Every finding on record at Shoreside Health and Rehabilitation Center

Based on observations, interviews, and record reviews, the facility did not document a prescribed order for oxygen therapy on time and did not ensure oxygen therapy was delivered as prescribed for one (Resident #23) out of one sample resident who has a primary diagnosis of Chronic Obstructive Pulmonary Disease. This was evidenced by the absence of a written order for oxygen therapy in the Electronic Medication Administration Records (EMAR). During an initial screening observation on 09/23/2025 at 8:30 AM, revealed Resident #23 in bed with eyes closed, receiving oxygen at two liters per minute (Lpm) via nasal cannula (NC); the oxygen tubing was positioned on the resident's forehead. At 8:34 AM, the surveyor requested Registered Nurse (RN) Staff A to come to the resident's room. Staff A, RN assessed the resident, washed her hands, donned gloves, and repositioned the oxygen tubing in the resident's nostrils.Observations on 09/24/2025 at 8:25 AM and on 09/25/2020 at 7:00 AM, noted Resident #23 in bed with eyes closed, displaying no signs of distress, and receiving oxygen at 2 Lpm via NC.Review of Resident #23's medical records showed the resident was initially admitted on [DATE] and readmitted [DATE]. Clinical diagnoses included Chronic Obstructive Pulmonary Disease (COPD).Review of the Physician's Orders Sheet for September 2025 revealed that starting from 09/24/25, there were orders for Resident #23 to receive oxygen at two liters per minute (Lpm) via nasal cannula continuously every shift for shortness of breath.A record review of Resident #23's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the following: Section C for Cognitive Patterns documented a Brief Interview for Mental Status Score (BIMS) as unable to determine. Section GG for Functional Status documented dependence for care. Section J for Health Conditions documented no shortness of breath. Section O for Special Treatments documented: None received.A review of Resident #23's Care Plan Reference dated 08/25/25 indicated that the resident is at risk for difficulty breathing related to COPD. The plan expects the resident to maintain a normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern through the review date. Interventions include administering medication/inhalers/nebulizers as ordered, encouraging adequate rest periods between tasks/activities, monitoring for signs and symptoms of respiratory distress, and reporting to the physician any increased respirations, decreased pulse oximetry, increased heart rate (tachycardia), restlessness, diaphoresis, headaches, lethargy, confusion, hemoptysis, cough, pleuritic pain, accessory muscle usage, or skin color changes to blue/grey. Additionally, it includes maintaining a clear airway by encouraging the resident to clear their own secretions with effective coughing, suctioning as ordered/required to clear secretions if necessary, using pain management as appropriate, and monitoring/documenting side effects and effectiveness.In an interview on 09/23/2025 at 8:37 AM, RN Staff A reported that the resident frequently removes his oxygen tubing. She checks on the resident often throughout her shift to ensure he is okay. She started her shift around 8:00 AM and had checked on the resident at the start of her shift; he was in no distress, and his tubing was in place.On 09/25/2025 at 2:55 PM, Staff A, RN revealed that the resident has been on oxygen therapy since last Friday, 09/19/25.In an interview on 09/25/25 at 3:15 PM, the Director of Nursing (DON) stated that she was not aware the resident did not have an order for the oxygen therapy he was receiving. The records show the order for the resident started on 09/24/25. The order states oxygen at 2 Lpm via NC continuously. She completed an in-service with all the nursing staff regarding checking all residents' orders for accuracy and instructed the nursing staff to make purposeful rounds to check on the resident daily.On 09/26/25 at 8:31 AM, the DON revealed that after further reviewing the resident's records, on 09/19/25, the 3:00 PM to 11:00 PM supervisor received an order from the resident's physician for oxygen at 8 liters per minute because the resident was in respiratory crisis and labs were ordered. The labs were completed, and results sent to the physician; new orders were given for oxygen at 2 liters per minute via nasal cannula on 09/19/25. The orders were not placed into the electronic medical records system until 09/24/25.A review of the facility policy and procedure titled Oxygen Therapy with a revision date of January 2025 states the purpose of this procedure is to provide guidelines for safe oxygen administration. It specifies verifying that there is a physician's order for this procedure and reviewing the physician's order or facility protocol for oxygen administration.

Based on observation and interview the facility failed to ensure residents' confidential medical records were secure. As evidenced, two medication carts (Cart #1, Cart #2) on Unit C, were left unattended and the screen for the Electronic Medication Administration Records (EMAR) was unlocked, displaying residents' information on the screen. There were 136 residents residing in the facility at the time of survey. The findings included: On 06/04/24 at 09:00 AM during observation on Unit C, Medication cart # 2 was left unattended with the Electronic Medication Administration Records (EMAR) screen unlocked, displaying patient s' information on the screen. The cart was assigned to Licensed Practical Nurse (Staff A). During this observation, the Director of Nursing (DON) was present in the hallway and noticed the open EMAR screen on the cart and placed a sheet of paper over the screen. The DON reported she is not sure if something is wrong with the screen, because it is not shutting down. On 06/04/24 at 09:02 AM (Staff A) approached the medication cart and noticed the unlocked screen, Staff A stated: I am so stressed, it is my first time with the state surveyors. The DON stated to the nurse; you cannot walk away and leave your computer screen open. The nurse (Staff A) acknowledged DON instructions. Staff A stated, I know I am not supposed to leave the computer screen open when I am not with the cart. 48906 On 06/04/24 at 9:11 AM. During medication administration observation was done on nursing unit C with Staff D, Licensed Practical Nurse, (LPN) using medication cart number one. During the medication administration observation Staff D, LPN walked away from the medication cart number one and entered a resident's room, leaving the computer screen open and resident's personal information visible. On 06/04/24 at 9:15 AM Staff D, LPN returned to medication cart number one and stated to surveyor, I made a mistake. I am supposed to close the computer screen whenever I leave the cart. I didn't close the screen because I forgot.

Based on observation and interview the facility failed to follow the facility's policy regarding pharmacy procedures. As evidenced by during medication administration observation on Unit C, Licensed Practical Nurse (Staff A) administered an incorrect dosage of insulin to Resident #87. There were two residents that receive routine insulin residing on Unit C. The findings included: On 06/04/24 at 9:17 AM during medication administration observation with Licensed Practical Nurse (Staff A). it was observed that Staff A administered 15 units of Lantus (R) (insulin glargine injection) to Resident# 87's left upper abdomen. Resident # 87 had an order for 16 units of Lantus, 100 Units /ML (units per milliliter) subcutaneously two times a day for Diabetes Mellitus. The surveyor requested Staff A check the orders for Resident #87's Lantus, Staff A checked Resident #87's orders and said the order is for 16 units of Lantus and she gave the resident 15 units. In a situation like this I will speak to my supervisor and see what I need to do, in the meantime I will keep an eye on the resident. On 06/04/24 at 09:37 AM, the Director of Nursing (DON) told the surveyor that Staff A told her about the incorrect insulin dose given to Resident #87, the DON reported she instructed the nurse (Staff A) to give the resident the additional 1 unit of Lantus insulin. Review of the medical records for Resident #87 revealed the resident was admitted to the facility on [DATE], readmitted on [DATE]. Clinical diagnoses included but not limited to: Type 2 diabetes mellitus with hyperglycemia. Review of the Physician's Orders Sheet for June 2024 revealed Resident #87 had orders that included but not limited to: Lantus 100 unit/ml-inject 16 unit subcutaneously two times a day for Diabetes Mellitus. Record review of Resident # 87's Quarterly Minimum Data Set (MDS) dated [DATE], Section C for Cognitive Patterns documented Brief Interview for mental Status Score is 10, on a 0-15 scale indicating the resident is moderately impaired cognitively. Review of the facility policy and procedure titled: Administering Medications revision date April 2019 states: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation Step 4. Medications are administered in accordance with prescriber orders, including any required timeframe Step 6. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. Step 9. The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medications.

Based on observation, interview and record review the facility failed to ensure the medication error rate was not five (5) percent or greater. As evidenced by during medication administration observations an incorrect dose of insulin was given to Resident #87 and Resident #97 did not receive a prescribed injection for Anemia. There were 136 residents residing in the facility at the time of survey. The findings included: Resident #87 On 06/04/24 at 9:17 AM during medication administration observation with Licensed Practical Nurse (Staff A). It was observed that Staff A administered 15 units of Lantus (R) (insulin glargine injection) to Resident# 87's left upper abdomen. Resident # 87 had an order for 16 units of Lantus, 100 Units /ML (units per milliliter) subcutaneously two times a day for Diabetes Mellitus. The surveyor requested Staff A check the orders for Resident #87's Lantus, Staff A checked Resident #87's orders and said the order is for 16 units of Lantus and she gave the resident 15 units. In a situation like this I will speak to my supervisor and see what I need to do, in the meantime I will keep an eye on the resident. On 06/04/24 at 09:37 AM, the Director of Nursing (DON) told the surveyor that Staff A told her about the incorrect insulin dose given to Resident #87, the DON reported she instructed the nurse (Staff A) to give the resident the additional 1 unit of Lantus insulin. Review of the medical records for Resident #87 revealed the resident was admitted to the facility on [DATE], readmitted on [DATE]. Clinical diagnoses included but not limited to: Type 2 diabetes mellitus with hyperglycemia. Review of the Physician's Orders Sheet for June 2024 revealed Resident #87 had orders that included but not limited to: Lantus 100 unit/ml-inject 16 unit subcutaneously two times a day for Diabetes Mellitus. 48906 Resident #97 During an observation on 6/05/24 at 09:19 AM Staff E, Registered Nurse (RN) weighed Resident #97 and transferred the resident to the in-house dialysis center. Staff E, RN was stopped by surveyor and asked who is responsible for administering the RETACRIT(R) injection scheduled to be given that morning to Resident #97. Staff E, RN responded: I am responsible for administering the injection. I was going to administer the injection, but time got away from me. I will speak with the doctor now. Record review of demographic sheet for Resident #97 revealed an admitted [DATE] and re admitted [DATE] with diagnosis that included Anemia. Review of physician orders for Resident #97 revealed an order dated 5/15/24 for RETACRIT(R) Injection Solution 4000 UNIT per Milliliter (ml) Inject 4000 ml subcutaneously in the morning, every Monday, Wednesday, and Friday for Anemia, schedule 8:00 AM. Record review of most recent laboratory blood work dated 5/22/24 revealed a hemoglobin level of 8.8 (may indicate anemia). On 6/05/24 at 10:25 AM the Director of Nursing (DON) stated: Every Friday we have a Standard of Care meeting where we discuss dialysis residents and the care needed. This medication should have been given by 9:00 AM. I informed [Resident #97's] primary care physician (PCP) about the medication omission, [Resident #97] was assessed by the PCP while in dialysis, and a new order was received to administer the RETACRIT(R) injection to [Resident #97] at noon today. During a follow up observation, Staff E, RN administered the RETACRIT(R) injection at 12:32 PM while Resident #97 was in dialysis. Review of the facility policy and procedure titled: Administering Medications revision date April 2019 states: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation Step 4. Medications are administered in accordance with prescriber orders, including any required timeframe Step 6. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. Step 9. The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medications.

