsequent vomiting and loss of consciousness. Further, the facility failed to ensure the physician was notified of a change in condition timely and the resident was transferred to the hospital timely. As a result, Immediate Jeopardy was identified. The facility Neurological Signs Policy, dated [DATE], directed in part, any resident who sustains a head injury or when a head injury is questioned or suspected, will have neurological signs monitored as follows: every fifteen minutes for one (1) hour. Neurological signs to be evaluated are inclusive of: Pupils reaction to light, level of consciousness, change mental status change in speech, change in strength in extremities, vital signs (blood pressure, pulse, respirations), head pain and nausea and vomiting. Although requested, interview with the DNS, RN #2 and the Administrator identified the facility did not have a policy that directed staff to call 911 immediately for a resident emergency. A review of the facility's Immediate Jeopardy removal plan on [DATE] identified all licensed staff will be educated on the falls management, neurological signs, and facility policies for accidents, change in condition, vital signs, and documentation. Education included timely notification to the physician, and licensed staff to call 911 in an emergency. Audits will be conducted to ensure comprehensive RN assessments are completed including neurological assessments, vital signs, range of motion, and timely physician notification after an unwitnessed fall. Audit results will be reviewed in Quality Assurance meetings. As a result of the corrective action that was implemented and verified as complete, the Immediate Jeopardy was identified as removed on [DATE].

Based on observation, clinical record review, facility policy review, and interviews for 2 of 7 residents reviewed for accidents (Resident #471 and Resident #68), the facility failed to ensure a resident who required Hoyer lift transfers was not left unattended in the shower and/or develop and/or implement interventions to prevent an accident for a resident with an identified risk. The findings include: a. Resident #471's [DIAGNOSES REDACTED]. The annual MDS assessment dated [DATE] identified that R #471 was alert and oriented, required extensive assist of two staff for transfers, and was a physical assist with transfers for showers. The Resident Care Plan (RCP) dated 11/15/18 identified a risk for falls due to history of knees buckling, required assistance with ADLs with interventions to provide assistance with showers, and educate resident on proper techniques for transfers. Review of facility documentation dated 12/20/18 at 7 AM identified R #471 was observed in the shower room sitting on the floor in front of the shower chair, and complained of right knee pain. Review of NA # 4's written statement dated 12/20/18 identified he/she took R #471 to the shower room and R #471 asked to be left alone in the shower. NA #4 statement further identified he/she told R #471 he/she could get hurt, gave R #471 the call bell, pulled the privacy curtain and left R #471 in the shower room. Review of the nurse's note dated 12/20/18 at 7:21 AM identified that R #471 was observed sitting on the floor in front of the shower chair. R #471 stated he/she had attempted to wash his/her feet and slid out of the chair. Review of the nurse's note dated 12/20/18 at 7:49 AM identified that the physician was notified of the fall, and x-rays were ordered. Review of x-ray reports dated 12/20/18 identified a right and left acute supracondylar femur fracture, and bones were osteopenic. Review of the physician's orders [REDACTED].#471 to the emergency room for evaluation. Review of the hospital record review identified that knee immobilizers were applied and R #471 would be non-weight bearing with orders for orthopedic follow up. Review of the clinical record, review of facility documentation and interview with NA #4 on 3/27/19 at 11:35 AM identified that she was the regular NA for R #471, and she usually assisted R #471 with washing his/her lower body and remained with R #471 when in the shower. NA #4 stated that on 12/20/18, R #471 refused assistance with bathing his/her lower body, and requested to be left alone in the shower. NA #4 stated she told R #471 it was a risk to leave him/her alone in the shower, she placed items and the call bell in reach, pulled the privacy curtain, and then left the shower room. NA #4 stated she then went down the hall to assist another resident, and stated the nurse was aware R #471 was alone in the shower. NA #4 stated when she returned for the first time to check on R #471 in the shower about 5 minutes later (but no more than 15 minutes later), she found R #471 sitting on the floor in front of the shower chair. R #471 did not call out for assistance. NA #4 stated R #471 told her that he/she was trying to wash his/her feet and slid out of the shower chair. Review of the NA care card identified R #471 was a Hoyer lift and required assistance with showering, and NA #4 stated she should not have left R #471 alone in the shower. Review of the clinical record, review of facility documentation and interview with RN #3 on 3/27/19 at 12:12 PM identified she was aware R #471 was alone in the shower room, and stated she did not go into the shower room to check on R #471 before the fall occurred. Further interview identified that after the fall occurred, she told R #471 he/she should not be alone in the shower. Review of the clinical record, review of facility documentation and interview with the DON on 3/27/19 at 12:25 PM identified that any resident who is a Hoyer lift transfer should not be left alone in the shower. Further interview with the DON identified that R #471 was a Hoyer lift transfer and should not have been left alone in the shower on 12/20/18. Interview with the DON on 3/26/19 identified that there was no facility policy for surveyor review, however, the expectation was that the resident should not have been left alone in the shower. B. Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum (MDS) data set [DATE] identified Resident #68 was severely cognitively impaired and required total assistance of 2 staff with bathing, transfers, dressing and grooming and extensive assistance of 2 staff with bed mobility and toilet use. A physician order [REDACTED]. The care plan dated 7/5/18 identified Resident #68 had an activities of daily living (ADL) deficit related to advanced dementia, limited mobility and contractures. Interventions included to provide half side rails as enablers/bed mobility and to provide 2 person assistance with ADL's. The care plan also identified the resident required assistance with all mobility with interventions including to provide 2 person assistance with bed mobility and to transfer with a mechanical lift. Additionally, Resident #68 was at risk for falls with interventions including to provide gripper socks while in bed and a motion sensor in room. Review of the Reportable Event form dated 9/6/18 identified that at 7:40 PM, Resident #68, who was alert, confused and dependent with ADL's and required 2 person assist for transfers using mechanical lift, was observed lying on the floor next to the bed. Resident #68 sustained a 7 centimeter (cm) by 2cm laceration to the left side of head. Witnesses were identified as NA#5 and NA#6. Further review of the Reportable Event form identified the physician was notified and Resident #68 was sent to the emergency room (ER) for further evaluation, returning to the facility with 7 sutures to the top of head. Actions taken included placement of floor mats and side rails were checked to ensure functioning. Review of the nurses note dated 9/6/18 at 10:02 PM and written by Registered Nurse (RN) #6, who was the Nursing Supervisor, identified being notified at 7:40 PM that Resident #68 had fallen out of bed. Upon entering Resident #68's room, RN #6 observed Resident #68 on the floor at his/her bedside, lying on his/her left side with moderate amount of bleeding from the left side of head. The laceration measured 7cm by 2cm, pressure was applied and assessment identified the resident was alert and awake, dysphagic per baseline, no signs or symptoms of pain, neurological and vital signs were within normal limits with both upper and lower extremities being at baseline range of motion. Additionally, the physician was notified, Resident #68 was sent to the ER for evaluation and family was updated. The note indicated the resident returned to the facility at 9:50 PM with 7 staples in place to left side [MEDICAL CONDITION] with no active bleeding. Review of the hospital ER documentation identified Resident #68 had a 5cm linear subcutaneous tissue laceration of the left parietal region which was sustained after falling out of bed. The wound was approximated and closed with 8 skin staples and [MEDICATION NAME] was applied prior to discharge. Review of NA #5 and NA #6's investigation statements dated 9/6/18 identified that they transferred Resident #68 from the wheelchair safely into bed via hoyer lift. Statements identified the bed was in low position and they placed both side rails up. Further review identified that NA #5 then turned his/her back to resident for approximately 10 seconds to move the wheelchair in order to have more room to continue to provide care. At the same time documentation identified that NA #6 also turned his/her back on resident for 10 seconds to move the hoyer lift out of the way. NA #6 identified hearing a thud and both NA's found Resident #68 on the floor with a [MEDICAL CONDITION] on left side. NA #5 remained with the resident, applying pressure to laceration and NA#6 summoned the nurse and supervisor. Review of statement by LPN #2 dated 9/6/18 identified being approached and informed that Resident #68 was on the floor. LPN#2 identified finding Resident #68 on the floor on left side facing the window with one NA holding pressure to the left side of head. LPN #2 identified he/she examined the laceration and continued applying pressure. Supervisor then assessed resident, cleansed and dressed laceration, called physician and 911. Ambulance arrived and resident was sent to the hospital for evaluation. Review of the facility investigation statement dated 9/7/18 by NA #7 identified being a regular aide who provided care for Resident #68 four times a week. NA #7 identified having witnessed resident roll in the bed, onto his/her sides from his/her back after being lowered and released from the hoyer. NA #7 further identified that Resident #68 comes very close to the edge of the bed when rolling onto his/her side and with Resident #68 being on an air mattress with side rails of bed being flush with the mattress, there was no way to stop Resident #68 from rolling all the way over with the weight of his/her body once resident gets moving on his/her own. An interview and observation of Resident #68's room with NA #7 on 3/26/19 at 11:00AM identified that at the time of Resident #68's fall he/she was the regular aide for resident, providing care 4 times per week. NA #7 identified that Resident #68 was very contracted and would be in a fetal position with his/her back curved. Additionally, NA #7 identified that when the resident was transferred onto the bed he/she would need to stay with the resident because Resident #68 was so stiff, unable to stay on his/her back and would suddenly turn to his/her side and would come close to the edge of the bed. An interview with NA #5 on 3/26/19 at 11:20 AM identified that on 9/6/18 during a mechanical lift transfer of Resident #68, he/she guided the resident while NA #6 operated the hoyer lift. After safely transferring the resident from wheelchair to bed with NA #6 he/she indicated he/she turned his/her back on the resident to move the wheelchair into the corner of the room. NA #5 identified that at the same time, NA#6 also turned to move the hoyer out of the way so they could continue to provide care to the resident. While they were both moving equipment, NA #5 identified resident fell to the floor. Additionally, NA #5 identified that he/she usually stayed with the resident when placing Resident #68 in the bed. Interview with the DNS on 3/27/19 at 8:25 AM identified that after Resident #68's fall, he/she and RN #4 (Staff Development Nurse) along with NA #5 and NA #6 did a re-enactment of the incident. It was identified that because of the resident's contractures and ball like position, it was possible for the resident to suddenly roll out of bed. Additionally, that an NA should have been next to the resident until care was completed. Further, that the NA's, who were aware of resident's tendency to roll over suddenly, should have communicated the concern to the nurse and/or DNS and an intervention would have been put into place. Review of the facility's falls management policy identified that the facility will utilize all resident related information made available upon admission and ongoing to determine resident at-risk for fall status. Although staff were aware of Resident #68's behavior of suddenly rolling to his/her side while in bed, the facility failed to develop a person-centered care plan with interventions to address the behavior and subsequently on 9/6/18, after the resident was put in bed, he/she rolled off the bed and sustained a laceration to the left side of his/her head requiring 7 staples.