Based on observation, interview and record review, the facility failed to ensure there was sufficient dietary staff in place to carry out the functions of the food and nutrition service department. There was only one dietary aide and one cook in the kitchen preparing breakfast. The deficient practice resulted in breakfast being delivered to the nursing units more than 30 minutes late. This has the potential to affect one hundred and twenty three residents out of one hundred and thirty seven residents who eat orally residing in the facility. The findings included: Record review of the facility's policy titled Staffing Policy and Procedure (reviewed date 01/2023) documented: Policy Statement-Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident's needs. Policy Interpretation and Implementation-2) Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care and 3) Other support services (dietary) are also staffed to ensure that resident needs are met. Review of the Job Description for the Dietary/Food Service Director documented: The Dietary/Food Service Director is responsible for planning, preparing and serving regular, modified consistency and therapeutic diets using the corporate menu program. This position will ensure full compliance with nutritional standards, internal procedures and government regulations while preparing and serving foods and beverage to all patients/resident. He/she is also responsible to specify standards and procedures for food preparation and supervise preparation and serving of modified consistency and therapeutic diets. Review of the Job Description for the [NAME] documented: The [NAME] is responsible for preparing large volumes of food for patients/resident. Prepare food that is nutritious and desirable so that patients/residents get the food intake they need. Will prepare food for a preset menu, may make a variety of meals from menu, and/or prepare special meals for patient/residents who require therapeutic diets. He/she is also responsible to prepare food on large scale and cooks various items according to menus, special dietary or nutritional requirements or numbers of portions to be served. This position reports to the Director of Dietary. Review of the Job Description for the Dietary Aide documented: The Dietary Aide is responsible for providing meal service to residents. Will ensure full compliance with nutritional standards, internal procedures and government regulations while preparing and serving foods and beverages to all patients/residents. He/she is also responsible to prepare meals and beverages using specific procedures. This position reports to the Director of Dietary. Review of the Job Description for the Dietitian documented: The Dietitian is responsible to monitor food service operations to ensure conformance to nutritional, safety, sanitation and quality standards, as well as all applicable state and federal regulations. He/she is also responsible for knowledge and understanding of regulatory process including all applicable federal, state and local regulations applicable to completing job responsibilities. This position reports to the Administrator and Dietary Consultant. Observation of the kitchen on 10/02/23 at 7:01 AM revealed three dietary workers observed in the kitchen. The [NAME] (Staff A) was preparing breakfast foods. The Dietary Aide (Staff B) was pouring juice into cups and placing bread in the toaster for the breakfast tray line and Dietary Aide (Staff C) was at the high temperature dishwasher loading dishes and washing dishes. Three carts of dirty dishes and utensils were observed from the previous dinner meal service. The Food Service Director was not in the kitchen and there were no other dietary workers preparing for the breakfast tray line. On 10/02/23 at 7:02 AM, interview with the Cook, Staff A. He stated, I only have two workers to help with breakfast. There should be more. We are running behind on breakfast. I am just the cook. The breakfast line should have started before now at 6:30 AM-7:30 AM. It is going to be very late because they have to wash dishes and pour the juice, before we can start the breakfast line. I have been working here for sixteen years. On 10/02/23 at 7:09 AM, interview with the Dietary Aide, Staff B. She stated, I have worked here for twenty-two years. We use to have five workers at breakfast and at the beginning of the year, they cut it to three people. We need more workers. We can't do this by ourselves. You see all the carts of dirty trays. The dishes have to be washed before we can start breakfast. They only have three people in the evening, that is why the dirty dishes are still here. On 10/02/23 at 7:14 AM, interview with the Dietary Aide, Staff C. He stated, When I come in the morning, I have to wash the dishes before they start breakfast. I have been working here for twenty-four years. We need more people to work in the kitchen. Observation of the Cook, Staff A on 10/02/23 at 7:31 AM placing pans of food on the breakfast tray line. On 10/02/23 at 7:34 AM, interview with the Registered Dietitian, Staff D. She stated, I have been here since August 30, 2023. We are fully staffed today. There are only three workers in the kitchen at this time. The breakfast trays are late today. I check the menus daily to make sure they are being followed. The Food Service Director lets me know if there are changes. I check the modified diets and if there any substitutions made, I am notified. I oversee the Food Service Director. I don't know the number of workers that are supposed to be working in the kitchen. Observation on 10/02/23 at 7:39 AM revealed the breakfast tray line was started. Three dietary workers were observed on the breakfast tray line. The Dietary Aide (Staff B) was observed preparing the trays, [NAME] (Staff A) was serving the food on the tray line and Dietary Aide (Staff C) who was observed washing dishes, placed the breakfast food trays on the food cart for delivery to the units. Observation on 10/02/23 at 7:40 AM revealed the breakfast trays consisted of: Scrambled eggs, Cream of Wheat, Sliced Toast, Boiled Eggs, Orange Juice, Milk, Oatmeal, Fruit Cup. No meat was observed on the tray line. Observation on 10/02/23 at 7:45 AM revealed another dietary aide enter the kitchen. This brought the total of dietary workers to four in the kitchen. Observation on 10/02/23 at 7:47 AM revealed the Food Services Director enter the kitchen. Review of the Meal Times schedule to be served documented the following: Breakfast: Unit A 7:00 AM to 7:30 AM, Unit B 7:30 AM to 8:00 AM and Unit C 8:00 AM to 8:30 AM. Observation on 10/02/23 at 7:58 AM revealed the breakfast trays arrived on Unit A. The breakfast trays for Unit A were scheduled to arrive 7:00 AM-7:30 AM. Observation on 10/02/23 at 8:02 AM revealed the staff delivering breakfast trays to the residents on Unit A. Observation and interview of Resident #1 on 10/02/23 at 8:05 AM residing on Unit B, revealed the resident sitting in a motorized wheelchair in his room, wearing glasses and a hat. Resident was waiting for breakfast to be served. He stated, It is pretty late for breakfast. Breakfast usually arrives around 8:30 AM to 9:00 AM. I have been here since Christmas. I am hungry now. I have snacks here that my family brings for me. They have always served breakfast since I have been here but not much is served. On 10/02/23 at 8:12 AM, interview with Licensed Practical Nurse (LPN), Staff E on Unit B. She stated, The breakfast is usually late. It is supposed to be here by 8:00 AM. Observation on 10/02/23 at 8:27 AM revealed the breakfast trays arrived on Unit B. The breakfast trays for Unit B were scheduled to arrive 7:30 AM-8:00 AM. Observation on 10/02/23 at 8:30 AM revealed the staff delivering breakfast trays to the residents on Unit B. Observation and interview of Resident #2 on 10/02/23 at 8:46 AM residing on Unit C, revealed the resident sitting in a motorized wheelchair in the Unit C dining room, with missing teeth. Resident was waiting for breakfast to be served. He stated, Breakfast is always late. I am hungry right now. I have been here since 2019. Observation on 10/02/23 at 9:07 AM revealed the breakfast trays arrived on Unit C. The breakfast trays for Unit C were scheduled to arrive 8:00 AM-8:30 AM. Observation on 10/02/23 at 9:10 AM revealed the staff delivering breakfast trays to the residents on Unit C. Review of the 4 Cycle Menus for Week 4 Monday Breakfast Menu documented: Scrambled Eggs, Bacon Sliced (for Regular Diet), Sausage Patty (for Chopped Diet, Mechanical Soft diet and Pureed diets), Whole Wheat Toast 1 slice, Cream of Wheat, Coffee, Fruit Juice, Milk Whole, Boiled Egg, Cold Cereal Bowl and Fruited Yogurt. On 10/02/23 at 9:51 AM, interview with the Food Services Director (FSD). He stated, Three diet aides and one cook is scheduled to work for breakfast for a total of four. One of the staff members called in this morning and I called someone else to come in this morning. We have a lot of patients who are slow eaters and trays are left over from the night before. Fourteen workers work in the kitchen. Four people work in the afternoon for the dinner shift. The people in the morning work for the breakfast and lunch shift. We always serve breakfast. Attendance is good but once in a while someone will call out. Breakfast was late this morning because someone called out. Review of the Demographic Face Sheet for Resident #1 documented the resident was admitted on [DATE] with a diagnosis of hemiplegia, multiple sclerosis, cardiomyopathy hypertension, muscle weakness, dysphagia, major depressive disorder, atherosclerotic heart disease and anxiety disorder. Review of the Minimum Data Service (MDS) Quarterly assessment dated [DATE] for Resident #1 documented the resident's Mental Status (BIMS) Summary Score was 15, indicating no cognitive impairment and he was able to make his needs known and he required extensive assistance to total dependence with one person physical assist for adls (activities daily living) and limited assistance with one person physical assist for eating. Review of the Demographic Face Sheet for Resident #2 documented the resident was admitted on [DATE] with a diagnosis of hemiplegia, peripheral vascular disease, hypertension, atherosclerotic heart disease and osteoporosis. Review of the Minimum Data Service (MDS) Quarterly assessment dated [DATE] for Resident #2 documented the resident's Mental Status (BIMS) Summary Score was 15, indicating no cognitive impairment and he was able to make his needs known and he required limited assistance to total dependence with one person physical assist for adls (activities daily living) and supervision with setup help only for eating. Review of the Resident Council Meeting Minutes dated January 2023-October 2023 documented the following: 1) At the 2/23/23 meeting, the former Food Service Director discussed upcoming changes in the kitchen. He emphasized the collaboration of the dietary department to ensure the timely delivery of food trays at nursing stations; 2) At the 3/29/23 meeting, the former Registered Dietitian (RD) discussed upcoming changes in the kitchen. She emphasized the collaboration of the dietary department to ensure the timely delivery of daily food trays at nursing stations. Feedback and Concerns from the resident: Residents expressed concerns over meals not being delivered on a timely manner when they get to the nursing stations. Review of the Facility Assessment, updated 3/29/23 documented there were 14 Dietary staff and the Nutrition department provided individualized dietary requirements, liberal diets, specialized diets, cultural or ethnic dietary needs. On 10/02/23 at 11:00 AM, interview with the Consultant RD (Registered Dietitian). She stated, The FSD is not a CDM (Certified Dietary Manager). She [RD, Staff D] is overseeing the kitchen. She has only been here for a month. Our staffing pattern is meeting industry standards with 4 scheduled in the morning and they should be able to function. My responsibilities is help to oversee the kitchen for compliance. During the interview the Consultant RD became very upset and proceeded to cry over the status of the kitchen. Subsequent interview on 10/02/23 at 11:39 AM. She stated, There is a total of 14 staff that work in the kitchen plus the Food Service Director which brings the total to 15 workers in the kitchen. There are 4 workers scheduled in the morning for breakfast, 4 workers scheduled in the afternoon for dinner with 8 people total for the whole day. Observation on 10/02/23 at 11:53 AM revealed the lunch tray line was in progress. Three dietary workers and the Food Service Director were observed on the lunch tray line for a total of 4 workers. Seven dietary workers plus the Food Service Director were observed in the kitchen for a total of eight workers for lunch. Observation and interview of Resident #3 on 10/02/23 at 11:58 AM residing on Unit A, revealed the resident lying in bed and watching television. He stated, Yes, I am the Resident Council President. The breakfast comes between 8:00 AM-8:30 AM. In resident council meetings, certain people would complain about breakfast being served late. I have been here for four years. Review of the Demographic Face Sheet for Resident #3 documented the resident was admitted on [DATE] with a diagnosis of multiple sclerosis, osteoporosis, major depressive disorder and osteoarthritis. Review of the Minimum Data Service (MDS) Quarterly assessment dated [DATE] for Resident #3 documented the resident's Mental Status (BIMS) Summary Score was 15, indicating no cognitive impairment and he was able to make his needs known and he required extensive assistance to total dependence with one person physical assist for adls (activities daily living) and supervision with setup help only for eating. On 10/02/23 at 1:48 PM, interview with the Human Resources (HR) Consultant. She stated, On 1/01/23, we had ten dietary aides, three dietary cooks and one director of dietary services employed. On 10/02/23, we have nine dietary aides, four dietary cooks and one director of dietary services employed. On 10/02/23 at 2:47 PM, interview with the Director of Nursing (DON). She stated, I have been here one year. The only time I notice breakfast is late is when the food service director comes in to assist when someone calls out. I agree that breakfast was late today, more than 30 minutes. On 10/02/23 at 3:05 AM, interview with the Administrator. She stated, I have been here seven months. Someone did call out today in the kitchen and that made breakfast late.