Based on clinical record review, review of the acute care record and interviews for the only sampled resident with a fecal impaction (Resident #85), the facility failed to initiate physician orders [REDACTED]. Resident #85's [DIAGNOSES REDACTED]. The admission MDS dated [DATE] identified that the resident had no significant cognitive impairments, required extensive assistance of 2 staff for transfers and bed mobility, extensive assistance for toileting, was continent of bowel, and experienced pain rated a 10 on a scale of 1 to 10. Physician orders [REDACTED]. Orders also directed a bowel regime for constipation as needed of Milk of Magnesia; use first, followed by [MEDICATION NAME] suppository if MOM is not effective, followed by a Fleet enema if the [MEDICATION NAME] suppository is not effective. Review of bowel movement records identified that the resident went from the 11 PM-7 AM shift on [DATE] until the 11 PM-7 AM shift on [DATE] (15 shifts) with only one small bowel movement. Nurse's notes dated [DATE] indicated that MOM was administered twice with no results and that the resident wanted to wait til the morning for the Fleet enema. The suppository was not mentioned in the nurse's notes as being offered and/or refused. On [DATE], a social work note indicated that the resident had opioid induced constipation that was causing discomfort to the resident and that s/he wanted extra water and warm prune juice. The physician was contacted and Senna was increased to 4 tabs twice a day. Nurse's notes indicated that the resident hyperactive bowel sounds and the resident had a large bowel movement; type not specified. On [DATE], the resident was lowered to the floor due to weakness and was unable to void. On [DATE], the resident had loose bowel movements, developed chills and complained of not feeling well. S/he was transferred to the emergency department. The hospital record dated [DATE] identified that the resident had lower left quadrant and abdominal pain that had been present since [DATE].[MEDICATION NAME] been started for suspected UTI, however urine was not suspicious for a UTI. CT of abdomen revealed acute stercoral [MEDICAL CONDITION] and acute perforated sigmoid colon with pericolonic phlegmon and abcess containing fecal like material. The area in question measured 5 by 6 by 7 cm. The resident declined treatment and was transferred back to the facility where s/he expired on [DATE]. Interview with MD#1 on [DATE] at 9:45 AM noted that acute stercoral [MEDICAL CONDITION] meant constipation with hard stool that leads to ulcers that perforated (through the bowel wall). MD#1 indicated that the loose stools were probably oozing around the fecal impaction. Interview and review of the clinical record with the DNS on [DATE] at 10:30 AM failed to provide documentation that a care plan to address the resident's complaints of constipation and/or potential for constipation with the use of opioid narcotics had been developed. Further review failed to provide documentation that nursing staff followed the physician orders [REDACTED].

Based on observation, staff interview, and review of facility policies for one of two soiled utility rooms (lower level) and for two of five residents observed for accidents (R #79 and R #80) the facility failed to secure biohazardous wastes and/or ensure the residents received adequate supervision and/or serve food at an appropriate temperature to prevent a burn. The findings include: 1. Resident #79's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified R #79 had short term memory problems, moderately impaired cognitive skills for daily decision-making, and required extensive assistance for feeding. The RCP dated 9/9/15 identified a problem with a self- care deficit requiring assistance with all activities of daily living. Interventions included set-up and assist for meals in the dining room. A physician's orders [REDACTED]. A nurse's note dated 9/19/15 at 12:27 PM identified that during lunch, R #79 was found with a piece of quiche on his/her left hand. The area was slightly red, and the resident denied any pain. The note indicated the area was evaluated by the supervisor and the APRN was made aware. A reportable event form dated 9/19/15 identified a 4 cm x 2.5 cm blister noted on the resident's left hand. The investigation indicated the resident developed the blister on his/her left hand after a piece of pureed egg fell on his/ her left hand during lunch on 9/19/15. A nurse's note dated 9/21/15 at 1:22 PM identified the resident had a 4 cm x 2.5 cm fluid filled blister to the left hand between the thumb and pointer finger. A physician's orders [REDACTED]. An interview with NA # 1 on 4/19/16 at 2:20 PM identified that on 9/19/15, a piece of pureed egg fell on R # 79's hand when the resident tried to feed himself/herself. When questioned as to why the resident was being allowed to feed himself/herself, NA#1 indicated that sometimes he/she needs help and sometimes he/she eats independently depending on his/her mood. An interview with the DNS on 4/21/16 at 11:37 AM identified that if the MDS identified the resident required extensive assistance with eating and the RCP directed the staff to set-up and assist with meals the expectation was that the resident receive assistance with his/her meal. 2. Resident #80's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified that R #80 had short-term memory problems, moderately impaired cognitive skills for daily decision making, and required total dependence for eating. The RCP dated 11/5/15 identified a self- care deficit requiring extensive assistance with all activities of daily living. Interventions included to significantly encourage and assist with meals. A physician's orders [REDACTED]. The nurse's note dated 12/7/15 at 7:54 PM identified a burn with blistered area on the resident's left fourth digit knuckle measuring 0.8 cm x 0.6 cm with reddened surrounding skin. An APRN order dated 12/7/15 directed skin prep be applied to the blister on fourth digit twice a day. A reportable event dated 12/7/15 identified R #80 with a blister on the knuckle of the fourth digit of the left hand. The investigation indicated during the dinner meal on 12/7/15, R # 80 touched his/her food and reacted as if it was too hot and subsequently tried to throw the plate off the dinner table. An interview with the DNS on 4/20/16 at 9:20 AM identified that R # 80 received the burn when he/she pushed the food away and some pureed food got on his/her finger. Review of facility documentation noted a plan of correction to the reportable event dated 12/7/15. The plan indicated the facility would plate pureed food first and serve puree food last. Additionally, an in-service dated 12/8/15 instructed pureed meals to be plated first, lidded and passed out last to allow temperature of pureed food to cool down. An interview with the Director of Dietary on 4/18/16 at 12:10 PM identified that the facility