Based on observation and interview, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety that include: failure to hold foods at regulatory temperatures, failure to clean and sanitize food preparation equipment after each use, failed to properly cover trash/garbage receptacle, failure to ensure cleaning cloth buckets have sufficient chemical levels, ensure that foods are thawed by regulatory regulations, failure to date and label all opened food containers, failure to eliminate dented food cans, and failure to handle clean silverware in a sanitary manor. The findings included: 1) Initial Kitchen/Food Service observation tour conducted on 12/19/22 at 9:00 AM, accompanied with the Food Service Director (FSD) noted the following: (a) Raw chicken (approximately 40 pounds) was noted to be thawing in the cooks sink with running cold water. The surveyor informed the FSD that regulation requires a continuous full stream of cold water at all times during thawing. (b) An overflowing trash/garbage container was noted to be leaning up against the condiment stand. The surveyor requested the trash be removed and the stand be sanitized. (c) A test of Cleaning Cloth Bucket #1 noted an insufficient level of chemical sanitizer as per regulation. (d) Observation of the cooks shelf noted an opened 5 pound container of Peanut Butter that was not labeled with an opening date per regulation. The surveyor requested that the container be discarded. (e) The bench mounted commercial can opener was noted to be heavily soiled and full of metal shavings. The surveyor requested that the opener not be used until proper cleaning, sanitizing, and a new replacement blade. (f) Observation of the dry storage room noted a dented #10 can of sliced Peaches. The FSD stated that dented cans are required to be checked upon delivery and removed from potential usage. (g) The cooks spice rack was noted to have numerous spices/ingredients ( garlic powder, paprika, thickener) that failed to have an opening date as per regulation. (h) The commercial slicing machine was noted to be soiled and pieces of dried food matter. The surveyor requested that the slicer be cleaned and sanitized prior to next use. (i) Soiled cleaning cloths were noted to be left on clean preparation counters when not in use. The surveyor requested that cleaning cloths be placed in sanitizing buckets when not in use. Also requested that the food preparation counters be cleaned and sanitized. (j) Food preparation skillets/pans (3) were noted to heavy thick layers of carbon. (k) During the observation of the food tray assembly line temperatures of hot foods located in the steam table were tested by the use of the facility's calibrated thermometer. The temperature testing noted that hot foods were not being held at the regulatory temperature of 135 degrees Fahrenheit ( F) or greater. The temperatures were recorded as follows: Scrambled Eggs (40 serving) = 122 degrees F Pancakes (30 portions) = 123 degrees F . 2) During a second Kitchen/Food service observation conducted on 12/20/22 at 7:00 AM. Temperatures of foods were take by the use of the facility's calibrated thermometer. The findings noted that food were not being held by regulatory requirement of 41 degrees or below or 141 F degrees or above, as evidenced by : Sausage Links (40) = 122 degrees F Waffles (40 ) = 123 degrees F Pureed Scrambled Eggs (20 portions) = 122 F Milk Cartons (30 servings) = 53 degrees F 3) During a third kitchen/food service observation tour conducted on 12/21/22, it was noted that a diet aide (Staff ) was wrapping silverware in plastic bags. Further observation noted that the staff was handling the silverware in an unsanitary manor, specifically the silverware was scattered an open dishrack and staff was handling the silverware by the eating portion. The FSD was asked to view the situation and hand the silverware rewashed and put into proper silverware cylinders for proper handling.

Based on observation, interview, and record review, it was determined that the facility failed to provide 37 residents with reasonable accommodations for food preferences. there were 132 residents residing in the facility at the time of the survey. The findings included: During the observation of the food tray line in the main kitchen on 12/20/22 at 7:00 AM, numerous tray meal tickets were observed by the surveyor. The tickets were noted to document specific food preference for every resident's meal. Further observation of the tray tickets noted request for Prune Juice and Yogurt potions (regular, fruited, and sugar free). The observation noted that these residents did not receive food preferences of prune juice and or Yogurt. Interview with Food Service Director (FSD) at the time of observation noted to state that these foods were not included in the last delivery and residents were without these food preferences for past 3 to 4 days and hoped that they would come with the next delivery on 12/21/22. It was also noted during the interview with the FSD that these foods could easily be easily obtained and delivered by different food companies in the area or designated staff could go out to local stores to purchase. Follow up interviews conducted with residents whose tickets indicated the request for these foods noted to state that the prune juice has not been available for weeks and Yogurt has not been available for a week. A review of resident meal tickets noted that there was documentation that 7 residents requested Prune Juice for every breakfast and 30 residents requested Yogurt for at least 1 to 3 meals daily. During an observation of the food tray line on 12/21/22 at 7:15 AM, it was noted that resident's requesting prune juice and/or Yogurt received a portion of their preference on their food tray. The FSD stated that she had gone to a local food company in the area on 12/20/22 and had purchased the prune juice and Yogurt.

Based on observation and interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 4 of 4 residential units (100 Unit, 200 Unit, 300 Unit and 400 Unit), in-house dialysis room, and laundry area. The findings included: During the initial resident screening conducted on 12/19/2022 and the environment tour conducted on 12/22/2022 to 12/23/2022 accompanied with the Corporate Maintenance Director, the following were noted on the 100 Unit: room [ROOM NUMBER]: Bathroom shower head would not shut off (continually running), and room walls damaged and in disrepair. room [ROOM NUMBER]: Numerous holes in bathroom wall, and 2 of 4 bathroom lights out. room [ROOM NUMBER]: Toilet requiring recaulking to floor, bathroom walls damaged and in disrepair, toilet seat loose, and 2 of 4 bathroom lights out. room [ROOM NUMBER]: Numerous small holes in bathroom wall, bathroom floor heavily stained throughout, and rusted metal glove box holder. room [ROOM NUMBER]: Shower curtain covered in black mold type matter, wheelchair arms cracked and torn. Observation on the 200 Unit revealed: room [ROOM NUMBER]: Nightstand exterior damaged and worn, room dresser exterior was damaged and on disrepair, over-bed table exterior heavily worn and damaged, 2 of 4 room lights out, and 2-4 bathroom lights out. room [ROOM NUMBER]: Room walls damaged and in disrepair, wheelchair arms (2) ripped and torn, toilet requires recaulking to the floor, over-bed table exterior worn and sharp exposed wood, shower stall floor heavily stained, room [ROOM NUMBER]: Room walls damaged and in disrepair. Observation on the 300 Hallway revealed: room [ROOM NUMBER]: Bathroom floor was heavily stained and a large part of linoleum was missing at the entrance to the shower stall. room [ROOM NUMBER]: Bathroom floor heavily stained and toilet requires recaulking to the floor. room [ROOM NUMBER]: Bathroom floor heavily stained, bathroom floor wet from pie leak, toilet seat stained yellow, and toilet requires recaulking to the floor. room [ROOM NUMBER]: Over-bed table exterior was in disrepair and required replacement, exterior of room chair heavily worn, and 2 of 4 room lights out, and 3 of 4 bathroom lights out. room [ROOM NUMBER]: Room walls (2) noted to have large black scuff areas, toilet requires recaulking to the floor, and bathroom floor heavily stained throughout. room [ROOM NUMBER]: Room base boards noted to have large black scuff marks, bathroom floor missing large piece of linoleum, toilet requires recaulking to the floor, and bathroom floor heavily stained. room [ROOM NUMBER]: Refrigerator (Bed-A) soiled and requires cleaning and sanitizing, bathroom floor grout stained black. Room #: 315: Room trash can had no plastic liner, bathroom shower tiles (3) broken with sharp edges, toilet requires recaulking to the floor, and room privacy curtain had multiple large stains. room [ROOM NUMBER]: Bathroom ceiling tiles (5) water stained and required replacement. room [ROOM NUMBER]: Over-bed table exterior damaged and requires replacement, bathroom door exterior damaged and disrepair, and toilet requires recaulking to the floor. room [ROOM NUMBER]: Toilet requires recaulking to the floor, exterior of room chair heavily worn, and room walls (2) damaged and in disrepair. room [ROOM NUMBER]: Water leak in bathroom, exterior of dresser in disrepair, and toilet requires recaulking to the floor. Observation on the 400 Unit revealed: room [ROOM NUMBER]: bathroom toilet requires recaulking to the floor. Pantry: Leftover foods (fish and french fries) left in kitchen cabinet, outside exterior of refrigerator was rust laden, and door gaskets heavily soiled. 41837 During a tour of the Dialysis room that was left unlocked and unattended on 12/20/22 at 2:35 PM an observation was made of an open wine bottle half full (Photographic Evidence Obtained). There was a large can of Insect Spray in cabinet with various dialysis supplies (Photographic Evidence Obtained). During a tour of the laundry room conducted on 12/21/22 at 1:00 PM with Corporate Director of Maintenance the following observations were made of covers for the clean linen carts that were worn thread bare and holes (Photographic Evidence Obtained), covers for the dirty linen were worn thread bare and holes (Photographic Evidence Obtained), the bins for the dirty linens were dirty, in the dryer room there was laundry detergent chemicals stacked up on wooden pallets (Photographic Evidence Obtained), also in the dryer room inside of the 2 dryers the drums were rusted and had melted debris (Photographic Evidence Obtained), the washer room floor had peeling/chipped paint (Photographic Evidence Obtained), also located in the washer room was a vent to the outside that was caked with dust and dirt (Photographic Evidence Obtained), in the folding room, the table had a wooden shelf located under the table that was broken and splintered (Photographic Evidence Obtained). During an interview conducted on 12/20/22 at 2:50 PM with the Administrator who was shown the findings in the unlocked/unattended dialysis room of the half bottle wine and the insect spray in with the dialysis supplies, she responded by saying those items should not be in there. During an interview conducted on 12/21/22 at 1:30 PM with Corporate Director of Maintenance he stated that he took notes during the tour and has a feeling he will be coming to this facility for quite some time.

Based on observation, interview, and record review, it was determined that the facility failed to ensure residents residing on the 300 Unit remained free of potential accident hazards from unsafe hot water temperatures in resident rooms and common shower areas. The findings included: During the screening of residents and rooms on the 300 Unit on 12/19/22 at 9 AM, the bathroom hot water was checked by the surveyor in room [ROOM NUMBER]. The check revealed that the surveyor could not keep his hand in the water and noted be scalding to the touch. The surveyor requested the Director of maintenance to the room to check the actual hot water temperature with the use facility's thermometer. The Director stated that he has only had the director's position for approximately 1 to 2 months and did not have a thermometer. The director stated that he takes hot water temperatures daily of resident rooms. The surveyor asked how that is accomplished if there is no thermometer available for testing. The surveyor then requested that the director bring whatever thermometer that is currently being used and any recorded temperature logs. The director returned with no temperature logs and a laser thermometer that he attempted to use to take the hot water temperature in room [ROOM NUMBER]. The surveyor informed the director that a laser beam cannot be used to test water temperature because the beam cannot penetrate the water stream to get an accurate temperature. The surveyor requested that the director obtain a bayonet thermometer from dietary to use as testing the hot water temperature. A test of the hot water in room [ROOM NUMBER] was recorded at 125 degrees F and informed the director that action to lower the temperature take place immediately. The director stated that the 300 Unit has its own hot water heater and the surveyor requested to observe the hot water/boiler room located on the 300 Unit. Observation of the hot water tank noted that it was set at 120 degrees F and the surveyor requested the temperature be turned down to an acceptable (non-scalding) temperature range of 105 - 110 degrees F. The surveyor also requested that the hot water tank be emptied immediately and filled with cool tap water. The surveyor also requested that a plumbing contractor be called to assess the facility's hot water tanks and to maintain a log of hot water temperatures hourly to ensure an acceptable hot water range of 105-110 degrees F. Temperatures of the 100, 200, and 400 units were also taken and noted to be in acceptable ranges. It was also noted that no residents on the 300 Unit use sink hot water or shower hot water independently. At 10:00 AM following the emptying of the 300 Unit water tank it was also noted that the hot water temperatures in resident rooms were lowered to acceptable temperature of 110 degrees F. On 12/19/22 the surveyor met with the plumbing contractor and was informed that the hot water systems were evaluated on all resident wings and stated that the Hot water Mixing Valve required replacement and the parts would be obtained and installed on 12/20/22. The surveyor requested that room temperature monitoring and documentation continue to be conducted until the issues was resolved. On 12/20/22 the temperature logs were reviewed by the surveyor and noted that hot water temperatures were in acceptable ranges on 105-110 degrees F. On 12/20/22 the surveyor again met with the plumbing contractor who stated the 300 Unit mixing valve had been successfully installed. Following the interview, the surveyor tested rooms in the 300 Unit (#308, #309, #317, and 312) and were recorded at 106 - 112 degrees F. Meeting with the administrator on 12/20/22 noted the surveyor to state that the hot water plumbing system be checked by a plumbing contractor on a regular basis to ensure safe hot water temperature and no potential resident hot water burns. Review of facility's Policy Statement: Water Temperatures. Submitted to survey team on 12/20/22 indicated: 1) Water heaters that service resident rooms and shower/tub areas shall be set to temperatures of no more than 105-110 F 2) Maintenance staff is responsible for checking thermostats and temperature controls in the facility and record the water temperatures in a safety log. 3) Maintenance staff shall conduct periodic tap water temperature checks and record water temperatures in a safety log. 4) If at any time water temperatures feel excessive to the touch staff will report these findings to the immediate supervisor. Meeting with the Administrator on 12/22/22 noted that the hot water mixing valve had been removed and replaced and no leakage. The administrator was informed that the Hot Water Policy was not followed for items #1 through #4.

Based on observation, interview, and record review, it was determined that the facility failed to follow physician ordered High Calorie/High Protein Diet (Fortified/Enhanced Foods) for 18 residents out of 18 that included 6 sampled residents (Resident #24, Resident #39, Resident #78, Resident #89, Resident #102, and Resident #122) failure to follow physician ordered Fluid Restriction for 1 of 2 (Resident #49), and failed to provide physician ordered supplements for weight loss for 51 residents ( Resident #63, Resident #68, Resident #83, and Resident #106). The findings included: During the observation of the tray line in the main kitchen for the lunch meal of 12/19/22 at 11:30 AM and the breakfast meal on 12/20/22 at 7:00 AM, it was noted that numerous meal tray tickets documented milkshakes with meals. Continued observation noted that a commercial milkshakes was not included on the residents meal trays for the breakfast and lunch meals. An interview conducted with the Food Service Director (FSD) at the time of the observations. The FSD stated that the commercial milkshakes are assessed by the Dietitian and ordered by the attending physician for residents at nutritional risk and weight loss. The FSD reported that the milkshakes are commercially prepared, packed, and delivered frozen to the facility. The facility vendor had not delivered the frozen commercially prepared milkshakes for the past 7 days and so the milkshakes have not been issues on the residents' trays. Further interview revealed that the FSD failed to order the commercial milkshakes from another vendor and failed to notify the facility's Dietitian for a possible replacement (puddings, ice cream, etc.) or prepared the milkshakes house. A review of the facility diet census noted that there were 51 residents with physician orders for Milkshakes. The 51 resident's included sampled Resident #63, Resident # 68, Resident #83, and Resident #106). During the observation of the lunch meal in the main kitchen on 12/20/22 at 1:30 PM, it was noted that the tray line did not have a Fortified/Enhanced (High Calorie/Protein) food prepared and or served. Interview conducted with the Food Service Director (FSD) and Cook (Staff A) at the time of the observation revealed that the fortified mashed potato were not made and that a fortified food would not be served for the lunch meal. Further investigation of the Fortified/Enhanced Food Program revealed that the fortified foods are limited daily to fortified oatmeal for breakfast and fortified mashed potato for the lunch and dinner meals. It was discussed with the FSD that more foods should be included in the Fortified Program to ensure a variety of foods for residents who are malnourished/underweight to ensure good intake of the high calorie/protein foods. During the interview the surveyor requested the facility's Fortified/Enhanced Food policy and procedure. On 12/20/22 the surveyor was informed by the FSD that the facility did not have a policy. it was discussed by the surveyor that a policy should be developed to ensure who is a candidate for the program, what meals fortified/enhanced food will be served, what food shall be provided, types of foods provided (entree, soups, starches, desserts, drinks, and supplements) to proved a variety, and periodic evaluation of the program to ensure effectiveness. During the review of the facility's Diet Census for 12/20/22 it was noted that 18 residents currently had physician ordered Fortified/Enhanced Foods (High calorie/high protein) for meals. Of the total 18 resident's of which 6 sampled residents were to receive fortified/enhanced foods for the lunch meal as of 12/20/22. The sampled resident reviewed for nutrition included Resident #24, Resident #39, Resident #78, Resident #89, Resident #102, and Resident #122. On 12/20/22 the surveyor requested the facility's policy statement for : Fortified/Enhanced Food Program. The surveyor was informed by the administration that a policy had not been developed and implemented for a Fortified/Enhanced Food Program. On 12/22/22 the FSD submitted the facility's Fortified Food Recipes to the surveyor for review. The review noted that the facility's Fortified program was limited to only 3 foods; Fortified Oatmeal, Fortified Mashed Potatoes, and Hi Ca; Hi Pro Cream Soup. It was discussed that a Fortified Food police needs to be developed and additional variety of Fortified Foods need to added to the fortified menu. During the observation of Resident #49 during the breakfast meal on 12/21/22 at 9:00 AM it was noted noted that the meal tray served to the resident's room. A review of the meal tray ticket noted the following: * Controlled Carbohydrate /Renal - Enhanced Foods - Double Portions * Fluid Restriction 240 ml (milliliters) - 8 oz coffee or 4 oz coffee and 4 oz juice - * Standing orders: Hot tea 8 oz , and 8 oz water A calculation of the fluids served on the tray noted 720 ml as per the following; 8 ounce Coffee (240 ml) 8 oz Tea (240 ml) 4 oz Water (120 ml) 4 oz Apple Juice (120 ml) Total amount of fluids served on the tray = 720 ml At the request by the surveyor a review of the resident's lunch meal ticket was noted to document the following: * Fluid Restriction 240 ml - 4 oz (ounces) water , 4 oz juice * Double Portion : Standing orders: 8 oz juice , 8 ounce water Total amount of fluid to be served was 720 ml on the tray. A review of the resident's dinner meal ticket also noted the following: * Soup 4 ounces (120 ml) * Water = 4 oz (120) *Standing Order: 8 oz Hot tea (240 ml) Total amount of fluid to be served was 480 ml A calculation of the total amount of fluids that would be included on the meal trays = 1920 ml Review of Resident # 49's clinical records noted the resident was admitted [DATE], clinical diagnoses include but not limited to End Stage Renal Disease (ESRD) and Dependence on Renal, Heart Failure and Diabetes. Dialysis. Current Physician Orders dated 3/25/22 included No Added Salt ( NAS), CCHO (Consistent Carbohydrate Diet), Renal Diet, 1200 ml Fluid Restriction. Order dated 10/14/22 - Fluid Restriction - 1200 - Nursing = 600, Supplement = 240, 7-3 = 120, 3-11 = 120 11-7 = 120. On 12/21/22 the resident's fluid restriction order and meal tickets were reviewed with the Food Service Director FSD). It was concluded that the fluids being provided on the meal trays exceeded the physician orders for 600 ml per day. It was further discussed that 1920 ml fluids were being provided. The FSD confirmed the the Fluid Restriction was not being followed as per physician order and would contact the facility's Registered Dietician to recalculate the fluid restriction and make appropriate changes to the resident's meal tickets.