did not have a policy directing what the temperature of the food should be when served to the residents, however he/she would expect residents to receive a puree diet at a temperature of 125-130 degrees. An interview with Cook #1 on 4/20/16 at 10:25 AM also identified that the facility did not have a policy directing what the temperature of the food should be when it is served to the residents however, he/she made a guess that 140 degrees is acceptable and he/she strived to serve the food at 140 degrees. An observation of the lunch meal on 4/19/16 at 12 noon identified five tables with three to five residents seated at each table. The residents receiving puree diets were seated together at one of the five dining room tables in the upper level dining room. Once all the regular diets were served the pureed diets were plated together along with a test tray. All the pureed diets were delivered to the residents immediately after all the puree diets had been plated. Temperature readings taken concurrently by surveyor and the Director of Dietary from the test tray of the pureed diet identified the resident's received their meal with a meat temperature of 155 degrees (surveyor) 140 degrees (Director of Dietary), a potato temperature of 140 degrees (surveyor) 139 degrees (Director of Dietary) and vegetable temperature of 155 degrees (surveyor) 150 degrees (Director of dietary). An interview with the Chef Manager on 4/19/2016 at 12:40 PM identified the process for serving pureed meals is to pan them out, let them sit and serve all other residents in the dining room. Once all other residents in the dining room have received their meals, the nurse aides should take the pureed meals to the table to feed the residents. Further interview with the chef manager identified that the process was not followed on 4/19/15 at 12 noon because when he/she went to plate the pureed food, the lip dishes were dirty. He/she had to have a dietary aide obtain clean lip dishes. By the time he/she had received the clean lip dishes, all the residents in the dining room had received their meals with the exception of the residents who were to receive a puree diet. Review of facility documentation of in-service on 9/25/15 instructed staff to report to kitchen staff if food is too hot. An interview with the DNS on 4/20/16 at 9:20 AM identified he/she did not have an answer as to how nurse aides determine if food is too hot to eat. A subsequent interview with the chef manager on 4/19/16 at 12:40 PM identified that when he/she used the steam tables, all of the heat control knobs are kept on the highest setting of 10 at all times. Review of facility provided manufacturer directions for steam tables indicated to preheat the water in the steam table by setting the heat control to the maximum setting for sixty minutes. Once containers of hot food have been placed in the preheated food warmer wells, the heat control knob should be set to maintain safe food holding temperature. A subsequent interview on 4/19/16 at 12:40 PM with the Chef Manager identified three heat control knobs are broken off on the steam table that is currently in use in the lower level dining room. The chef manager identified that he/she notified both the Director of Dietary and the maintenance department when the heat control knobs broke off in December of 2015. An interview with the Director of Maintenance on 4/20/16 at 10:20 AM identified he/she did not do any preventative maintenance on the steam tables. He/she indicated the knobs had been missing from the steam table for approximately 1-2 months and that he/she needed to order a thermostat for the steam table because when he/she attempted to replace the missing knobs he/she noted the knobs were connected to a thermostat. After speaking to an electrician and a representative from the steam table company he/she discovered a thermostat had to be ordered to replace the knobs on the steam table. The director of maintenance identified he/she felt the steam tables were working properly because he/she could feel the heat from the steam table and because the kitchen staff test the temperatures of the water and food. Review of facility documentation identified 3 replacement knobs for steam table were ordered on [DATE] and delivered on 3/1/16 and the thermostat for the steam table was ordered on [DATE]. A facility policy for steam table set-up identified prior to placing any hot food in the steam table water well, temperatures must reach a minimum of 165 degrees. An interview on 4/20/16 at 1:10 PM with Cook #1 identified that he/she had never taken the temperature of the water in the wells before placing the food in the steam table. Cook #1 also identified he/she held the thermometer in the food for 10-12 seconds until the needle stops before recording the temperature of the food on the food temperature log. Interview on 4/20/16 at 1:35 PM with the Chef manager identified he/she did not take the temperature of the water in the wells of the steam table before placing the food in the steam table. He/she indicated the water is boiling so he/she assumed the water temperature was over 200 degrees. Review of facility documentation identified random audits of food temperatures at all meals would be done 9/15 and 12/15. An interview with the Director of Dietary on 4/19/16 at 11:15 AM identified that although the facility performed random audits of food temperatures, these audits were unavailable for review because the audits were accidentally thrown away. An interview with the Director of Dietary on 4/19/16 at 11:15 AM identified the facility did not retain temperature food logs for more than three months therefore, the temperature food logs from September 2015 and December 2015 were unavailable for review. Review of food temperature logs from 1/2/16 through 4/16/16 identified 6 meals that did not have any food temperatures documented on the food temperature logs. Further interview with the Director of Dietary identified at times the dietary department is short staffed and dietary staff is trying to get meals upstairs and have not documented food temperatures. He/she indicated if the temperature of the food is not taken he/she did not know that the food had reached the appropriate temperatures and that he/she took it for granted that the steam tables were working and the food temperatures were at safe levels. The Director of Dietary indicated he/she just talked to dietary staff when food temperatures were not recorded on the food temperature log. The Director of Dietary had not done any in-servicing nor taken any disciplinary action towards dietary staff when they had not recorded food temperatures on the food temperature log. 3. Observations on 4/18/16 at 6:25 AM and 9:00 AM on the lower level dementia unit identified several residents sitting in wheelchairs and rocking chairs in the common area near the nurse's station and soiled utility room. At that time, the soiled utility