Based on observations, interviews, and policy review, the facility failed to provide a safe sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. The findings included: Review of the facility's policy titled, Isolation - Categories of Transmission-Based Precautions, with a revised date of January 2022 included: Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. The signage informs the staff of the type of CDC (Center for Disease Control) precaution(s), instructions for use of PPE (Personal Protective Equipment), and/or instructions to see a nurse before entering the room. Gloves, gown, and goggles should be worn if there is risk of spraying respiratory secretions. Review of the facility's policy titled, Sharps Disposal, with a revised date of January 2022 included: This facility shall discard contaminated sharps into designated containers. Whoever uses contaminated sharps will discard them immediately or as soon as feasible into designated containers. Contaminated sharps will be discarded into containers that are: Closable, puncture resistant, Leakproof on sides and bottom, Labeled or color-coded in accordance with our established labeling system; and Impermeable and capable of maintaining impermeability through final waste disposal. Review of the facility's policy titled, Homelike Environment with a revised date of January 2022 included: Residents are provided with a safe, clean, comfortable, and homelike environment. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean, sanitary, and orderly environment. 1 On 12/19/22 at 7:50 AM during a drive around the parameter of the facility, prior to entering the facility an observation was made of the dumpster top propped open with medical waste (including used gloves, used syringe, used intravenous [IV] tubing, used IV bags, and medication containers, used tube feeding bags, used medical/treatment tubing, and used masks) were piled up directly in front of the dumpster (Photographic Evidence Obtained). 2 During an observation on 12/19/22 at 12:58 PM of Staff F Certified Nursing Assistant (CNA), knocked on entrance door to room [ROOM NUMBER] (labeled contact-based and droplet-based precautions), Staff F CNA notified the resident that she would be in in a moment. Staff F CNA was wearing an N-95 mask and proceeded to put on an isolation gown and gloves, she did not put on any personal protective equipment for her eyes (Face Shield or Goggles) and entered room [ROOM NUMBER] at 12:59 PM. 3 During an observation on 12/20/22 at 8:37 AM in room [ROOM NUMBER] there was biohazard waste bin (Red biohazard bag lining a cardboard box) that was full and uncovered. Next to the full and uncovered biohazard bin was a full and open/untied red biohazard bag (Photographic Evidence Obtained). 4 During an observation on 12/20/22 at 9:30 AM of Staff H Certified Nursing Assistant (CNA), was bringing a breakfast tray into room [ROOM NUMBER]. The entrance door to room [ROOM NUMBER] was labeled contact-based and droplet-based precautions. Staff H (CNA) was observed wearing an N-95 mask covered with a surgical face mask, she put on an isolation gown and proceeded to bring the breakfast tray into room [ROOM NUMBER]. Staff H (CNA) was observed not wearing any gloves or eye protection (Face Shield or Goggles). 5 During a tour of the unlocked and unattended Dialysis Room on 12/20/22 at 2:35 PM an observation was made of the only sharps container (half full) which had an opening on the top that was approximately 6 inches wide by 3 inches high (Photographic Evidence Obtained). During an interview conducted on 12.20/22 at 9:35 AM with Assisted Director of Nursing (ADON), who was assisting passing breakfast trays in the isolation hallway on Unit A, when asked what PPE the staff need to wear when they enter a room that was labeled with droplet-based and contact-based precautions, protection, The ADON stated they should wear a face shield or goggles and gloves. The ADON stated that staff should not wear gloves if they are feeding a resident because it is a dignity issue. When asked to clarify that staff do not need to wear gloves to feed a resident who is on droplet-based and contact-based precautions, she stated that is correct. During an interview conducted on 12/19/22 at 2:00 PM with Staff G, a Licensed Practical Nurse (LPN) when asked what PPE is required to be worn when going into a room that has a label on the entrance door for droplet-based and contact-based precautions, Staff G stated the PPE that is needed is an N-95 mask, a gown, gloves, and face shield or goggles. During an interview conducted on 12/20/22 at 9:45 AM with Staff H, a Certified Nursing Assistant (CNA), when asked what PPE is required to be worn when going into a room labeled droplet-based and contact-based precautions, such as room [ROOM NUMBER], Staff H stated that she went into room [ROOM NUMBER] to feed the resident breakfast and the resident is not Covid positive so the staff do not have to wear gloves to feed the resident because it is a dignity issue. when asked about a face shield or goggles, she replied she wears glasses. During an interview conducted on 12/20/22 at 10:50 AM, the Director of Nursing (DON) stated that when staff go in to feed a resident who is on droplet-based and contact-based precautions, staff are required to wear personal protective equipment (PPE) N-95 mask, gown, eye protection, and gloves.

Based on observations, interviews, and record review the facility failed to provide showers per resident preferences for three sampled residents reviewed for showers (Resident #38, Resident 83, and Resident #110). The findings included: 1) During the initial tour of the facility and initial resident interview conducted on 12/19/22 at 9:35 AM, Resident #38 stated she only receives showers one time per month. When asked to clarify, Resident #38 stated she prefers to have showers at least one time per week. During this interview, the surveyor observed that Resident #38 appeared unkempt. Record review revealed Resident #38 had a medical history significant for cerebral infarction, heart failure, chronic obstructive pulmonary disease, obesity, atrial fibrillation, kidney disease, depression, falls, and anxiety. A Quarterly Minimum Data Set (MDS) was done for Resident #38 on 10/25/22. This MDS documented Resident #38 had a Brief Interview of Mental Status (BIMS) score of 10, which indicates she had moderate cognitive impairment. This MDS also documented Resident #38 was totally dependent on facility staff for bathing activities. Review of Resident #38's Care Plan revealed there was no care plan in place regarding Resident #38 refusing showers. Review of the Certified Nursing Assistant (CNA) task sheet for Bathing for the date range of 11/23/22-12/21/22 showed no documentation of Resident #38 having received a shower during that time, only bed baths were documented. This document also showed Resident #38 was totally dependent on staff for bathing activities. On 12/22/22 at 9:14 AM, during an interview Resident #38 stated she still had not had a shower but that she wanted one. 2) During the initial tour of the facility and initial resident interview conducted on 12/19/22 at 9:27 AM, Resident #83 stated that he was supposed to be receiving a special shampoo for his hair but was not sure if he was receiving it. When asked how often he would prefer to shower, Resident #83 stated he would like showers multiple times per week. The surveyor noted during the interview that Resident #83's hair appeared to be greasy and unkempt. Record review revealed Resident #83 had a medical history significant for heart failure, cerebral infarction, diabetes, cardiomyopathy, chronic kidney disease, malnutrition, depression, and transient ischemic attack. A Quarterly Minimum Data Set (MDS) was done for Resident #83 on 10/25/22. This MDS documented Resident #83 had a Brief Interview of Mental Status (BIMS) score of 6, which indicates he had moderate cognitive impairment. This MDS also documented Resident #83 was totally dependent on facility staff for bathing activities. Review of Resident #83's Care Plan revealed there was no care plan in place regarding Resident #83 refusing showers. Review of the Certified Nursing Assistant (CNA) task sheet for Bathing for the date range of 11/23/22-12/21/22 documented Resident #83 received one shower on 12/07/22 but the rest documented bed baths only. This document also showed Resident #83 was totally dependence on staff for bathing activities. An interview was conducted on 12/22/22 at 9:17 AM with Resident #83. He stated he is still not sure if they are using the special shampoo on him and that he has not had a shower since the beginning of the survey. The surveyor noted at this time that Resident #83's hair still appeared to be greasy and unkempt. 3) During the initial tour of the facility and initial resident interview conducted on 12/19/22 at 9:32 AM, Resident #110 stated she never gets showers, only bed baths. When asked to clarify, Resident #110 stated she prefers to have showers at least one time per week. During this interview, the surveyor observed that Resident #110 appeared unkempt. Record review revealed Resident #110 had a medical history significant for diabetes, cerebral infarction, depression, and malnutrition. A Quarterly Minimum Data Set (MDS) was done for Resident #110 on 09/23/22. This MDS documented Resident #110 had a Brief Interview of Mental Status (BIMS) score of 15, which indicates no cognitive impairment. This MDS also documented Resident #110 was totally dependent on facility staff for bathing activities. Review of Resident #110's Care Plan revealed there was no care plan in place regarding Resident #110 refusing showers. Review of the Certified Nursing Assistant (CNA) task sheet for Bathing for the date range of 11/23/22-12/21/22 showed no documentation of Resident #110 having received a shower during that time, only bed baths were documented. This document also showed Resident #110 was totally dependent on staff for bathing activities. During an interview on 12/22/22 at 8:05 AM, Resident #110 stated she still had not had a shower but that she wanted one.