room was noted to be unlocked and freely accessible. In the soiled utility room, a lower cabinet labeled bio-hazard was noted with a key-lock mechanism that was unlocked. The unlocked lower cabinet contained a cardboard box without a cover and a red plastic bag liner in the box. Used sharps containers were noted in the box. An observation of the lower level soiled utility room and interview on 4/18/16 at 11:50 AM with RN # 1 noted the lower cabinet containing the used sharps containers and labeled bio-hazard remained unlocked. RN # 1 indicated he/she did not know if the cabinet should be locked. Subsequent to surveyor inquiry, RN # 1 locked the cabinet. An interview on 4/18/16 on 4/18/16 at 11:55 AM with the director of maintenance/housekeeping indicated bio-hazard cabinets are to be locked at all times to prevent resident access to used syringes and/or biohazards. Review of a facility policy on Material Handling and Storage indicated a designated storage room will be used for storage of bio-medical waste and will be kept secured with keys provided to designated personnel only. Sharps will be placed in a puncture resistant container labeled biohazardous and placed in the designated locked area in the soiled utility room.

Based on clinical record review, staff interview, and review of facility documentation for one of two residents in the survey sample reviewed for hydration (R #60), the facility failed to monitor the resident and/or initiate interventions to prevent dehydration when the resident reported loose stools and/or experienced ongoing weight loss while receiving high doses of diuretic medications resulting in dehydration. The findings include: Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A subsequent order dated 11/9/15 directed to discontinue intake and output monitoring. An admission MDS dated [DATE] identified R #60's cognition was intact and s/he was independent with eating, personal hygiene, and locomotion on and off the unit. The resident required supervision for bed mobility, transfer, dressing and toilet use. A review of the nursing progress notes from 11/12/15 through 11/25/15 identified the resident was independent with ostomy care. Review of bowel movement records identified the following: 11/15/16- large BM x 1 11/16/15- large BM x 1 11/17/15-3 medium, soft BM's 11/18/15-No BM x 3 shifts, however the nursing progress note dated 11/18/15 identified the [MEDICAL CONDITION] was patent and resident was providing own [MEDICAL CONDITION] care. 11/19/15-5 small BM's 11/20/15-3 medium, loose stools 11/21/15-no BM x 3 shifts, however the nursing progress note dated 11/21/15 identified the resident had two large bowel movements 11/22/15-small soft BM x 1 on the 7-3 shift, however the nursing progress note dated 11/22/15 identified it was a large amount and medium soft x 1 on the 3 PM-11 PM shift. 11/23/15-2 medium and 1 large BM. A review of a weight record identified R#60 weighed 234 lbs on 11/5/15, 231 lbs on 11/17/15, 228 lbs on 11/18/15, and 215 lbs on 11/24/15 (13 lb weight loss in 1 week and a total weight loss of 19 lbs in 19 days). The clinical record lacked documentation to identify that the Physician and/or APRN were notified of the 13 lb weight loss that was identified on 11/24/15. A nursing progress note dated 11/23/15 identified that R #60 reported he/she vomited twice the day before as well as experienced continuous diarrhea. The resident indicated that the diarrhea started about a week prior. The note further indicated that the resident changed his/her own [MEDICAL CONDITION], therefore the facility could not verify the diarrhea. The resident at that time was instructed to tell the nurse before emptying the bag so the nurse could evaluate the stool. A dehydration assessment dated [DATE] identified the resident was free from signs and symptoms of dehydration, however one of the questions on the assessment asked if output was significantly greater than intake and RN #3 answered indicated no. No intake and output records were available for that day to answer that question accurately and stool had not been measured/assessed. An interview on 4/19/16 at 12:10 PM with RN # 3 indicated he/she answered no on the dehydration assessment regarding output being significantly greater than intake, because he/she observed the resident's intake that morning. He/she further indicated, although the resident had reported vomiting and diarrhea, he/she did not initiate intake and output monitoring at that time because the information was reported by the resident and not verified and/or witnessed by the staff. An APRN progress note dated 11/23/15 identified R #60 was seen due to a complaint of diarrhea and an increase in the [MEDICAL CONDITION] output. An APRN order dated 11/23/15 directed the facility to draw a complete blood count and basic metabolic panel on the next lab day, obtain a stool specimen for [MEDICAL CONDITION] and a KUB for 11/24/15. A laboratory result dated 11/25/15 identified a BUN level of 78 (normal level 9-20), a creatinine level of 5.25 (normal level .66-1.25) and a Potassium level of 6.8 (normal level is 3.5-5.1) A nursing progress note dated 11/25/15 identified the resident continued with loose ostomy output, had dry mucous membranes and abnormal lab results. The resident was transferred to an acute care hospital ED for evaluation. A hospital history and physical dated 11/27/15 identified the resident was admitted to the ICU on 11/25/15 with a [DIAGNOSES REDACTED]. An interview with APRN #1 on 4/18/16 at 12:55 PM identified that it was his/her decision to have labs drawn on the next scheduled lab day as opposed to having them checked on 11/23/15. In addition, when the resident complained of the vomiting and increased output to the [MEDICAL CONDITION] (not actually observed by staff), the resident did not clinically present as dehydrated. Interview with the DNS on 4/20/16 at 9:20 AM identified that the decision to discontinue the monitoring of intake and output on R #60 was based on the fact that the resident met his/her estimated fluid needs during the 72 hours after admission. The DNS indicated that his/her expectation was that intake and output monitoring should have been initiated when the resident identified that he/she was experiencing vomiting and/or diarrhea on 11/23/15. The facility's hydration policy identified that at risk residents will be reviewed and will be provided with interventions to promote hydration and residents identified for a potential at risk for dehydration will be placed on intake and output (I&O) monitoring until adequate hydration status is achieved or until I&O monitoring is no longer clinically indicated. The facility's Intake and Output Monitoring policy and procedure identified intake and output will be monitored initially for 72 hours after a resident is admitted or readmitted and continued monitoring may be required based on the resident's risk factors for dehydration.