Based on interviews and record reviews the facility failed to update the code status for 1 resident out of 3 sampled residents (Resident #106). The findings included: Review of the facility's policy titled Do Not Resuscitate Order with a revised date of [DATE] included: Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a DO Not Resuscitate Order in effect. Record review for Resident #106 revealed that the resident was originally admitted to the facility on [DATE] with the most recent readmission on [DATE] with diagnoses that included: Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Type 2 Diabetes Mellitus with Hyperglycemia, Unspecified Severe Protein-Calorie Malnutrition, Immunodeficiency, and Systemic Inflammation Response Syndrome (SIRS) of Non-Infectious Origin without Acute Organ Dysfunction. Review of the Minimum Data Set (MDS) for Resident #106 revealed the MDS was not completed and therefore no Brief Interview of Mental Status BIMS score was obtained. Review of the Documents in the electronic medical record revealed a signed and dated Do Not Resuscitate Form for Resident #106. Review of the face sheet/profile sheet for Resident #106 revealed the code status was left blank. Review of the Physician's Orders for Resident #106 revealed there was no order regarding code status. During a review of the Care Plans for Resident #106 on [DATE] there was no care plan for advance directives. During an interview conducted on [DATE] at 12:25 PM with Resident #106, when the resident was asked about her advanced directive status, she simply just looked at the surveyor and did not speak. During an interview conducted on [DATE] at 3:00 PM with the Director of Nursing (DON), when asked how staff know the code status of a resident, the DON stated that it is located on the face sheet in the electronic medical record, it will say Do Not Resuscitate (DNR) or Full Code. If the resident is a DNR they will also have an order for DNR as well. When asked how the code status is populated to the face sheet, she stated the admission nurse will fill in that information if they know it when taking the information from the transferring facility, before of the admission of the resident and then the admitting nurse verifies the code status information to make sure it is correct, and an order is entered. During an interview conducted on [DATE] at 10:14 AM with the Assistant Director of Nursing (ADON) when asked who obtains information from the transferring facility for a resident being admitted or readmitted , she stated it would be one of the supervisors, including herself. When asked if advanced directives information is obtained at that time, she stated yes of course. When asked how staff identify the code status of a resident, she stated it would be on the face sheet/profile sheet in the electronic medical record and there would be an order (DNR or Full Code), and if the resident is a DNR a copy of the form would be uploaded under documents and the original DNR form would be in the front of the resident's paper chart. When asked if a resident is a full code, where is this documented, she stated it is put in as an order in the Medication Administration Record and this gets populated to the face sheet/profile sheet for the resident. When asked if a resident has a DNR status where is this documented, she stated this also is put in as an order in the Medication Administration Record and this gets populated to the face sheet/profile sheet for the resident, with a copy of the DNR sheet uploaded to the electronic medical record and the original is in the front of the paper chart. When asked who enters the DNR order, she stated the admitting nurse will verify the resident has a DNR form, she then confirms this with the resident or their representative that they wish to be a DNR. The nurse will then communicate with the physician to obtain the order for DNR and enter it as a physician's order into the resident's electronic medical record. When asked if the code status on the resident's face sheet/profile sheet is blank and there was an emergency how would you expect staff to address the resident, she stated that the staff would have to treat the resident as if they were a full code and initiate CPR until they verify in the chart what the code status is. The staff would verify the code status for the resident by looking in the paper chart for the original DNR form. The ADON and surveyor went to clarify if there was a DNR form in the front of the chart for Resident #106, and there was no DNR form in the front of the chart, nor was it under the Advance Directives tab in the paper chart. The ADON did eventually locate the DNR form in the paper chart for Resident #106. She agreed that there was a potential for Resident #106 to have life saving measures in an emergency despite having a completed DNR.

Based on observations, interviews, and record review the facility failed to secure the confidentiality of medical information for residents receiving dialysis for 10 (Resident #40, Resident #53, Resident #92, Resident #100, Resident #107, Resident #118, Resident #177, Resident #330, and Resident #424) out of 10 residents with dialysis services and the facility failed to secure the confidentiality of medical information for a resident receiving podiatry services (Resident #100). The findings included: Review of the facility policy titled Protected Health Information (PHI), Management and Protection of with a reviewed date of January 2022 included: Protected Health Information (PHI) shall not be used or disclosed except as permitted by current federal and state laws. It is the responsibility of all personnel who have access to resident and facility information to ensure that such information is managed and protected to prevent unauthorized release or disclosure. Physical access to health information is limited to individuals who are authorized to access the records or continuity of care and must be safeguarded. Review of the facility's policy titled Protected Health Information (PHI), Management and Protection of with a revised date of January 2022 included: Protected Health Information (PHI) shall not be used or disclosed except as permitted by current federal and state laws. It is the responsibility of all personnel who have access to resident and facility information to ensure that such information is managed and protected to prevent unauthorized release or disclosure. 1) During a tour of the Dialysis room that was left unlocked and unattended on 12/20/22 at 2:35 PM an observation was made of Facility In-House Dialysis Schedule dated 12/19/22 that included 9 of the following resident names listed: Resident #40, Resident #53, Resident #92, Resident #100, Resident #107, Resident #118, Resident #177, Resident #330, and Resident #424. During a tour of the Dialysis room that was left unlocked and unattended on 12/20/22 at 2:38 PM an observation was made in the dialysis room of a Patient Care Information Between Nursing Home and Kidney Center form with Resident #53 medical information on a clipboard located on a shelf under a copy/fax machine. During an interview conducted on 12/22/22 at 11:20 AM with the Director of Nursing (DON) when asked about keeping resident information confidential and secure, she stated that all staff are responsible to keep resident personal and health information secure and confidential with paper and electronic medical records. 45951 2) During a tour of the facility conducted on 12/21/22 at 9:37 AM, the surveyor observed a piece of paper containing resident information, including the information of Resident #100, sitting on top of the nurse's station on the 300-Unit along with personal belongings (photographic evidence obtained). The surveyor asked staff who were near the nurse's station. The staff stated it belonged to the nurse of the podiatrist. The surveyor asked the podiatrist's nurse if the paperwork was hers. She agreed it was her paperwork and removed it from on top of the nurse's station. When the surveyor asked her for her name, she walked away and did not respond.

Based on record review and interviews the facility failed to initiate an investigation following an incident affecting 1 of 3 residents reviewed for accidents and incidents (Resident #226). The findings included: The policy of the facility titled Accidents and Incidents-Investigating and Reporting revised January 2022 reveals All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Review of clinical records revealed Resident #226 was admitted post hospitalization to the facility on [DATE]. Resident #226 was a [AGE] year-old female with diagnoses that included Acute Respiratory Failure with Hypoxemia, Tracheostomy Status, Unspecified Dependence on Renal Dialysis, Cerebral Infarction and Dysphagia. A review of nursing progress noted dated 03/26/22 revealed the resident had a dialysis catheter in place to right upper chest. Dialysis catheter placement inserts a tube (catheter) under the skin and into a major vein. On 03/27/22 at 8:15 PM in the first nursing progress note of the day, the note reveals the resident accidentally pulled out her dialysis catheter and call had been placed to MD (Medical Doctor). Dialysis catheter noted on chest as reported. No bleeding noted. 8:40 PM call placed to 911. 8:47 PM 911 transferred resident to .(hospital). On 12/21/22 at 3:30 PM this event was discussed with the Administrator who stated she was unaware of the incident. She stated an incident report should have been done. An interview was conducted with Staff D, Registered Nurse, on 12/22/22 at 8:24 AM. Staff D stated that she worked the 3:00 PM to 11:00 PM shift and the daughter was in the room with the resident, and everything was ok. She was told that the resident pulled out the catheter and she saw the catheter on her chest. There was no blood on the sheets, and she called the doctor. Doctor said to send the resident 911 and she went back to the room to tell the daughter and the daughter said to send her to . [hospital name]. Staff D was asked when the catheter came out and she was unable to give a time. Staff D revealed she told the next shift, and she is unsure if a call was made to the hospital to see if the resident was admitted . Staff D stated she was unsure if she was to do an incident report and did not do a report.

Based on observations, interviews, and record review, the facility failed to provide fingernail care for 5 out of 6 residents reviewed for Activity of Daily Living (ADL) care (Residents #79, Residents#112, Residents#39, Residents#68, Residents #110). The findings included: Review of the facility's policy titled Fingernails, Care of with a revised date of February 2022 included: The purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infections. Nail care includes regular trimming. Proper nail care can aid in the prevention of skin problems around the nail bed. Review of the facility's policy titled Activities of Daily Living (ADLs), Supporting with a revised date of January 2022, included: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain food nutrition, grooming and personal and oral hygiene. 1) Record review for Resident #79 revealed the resident was admitted on [DATE] with diagnoses that included: Personal History of Traumatic Brain Injury, Adult Failure to Thrive, Epilepsy, and Todd's Paralysis. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #79 had a Brief Interview for Mental Status of 6, which indicated that he had severe cognitive impact. Review of Section G revealed that Resident #79 had a self-performance for bed mobility, dressing, and personal hygiene of extensive assistance with support of one-person physical assist. Review of the Care Plan for Resident #79 with a focus on the resident has an ADL self-care deficit r/t (related to) Dx (Diagnoses) of Todd's Paralysis, Seizure Disorder, h/0 (history of) TBI (Traumatic Brain Injury) HTN (Hypertension), with a goal for the resident to maintain and/or improve ADL functioning through next review date. Interventions included: Encourage and assist with ADL tasks as indicated, as tolerated by resident, including locomotion/ambulating, bathing, bed mobility, transfers, toileting tasks, meals, personal/oral hygiene, etc. During an observation conducted on 12/19/22 10:40 AM, Resident #79's fingernails noted to be extremely long (approximately 2 inches past the tip of the fingers), with jagged edges, yellowed, and very thick (Photographic Evidence Obtained). During an interview conducted on 12/19/22 at 10:42 AM, Resident #79 was asked if he likes his nails long, he said no and made a cutting motion on his nails. When asked if he has asked staff to cut his nails, he said yes but they never come to cut his nails. 2) Record review for Resident #112 revealed that the resident was admitted to the facility on [DATE] with diagnoses that included Rheumatoid Arthritis, Dementia, and Muscle Weakness. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #112 had a Brief Interview for Mental Status of 7, which indicated that she had severe cognitive impact. Review of Section G revealed that the resident had a self-performance for bed mobility, dressing, eating, toilet use, and personal hygiene of total dependence with support of one person assist. Review of Nutrition Note for Resident #112 dated 10/26/2022 included: Resident is on regular, puree/nectar liquid diet with snacks HS (hour of sleep). Per nursing, resident has poor appetite and prefers to drink liquids, eat sweets, and finger food she can hold. Review of the Care Plan for Resident #112 dated 11/09/2022 with a focus on the resident requires assistance with ADL care related to multiple factors including weakness/decreased mobility s/p recent hospitalization /illness. Dx (Diagnoses): Dementia, FTT (Failure to Thrive), and Rheumatoid Arthritis. The goal is for the resident to maintain and/or improve current level of function through next review date. Interventions included: Encourage and assist with all ADL tasks as indicated, as tolerated by resident, including locomotion/ambulation, bathing, bed mobility, transfers, toileting tasks, meals, personal/oral hygiene, etc. During an observation conducted on 12/19/22 at 10:58 AM, Resident #112's fingernails were very long (approximately 1.5 inches past the tip of her fingers) with jagged edges and dried black substance under her nails. During an interview conducted on 12/19/22 at 11:00 AM with Resident #112 when asked if she would like her nails to be cut, she said yes. During an interview conducted on 12/21/22 at 9:38 AM with Director of Activities when asked if they provided nail care, she reported they do not do any clipping, they have Nail Days once a week that include cleaning, polishing and hand massages only. The CNAs (Certified Nursing Assistants) are responsible for cutting the fingernails. During an interview conducted on 12/22/22 at 11:00 AM with the Director of Nursing, when asked who is responsible for the cutting of the fingernails for the residents, she stated the Certified Nursing Assistants (CNAs) cut and clean the fingers for residents who are not diabetic, and the nurses are responsible to cut the fingernails for the diabetic residents. When asked where it is documented that the residents' nails have been cut, filed, or cleaned, she stated, it could be under the tasks for the CNAs, but I do not think they document it anywhere, it is just understood that nail care is provided as part of routine care for the resident. 45951 3) During the initial tour of the facility and initial resident interview conducted on 12/19/22 at 9:32 AM, the surveyor observed that Resident #110 had long fingernails that appeared jagged and dirty. When asked to clarify, she stated she did want her nails to be cut. Clinical records revealed Resident #110 had a medical history significant for diabetes, cerebral infarction, depression, and malnutrition. A Quarterly Minimum Data Set (MDS) was done for Resident #110 on 09/23/22. This MDS documented Resident #110 had a Brief Interview of Mental Status (BIMS) score of 15, which indicates no cognitive impairment. This MDS also documented Resident #110 was totally dependent on facility staff for activities of daily living. Review of Resident #110's Care Plan revealed there was no care plan in place regarding Resident #110 refusing nail care. An interview was conducted on 12/22/22 at 8:05 AM with Resident #110. She stated she still had not received nail care, but still wanted to have her nails cut. 4) During the initial tour of the facility and initial resident interview conducted on 12/19/22 at 10:11 AM, it was observed by the surveyor that Resident #68 had long, dirty looking fingernails. The surveyor asked Resident #68 if he wants his fingernails cut, and he said yes. Clinical records revealed Resident #68 had a medical history significant for diabetes, falls, depression, and schizophrenia. A Quarterly Minimum Data Set (MDS) was done for Resident #68 on 09/27/22. It documented Resident #68 had a Brief Interview of Mental Status (BIMS) score of 15, which indicates no cognitive impairment. This MDS also documented Resident #68 required extensive assistance from staff for activities of daily living. Review of Resident #68's Care Plan revealed there was no care plan in place regarding Resident #68 refusing nail care. An interview was conducted on 12/22/22 at 9:15 AM with Resident #68. He showed the surveyor his fingernails and stated they were still long, and he still wanted them cut. 5) During the initial tour of the facility and initial resident interview conducted on 12/19/22 at 9:27 AM, the surveyor observed that Resident #39 had very long, dirty looking fingernails. When the surveyor asked Resident #39 if he wanted his fingernails cut, he nodded his head yes. Clinical records revealed Resident #39 had a medical history significant for diabetes, malnutrition, rhabdomyolysis, psychosis, and depression. A Quarterly Minimum Data Set (MDS) was done for Resident #39 on 10/19/22. It documented Resident #39 had a Brief Interview of Mental Status (BIMS) score of 7, which indicates moderate cognitive impairment. This MDS also documented Resident #39 required extensive assistance from staff for activities of daily living. Review of Resident #39's Care Plan revealed there was no care plan in place regarding Resident #39 refusing nail care. An interview was conducted on 12/22/22 at 9:17 AM with Resident #39. Resident #39 showed the surveyors that his fingernails were still long. When asked if he still wants them cut, Resident #39 nodded his head yes.

Based on observation, interview, and record review, the facility failed to provide adequate nutrition for tube feeding for 1 of 4 residents reviewed for tube feedings (Resident #177). The findings included: Record review revealed Resident #177 was admitted to the facility on [DATE]. Resident #177 had diagnoses included Stroke, End Stage Renal Disease (requiring dialysis), and a gastrostomy (feeding tube). Resident #177 was care planned for receiving Dialysis, feeding tube present, at risk for alteration in nutrition, and at risk for dehydration. A review of Resident #177's orders revealed an order dated 12/15/22 for Nepro tube feeding at 56 milliliters/hour (ml/hr) for 18 hours. On at 4:00 PM, and off at 10:00 AM. Further review of the resident's orders revealed an order dated 12/13/22 for dialysis every Monday, Wednesday, and Friday (the facility had in-house dialysis). Resident #177 was observed on 12/19/22 at 9:30 AM receiving Nepro tube feedings at 65 ml/hr. Resident #177 was observed on 12/19/22 at 3:00 PM. The resident was not receiving tube feedings. A review of Resident #177's progress notes revealed a note dated 12/19/22 at 11:51 PM, that documented: Resident went to dialysis early evening , return to the unit in stable condition. An interview was conducted with Staff Z, a Registered Nurse, on 12/21/22 at 10:00 AM. Staff Z stated Resident #177 goes to dialysis on Monday, Wednesday, and Friday in the evenings around 4:00 PM. Staff Z stated the resident's tube feedings does not go with the resident. An interview was conducted with the Regional Consultant Registered Dietician (RD) on 12/21/22 at 12:20 PM. The RD confirmed Resident #177 received dialysis 3 days a week, and was ordered tube feedings from 4:00 PM until 10:00 AM daily. The RD further stated the resident's tube feedings should not be interrupted in order for the resident to receive the calculated nutritional needs. A subsequent interview was conducted with the RD on 12/21/22 at 3:00 PM. The RD confirmed Resident #177 received dialysis treatment starting around 3:00-4:00 PM for 3.5 hours, 3 times a week, and does not receive tube feedings during that time. The resident was missing 410 calories, 18 grams of protein, and 231 ml of fluids per dialysis treatment time (1230 calories, 54 grams of protein, and 693 ml fluids weekly). Resident #177 was observed receiving dialysis treatment in the dialysis room on 12/21/22 at 4:30 PM. The resident was not receiving tube feedings during treatment. An interview was conducted with the dialysis nurse on 12/22/22 at 12:30 PM. The dialysis nurse stated residents do not receive tube feedings during dialysis treatments.

Based on observations, interviews and record review, the facility failed to obtain an order and document use of oxygen or changing of oxygen tubing (Resident #43) and failed to date oxygen tubing and place signage for Oxygen in Use outside of resident's room (Resident #326), for 2 of 3 residents reviewed for Respiratory therapy. The findings included: 1)During an observation on 12/19/22 at 10:25 AM of Resident #43 with oxygen on at 2 liters/minute via nasal cannula with the oxygen tubing dated 12/12/22. During an observation conducted on 12/20/22 at 8:00 AM of Resident #43 with oxygen on at 2 liters/minute via nasal cannula with the oxygen tubing dated 12/19/22. Record review revealed Resident #43 was admitted on [DATE] with a recent readmitted [DATE]. Diagnoses included: Atherosclerosis of Aorta, Thrombocytopenia, Cardiomegaly, and Anxiety. Review of the Physician's Orders for Resident #43 revealed that there was no active order for oxygen. Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for Resident #43 from 10/01/22 to 12/19/22 revealed no documentation for the use of oxygen or changing of oxygen tubing, Review of the Care Plan for Resident #43 with an initiated date of 06/04/22 and a revised date of 08/04/22 with a focus on the resident has an altered cardiovascular status r/t (related to) ASHD Atherosclerosis Heart Disease) and HTN (Hypertension) with a goal for the resident to be free from s/s (signs/symptoms) of complications of cardiac problems through the review date. Interventions included: Give oxygen as ordered by the physician. Review of the Care Plan for Resident #43 with an initiated date of 06/16/22 with a revised date of 08/04/22 with a focus on the resident has Oxygen Therapy r/t ineffective gas exchange, with a goal for the resident to have no s/s of poor oxygen absorption through the review date. Interventions included: O2 (Oxygen) via nasal cannula as ordered. Give medications as ordered by physician. Monitor/document side effects and effectiveness. Review of the Care Plan for Resident #43 with an initiated date of 11/15/21 with a revised date of 08/04/22 with a focus on the resident is at risk for shortness of breath r/t COPD (Chronic Obstructive Pulmonary Disease) and ASHD with a goal of resident will have no s/s of poor oxygen absorption through the review date. Interventions included: Give medications as ordered by physician. Monitor/document side effects and effectiveness. Review of Admission/Readmission Nursing Note dated 02/01/22 included under respiratory oxygen order -yes, specify order - O2 at 2 Liters via nasal cannula continuously. During an interview conducted on 12/19/22 at 12:30 PM with the Director of Nursing (DON), when she came into the room to change the oxygen tubing for Resident #43, she stated the oxygen tubing was due to be changed today. The DON stated that the oxygen tubing gets changed weekly. The DON verified that the resident is receiving oxygen at 2 liters/minute via nasal cannula. Review of the facility's policy titled Oxygen Administration with a revised date of January 2022, included the purpose of the procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Place an Oxygen in Use sign on the outside of the room entrance door. Change nasal cannula, oxygen mask weekly and as needed. 2) During an observation on 12/19/22 at 12:45 PM, revealed Resident #326 has oxygen in use, with no date on the oxygen tubing, and no oxygen sign on outside of door (Photographic Evidence Obtained). During an observation on 12/20/22 at 8:20 AM of Resident #326 it was revealed the resident has oxygen in use, with no date on the oxygen tubing, and no oxygen sign on outside of door. Record review for Resident #326 revealed that the resident was admitted to the facility on [DATE], diagnoses included Chronic Obstructive Pulmonary Disease, Encounter for Palliative Care, and Covid-19. Review of the Minimum Data Set (MDS) for Resident #326 dated 10/05/22 revealed in Section C that a Brief Interview for Mental Status (BIMS) score could not be obtained due to the resident is rarely/never understood. Review of Physician's Orders for Resident #326 revealed an order dated 12/17/22 for Oxygen at 2 L/M (liters/minute) via N/C (nasal cannula) PRN (as needed) for SOB (shortness of breath) every 8 hours. Review of the Medication Administration Record and the Treatment Administration Record from 12/16/22 to 12/19/22 revealed orders for the Oxygen at 2 L/M via N/C PRN (as needed) for SOB every 8 hours was not documented as in use now was and there any documentation of the oxygen tubing being changed. Review of the Care Plan for Resident #326 dated 12/19/22 with a focus on the resident has confirmed positive COVID 19 and is at risk for complications. Goal is for Resident to maintain respiratory health through next review date. Interventions included: Actively monitor residents Q shift and PRN. Monitoring includes a symptom check, vital signs, lung auscultation and oxygen saturation levels (pulse oximeter). Report changes in condition to MD. Review of the Care Plan for Resident #326 dated 12/19/22 with a focus on the resident is on Hospice Care for ES COPD (End Stage Chronic Obstructive Pulmonary Disease), with a goal for the resident to always remain pain free and comfortable through review date. Interventions included: Administer all meds as ordered. Monitor for verbal/non-verbal cues of pain and intervene accordingly. Notify Hospice for any changes in condition. Oxygen as indicated and tolerated. Provide adequate rest periods in between activities . During an interview conducted on 12/22/22 at 11:10 AM, the Director of Nursing (DON) was asked if there needs to be an order to administer oxygen, she stated that when a resident's oxygen level falls below 92%, they notify the physician and obtain an order for oxygen. When asked about when oxygen is administered, where is it documented, the DON stated it should be on the MAR or the TAR. When asked how often the oxygen tubing is changed, The DON stated it is changed every 7 days (weekly) and as needed, and the tubing is dated when changed. The DON added that she encourages the 11:00 PM to 7:00 AM staff to change the tubing. When asked where the tubing change is documented, she stated if it is documented, it would be in a progress note.