Based on review of the clinical record, facility documentation, facility policies and procedures for one three resident's reviewed for accidents (R#125), the facility failed to ensure that adequate supervision was provided while utilizing a thermal device to prevent an accident. The findings included: 1. Resident #125 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment dated [DATE] identified the resident was independent for decision-making skills and required limited to extensive assistance from 1 to 2 staff for activities of daily living. a. The RCP dated 10/26/13 identified problem and/or alteration with comfort and/or pain. Interventions included assess physical symptoms, administer pain meds, monitor/record med effectiveness, and side effects, teach pain relievers, notify MD prn, comprehensive pain assessment quarterly and prn, Nurse aide to position for comfort, offer diversions, assist with ADL's as needed, encourage rest periods and report pain to the nurse. Physician orders [REDACTED]. A review of facility documentation dated 10/30/13 identified that the rehab department gave the resident a hot pack for the ride to the orthopedic physician. As a result the resident sustained [REDACTED]. The appearance of the wound was that of a ruptured blister that was triangular in shape and red in color, measuring 13 centimeter (cm) long by 4 cm and a 2 cm redden area surround the blister with serous drainage noted. On 6/24/14 at 12:19 P.M. and 1:52 P.M., interviews and review of facility documentation with NA #1 and NA #2 who were responsible for accompanying R #125 during his/her transport to the orthopedic surgeon for a follow-up appointment, indicated that they were not aware that the resident was utilizing a hot pack and/or hyrdrocollator pack. Both aides noted that they weren't aware that the resident had the thermal device until the layers of blankets that were covering the resident were removed. Upon the discovery of the hot pack by the resident's physician, NA #2 indicated that the physician noted the resident had an area that looked "red" and once the hot pack was removed, it wasn't reapplied. On 6/25/14 at 3:10 P.M. an interview and review of the clinical record and facility documentation with RN #1 indicated that upon being notified of the resident's wound by NA #1 and NA#2, the physician was notified and he ordered Silvadene cream as a treatment. On 6/24/14 at 10:20 A.M. an interview and review of facility documentation with NA#3/Rehab Tech (RT) indicated that s/he placed the hot pack on the resident's left anterior thigh prior to him/her leaving for his/her appointment under the direction of Physical Therapist #1 (PT#1). NA#3/RT further noted that s/he applied 8 layers of linen prior to placing the hyrdrocollator pack on the area of the resident's left hip to relieve stiffness and/or pain. NA#3/RT estimated that the appropriate length of time to leave the hot pack in place was anywhere between 15-20 minutes. On 6/24/14 at 2:30 P.M. and 6/25/14 at 3:45 P.M. interviews with PT #1 and the Director of Rehab (DOR) indicated that the event of 10/30/13 was the first time that a resident was allowed to leave the facility with a hot pack and that the thermal device was utilized in the interest of the resident who was concerned about pain and stiffness from the long distance ride from the facility to the physician's office more than 30 minutes away. PT#1 indicated that the limit for utilizing a hyrdrocollator pack is 10 minutes and/or no more than 15 minutes. The DOR indicated that in retrospect they realize that it was poor judgment on their part in allowing the resident to leave the facility with the hyrdrocollator pack. b. Review of facility documentation during the period of 9/1/13 to 10/30/13 lacked documentation to reflect that the temperature of the hyrdrocollator unit was monitored on a daily basis. On 6/25/14 at 3:45 P.M. interview and review of the temperature log for the hyrdrocollator storage unit for the hot packs with the DOR identified that documentation was lacking to reflect the water temperature of the hyrdrocollator on 10/30/13 when R #125 acquired a burn from a hot pack. The DOR indicated as part of the facility's plan of correction, the temps are obtained daily even though the policy prior to the resident's burn noted that temperatures are to be obtained at least five times a week. According to the facility policy and procedure for regulating water temperature of the hyrdrocollator machine noted in part that the water temperature should be within 155-170 degrees Fahrenheit. The water temperature will be checked and recorded at least 5 x/week by a designated staff member.

Based on clinical record reviews, review of facility investigations and interviews for 3 of 8 residents reviewed for medications (R # 7, R # 26, R # 57), the facility failed to ensure that medications were administered to the residents in accordance with physician orders [REDACTED]. The findings include: 1. Resident #7's [DIAGNOSES REDACTED]. The annual MDS dated [DATE] identified that the resident was without cognitive impairment, was independent or required supervision with ADL's, was on a scheduled pain medication regime, and had experienced almost constant pain over the previous 5 days. The care plan dated 4/8/14 identified the presence of chronic pain with history of implantation of a spinal stimulator that had since been removed in February 2014. Interventions included to assess pain, administer pain medications as ordered, help find a comfortable position, and assess effectiveness of pain medication. Physician orders [REDACTED]. Nurse's documentation dated 4/14/14 noted that the resident "was in excruciating pain" in the morning and upon review of the narcotic sign out sheet, it was noted that the resident did not receive the 8:30 PM dose of [MEDICATION NAME] 15 mg as ordered on [DATE]. Interview with the DNS on 6/26/14 at 12:02 PM noted that the nurse responsible for the error was re-educated and subsequently resigned and moved out of state. 2. Resident #26 was admitted to facility on 04/08/2014 with [DIAGNOSES REDACTED]. An admission assessment dated [DATE] identified the resident was without cognitive impairment and required extensive assistance with activities of daily living (ADL). The resident care plan (RCP) dated 04/21/14 identified a [DIAGNOSES REDACTED]. Nurse's notes dated 04/29/14 identified that LPN #3 noticed after administering medication to R#26, that s/he was viewing the wrong Medication Administration Record [REDACTED]. Physicians orders dated 04/29/14 directed to check blood pressure, respirations every shift for twelve (12) hours and to notify the MD of heart rate less than 60 and sytolic blood pressure less than 100. A subsequent order dated 04/29/14 directed to send the resident to the emergency room for evaluation and monitoring. A hospital discharge summary dated 04/29/14 identified the reason for admission was due to a medication error. It further identified that R#26 was inadvertently given the above noted medications in addition to his/her own and that R#26 complained of nausea prior to being transported to the hospital. An interview and review of R#26's clinical record with the Director of Nursing (DNS) on 06/25/14 at 11:55 AM indicated that LPN#3 was distracted/called away from medication cart after s/he had started pouring R#'26's medications. After returning, s/he poured R#31's medication into R#26's cup and administered them to the (R#26) resident. The DNS indicated that LPN#3's employment with the facility was terminated. Review of the facility medication administration policy procedure identified that facility staff should verify each time a medication is administered that it is the correct medication, at the correct dose, via the correct route, at the correct rate, at the correct time and for the correct resident. 3. Resident #57's [DIAGNOSES REDACTED]. A minimum data set assessment dated [DATE] identified the resident had no cognitive deficits. A resident care plan dated 4/21/14 identified the potential for unstable blood sugars. Interventions included check blood sugars, monitor for noncompliance, and give sliding scale as needed. A physician's progress note dated 4/3/14 indicated the resident blood sugars were high. A physician's orders [REDACTED]. Review of a Medication Administration Record [REDACTED]. A physician's progress note dated 5/15/14 indicated diabetes is poorly controlled. A nurse's note dated 5/15/14 at 7:09 AM indicated the resident had a hyperglycemic episode with a blood sugar of 519. The Physician was called and the resident received 10 units of insulin at that time. A review of a facility investigation dated 5/19/14 and interview on 6/26/14 at 11:55 AM with the DNS indicated the Invokana medication was not given from May 12- 19, 2014 because it required an authorization from the facility to reorder. The DNS indicated he/she did not become aware of the authorization request until 5/19/14. At that time he/she authorized the medication and it was restarted on 5/20/14. The DNS indicated the Physician was not made aware that the medication was not available and not administered to the resident from May 12- 19, 2014. The DNS further indicated that although he/she had thought about it, he/she had not developed a new system of pharmacy notification for medications requiring authorization for reorder.

Based on clinical record review, review of facility investigation documentation, and interviews for one of three sampled residents reviewed for abuse/neglect (R#43), the facility failed to ensure the resident was free from abuse. The findings include: Resident #43's [DIAGNOSES REDACTED]. An annual MDS dated [DATE] identified the resident had severe cognitive impairment, required the extensive assistance of staff for ADL's, and displayed abusive behavior towards others. The care plan dated 12/14/12 identified the resident had combative behaviors. Interventions included watching for signs of increased anxiety, approach in a calm manner, allow resident to vent, do not attempt care while combative, re-approach when calm and approach with two caregivers when resistive to care. Review of all nurse's notes from January 2013 through February 2013 documented only two incidents where the resident displayed agitation and combativeness with care. Facility investigation dated 2/10/13 at 2:15 am documented that NA #2 reported to RN #5 that R #43 became combative during care and grabbed NA #2 by the hair. NA#2 reported that while he/she was attempting to release the resident's grasp on his/her hair, the resident sustained [REDACTED]. A nurse's note dated 2/10/13 at 2:39 AM noted the resident was found with a 2 cm laceration to the side of the nose, a 2.5 cm laceration to the left neck, a 0.75 cm laceration to the left cheek, and a 3 cm laceration to the right cheek. On 2/12/13, the resident's right eye was documented as "black". On 2/13/13, the resident was noted to "continue to have complaints of discomfort to the face, primarily on the right side. Tylenol given with good effect". A written statement from NA #2 dated 2/10/13 documented the resident was being "disgruntled" with NA #2 and grabbed his/her hair during care. NA#2 documented that he/she removed the resident's hands from his/her hair and held the resident's hands up towards the resident's face while continuing to provide/finish care. R #43 reached out to grab NA #2 again but instead scratched his/her own face according to NA#2's written statement. A written statement from RN #5 dated 2/11/13 indicated that upon entering the room of R #43, multiple lacerations were present on the resident's face with bruising observed to the right eye. RN #5's statement indicated that when the resident was asked what happened, the resident stated "I started the fight and I won it." On 7/24/13 at 9:50 am, an interview with the Administrator indicated that upon completion of the investigation of the incident, it was determined that NA #2 did many things wrong that night including not following facility policy or care plan and therefore was terminated. On 7/24/13 at 10:00 am, an interview with RN #5 noted that NA #2 called her into the resident's room after the incident and RN#5 observed multiple lacerations and bruising to the resident's face. RN#5 noted that R#43 stated that he/she didn't like NA #2. RN #5 then completed the resident's care without any difficulties. RN #5 was told by another aide the next day that R #43 stated to the aide that "I hit her (NA #2) first and it was wrong but then I got struck back." Review of nurse's notes after the incident on 2/10/13 and up two weeks later, identified that R#43 was upset, refusing to leave room due to facial bruising, fearful of the nurse aide returning, and fearful for his/her safety from NA#2. On 2/21/13, the nurse's notes indicated that the resident stated that he/she was afraid to come out of the room, "I got beat up before, look at what they did to me. If it was so safe, how did I get a black eye? "

Based on observation, interviews and review of the clinical record for one of three sampled residents reviewed for pressure ulcers (R#2), the facility failed to assess and monitor a pressure ulcer to prevent a decline and/or assist in healing, and/or failed revise the care plan to develop interventions to aide in healing and prevent re-occurence. The findings include: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nursing admission skin assessment on 3/26/12 revealed that Resident #2 was admitted with a slit to the coccyx which measured 2 centimeters x 0.1 centimeters. No further description of the area was noted. The admission MDS dated [DATE] identified the resident was without significant cognitive impairment, required the extensive assistance of 2 staff members for transfers and bed mobility, was frequently incontinent of bowel and bladder, was at risk for pressure sore development and did not have any pressure sores. A care plan dated 3/27/13 identified the risk of pressure sore development. Interventions included weekly body audits and to monitor " pressure reducing plan " . A care plan update on 6/18/13 identified a pressure ulcer on the coccyx that was unstageable at that time. Interventions included to change dressing, low air loss mattress, and chair cushion. MD orders dated 3/26/13 directed staff to apply [MEDICATION NAME] to right buttock ulcer three times per week. MD orders on 4/26/13 directed staff to apply [MEDICATION NAME] to affected areas on buttock each shift and as needed until resolved. MD orders dated 5/9/13 directed staff to apply [MEDICATION NAME] each shift and prn to coccyx to stage II pressure ulcer as a " nursing measure " . MD orders dated 5/14/13 directed staff to apply [MEDICATION NAME] to coccyx wound followed by Allevyn dressing and change every 3 days and as needed. MD orders dated 5/30/13, 6/5/13, 7/20/13 directed application of Santyl to the coccyx wound. MD orders dated 7/1/13 directed use of an APM mattress set at 10/220, and to check setting and functions every shift. On 5/5/13 a skin and wound assessment identified a right buttock "abrasion" 0.5 x 0.5 centimeters, pink, no drainage, and that calmeseptine barrier cream was being used. On 5/9/13 a skin and wound assessment identified that the nursing staff reported to the physician a stage 2 "abrasion" to the coccyx measuring 1.0 cm x 1.0 cm x 0.1 cm depth. and a wound care note identified 100% healthy tissue and that the area was a stage II pressure ulcer and that [MEDICATION NAME] was to be used each shift and as needed. Furthermore, the APRN and the supervisor were notified of the area and the treatment. On 5/10/13 a skin and wound assessment identified a stage 2 area measuring 3 cm x 1 cm on the coccyx, 100% healthy tissues, no slough, and the dressing was changed to Allevyn. No physician order could be identified to direct staff to place Allevyn on the coccyx. On 5/14/13 wound and skin care assessment identified the coccyx area measured 2 cm x 2 cm. with 75% slough, the family was notified and Resident #2 was educated to go back to bed after lunch. Interview and review of the clinical record with RN #2 on 7/23/13 at 9 AM identified that the admission skin assessment on 3/26/12 revealed that Resident #2 was admitted with a slit to the coccyx which measured 2 centimeters x 0.1 centimeters. Facility skin and wound notes on 4/10/13 identified that the coccyx slit had healed and that [MEDICATION NAME] was discontinued. No measurements of the wound could be identified in the clinical record between 3/26/13 and 4/10/13 (15 days). Although further skin and wound assessments and infection control notes described the amount of slough, healthy tissue and effectiveness of the treatment, the facility failed to measure the wounds from 5/14/13 through 5/27/13 (13 days). Further interview with RN #2 identified that per the facility policy skin and wound measurements should be done weekly. Review of the care plan failed to provide documentation that further interventions were initiated to aide in healing when the resident developed the second pressure sore on 4/26/13, and/or that appropriate treatments were initiated to protect the wound and/or aide in healing in an incontinent resident. Interview, review of facility records and facility policy with RN#4 on 7/24/13 identified that an audit identified that facility documentation lacked appropriate staging, assessment and measurements, and that facility acquired pressure sores were not correctly identified as pressure sores (i.e. abrasions, slits). The concerns had been identified and a corporate nurse had been coming to the facility since the beginning of June to assist with this process and education.