Based on record review and interview, the facility failed to provide pain medication for 1 of 1 resident reviewed for pain (Resident #225). The findings included: Clinical records revealed Resident #225 was a [AGE] year-old male who was admitted to the facility on [DATE] from an acute care hospital. Resident #225 had diagnoses that included Malignant neoplasm of colon, Colostomy, and Anxiety disorder. A review of the nursing progress notes revealed the resident arrived at the facility at 8:15 PM on 06/03/22. The resident arrived from an acute care hospital where he was receiving Hospice care. Nursing note revealed the resident did not have pain upon arrival to the facility. Physician orders for Resident #225 were to monitor pain scale with pain rating every shift. Pharmacy orders for pain medication included Hydrocodone-Acetaminophen tablet 7.5-325 mg(milligrams) give 1 tablet by mouth every 6 hours as needed for pain; Methadone HCL solution 10 mg/ml(milliliter) give 3 mg by mouth every 8 hours for pain; and Tylenol Tablet 325 mg give 2 tablets by mouth every 6 hours as needed for mild pain or pain scale 1-3. Review of the Medication Administration Record (MAR) for Resident #225 revealed he was not given anything for pain until 2:00 PM on 06/04/22 when the resident received Methadone. Review of the MAR also revealed the resident's pain scale was not listed on the MAR. A nursing progress note dated 06/04/22 at 6:11 AM revealed Methadone solution is not available from the pharmacy. On 06/04/22 a hospital transfer form revealed the resident was transferred to a hospital at 2:42 PM. A nursing progress note dated 06/04/22 revealed the patient was transferred per family request. An interview was conducted with the consultant pharmacist on 12/21/22 at 2:30 PM as to why the facility did not have the pain medication available for Resident #225. The consultant pharmacist stated there was no written prescription for the Methadone and the prescription for the Hydrocodone was not signed so the medication was never sent. The pharmacist does not know how the resident received the 2:00 PM dose of Methadone on 06/04/22 when the facility was not sent the medication. This surveyor asked the social service director on 12/21/22 at 3:30 PM for the grievance complaint made to the facility on [DATE] by the resident's wife. A review of the grievance revealed the wife was concerned regarding medications. The Director of Nurses at the time reviewed the medical record of the resident and noted that the prescriptions for Methadone, Hydrocodone, Haldol and Ativan were sent to the pharmacy and were awaiting delivery. The initial Methadone dose was administered from resident home meds brought by wife while waiting for pharmacy. The grievance was discussed with the Director of Nurses (DON) on 12/21/22 at 4:00 PM and the DON was informed that there was no documentation that the facility called the physician regarding the medication. There was also no documentation that the medication brought from home was verified with the pharmacy. The DON stated she was not aware of any policy for bringing medication from home and stated, at least he got medication for pain. On 12/21/22 at 4:15 PM during a discussion the Administrator stated that she was aware of this situation and provided the policy on Medications Brought to the Facility by the Resident/Family. The policy of the facility titled Medications Brought to the Facility by the Resident/Family revised January 2022 reveals If a medication is not otherwise available and/or it is determined to be essential to the resident's life, health, safety, or well- being to be able to take a medication brought in from outside, the Director of Nursing and nursing staff, with support of the Attending Physician and Consultant Pharmacist, shall check to ensure that: State law and regulations allow such use; The medications have been ordered by the resident's Attending Physician, and documented on the physician's order sheet; The contents of each container are labeled in accordance with established policies; and The contents of each container have been verified by a licensed pharmacist.

Based on observations, interviews, and record review, the facility failed to secure medications at the bedside for 2 of 39 sampled residents (Resident #49 and Resident 424), and facility failed to secure medications and supplies in the unlocked, unattended inpatient dialysis room. The findings included: Review of the facility policy titled Storage of Medications, revision date January 2022, revealed the following: Drugs and biologicals used in the facility are stored in locked compartments. The nursing staff is responsible for maintaining medication storage. Only persons authorized to prepare and administer medications have access to locked medications 1) During the initial tour of the facility conducted on 12/19/22 at 10:25 AM, the surveyor observed a bottle of prescription lotion in a basket in Resident #49's bedroom. The prescription label on the bottle noted a dispensed date of 03/13/22, but no expiration date. (Photographic evidence obtained). When the surveyor asked Resident #49 about the lotion, the resident stated that she uses it daily. Clinical records revealed Resident #49 had a medical history significant for end stage renal disease on dialysis, heart failure, chronic obstructive pulmonary disease, diabetes, Alzheimer's/dementia, and depression. A Quarterly Minimum Data Set (MDS) was done for Resident #49 on 12/06/22. This MDS documented Resident #49 had a Brief Interview of Mental Status (BIMS) score of 14, which indicates she had no mental impairment. This MDS documented Resident #49 required extensive assistance from staff for activities of daily living. There was no documentation found in Resident #49's chart regarding her being assessed for self-administering medications. Additional observations were made on 12/20/22, 12/21/22, and 12/22/22 and the prescription lotion still remained in Resident #49's room. 2) During a tour of the facility conducted on 12/20/22 at 1:25 PM, the surveyor observed unattended medications on the bedside table of Resident #424. Present was three bottles of Refresh eye drops, one bottle of Nerve Relief tablets, one bottle of Fluticasone nasal spray, and two containers of Lactulose solution (photographic evidence obtained). The surveyor interviewed Resident #424 and the resident stated she used the eye drops for her dry eyes, the nose spray was because she got nose bleeds, and she no longer used the Nerve Relief tablets. The resident stated during the interview that her relative brought in her belongings earlier that day. Clinical records revealed Resident #424 medical history included significant for end stage renal disease on dialysis, gout, obesity, and nerve pain. There was no Minimum Data Set (MDS) done for Resident #424 as she was admitted to the facility on [DATE]. There was no documentation found in Resident #424's chart regarding her being assessed for self-administering medications. The surveyor brought the facility Director of Nursing (DON) into Resident #424's room on 12/20/22 at 4:00 PM and showed her the unattended medications. The DON stated that the medications should not have been left unattended and stated she would have the nurse remove the medications from the room. During a tour of Resident #424's room conducted on 12/21/22 at 8:06 AM, the surveyor noted the medications had been removed from the room. 3) During a tour of the facility conducted on 12/20/22 at 2:35 PM, the surveyors noted the inpatient dialysis room and attached medication room had been left unlocked and unattended. Found in the medication room were three drawers filled with needles. Also found in the medication room in a cabinet was an unlocked metal box containing several multi-dose vials of Heparin 30,000 units per 30 milliliters (photographic evidence obtained). A tour and interview were conducted with the facility Administrator and Director of Nursing on 12/20/22 at 2:45 PM. The Administrator and Director of Nursing both agreed that the room should be kept locked when not in use. They also agreed that it is dangerous to leave the needles and Heparin unattended. An interview was conducted on 12/22/22 at 8:55 AM with Staff E. Staff E stated she is the dialysis nurse on Tuesdays, Thursdays, and Saturdays. Staff E stated it was her understanding that a delivery driver left the dialysis room unlocked after making a delivery of dialysis supplies and medications. The surveyor asked if the room and the metal box containing Heparin are typically locked by the dialysis staff-Staff E stated they are.

Based on record review and interviews, the facility failed to implement policies and procedures to prevent neglect and self harm for one (Resident #1) out of three sampled residents as evidenced by Resident #1 was able to obtain an electrical extension cord and committed suicide using the extension cord. As a result of the additional investigation conducted [DATE] to [DATE], the scope and severity was determined to be at a level of J and posed Immediate Jeopardy to the health and safety of the residents admitted to the facility. There were 116 residents admitted to the facility during the survey. The findings included: Review of the facility's Abuse, Neglect and Exploitation Policy and Procedure, revised on ,d+[DATE] revealed, neglect means the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or humiliate a resident(s). Review of the facility's Resident's Valuables/Personal Property Policy and Procedures, the policy was undated, revealed, All items brought to the facility by residents or representatives, shall be inventoried. All items must be brought to the nurse in charge to be added to the inventory. Any item determined to be unsafe to have at the facility with the potential to cause harm or potential harm to resident or others, will not be allowed in the facility. All electric items brought to the facility by residents or representatives shall be inspected by the maintenance staff and inventoried to include at the minimum: brand name, serial number, and dimensions. Review of the facility's federal five-day report revealed, at approximately 5:20 AM on [DATE] the nurse (Staff A) entered Resident #1's room and noted that Resident #1 was not in bed. The nurse (Staff A) proceeded to check the bathroom and noted Resident #1 with an extension cord wrapped around his neck in a sitting position. Upon assessment no pulse, no respiration noted. Staff A called out for assistance, CPR (Cardiopulmonary Resuscitation ) initiated, 911 and MD (Medical Doctor ) notified, Emergency Medical Services (EMS) and law enforcement arrived in the building, unable to obtain pulse, respiration or blood pressure. Resident #1 was pronounced dead by the paramedics in the facility. Review of the face sheet for Resident #1 revealed an admitted [DATE]. Clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE] for Resident # 1 indicated in Section C - Cognitive Patterns revealed, a Brief Interview Mental Status (BIMS) of 13 out of 15, indicating Resident #1 was cognitively intact. For Section G revealed, Resident #1 required limited assistance for bed mobility, transfer, walking in corridor, toilet use, personal hygiene and supervision for locomotion, eating (to setup). The MDS indicated that Resident #1 was on anti-anxiety medication for 7 days per week. Review of weight records revealed on [DATE] Resident #1 weighed 148 pounds. Review of the Nursing Progress Notes documented by Registered Nurse (RN), Staff A dated [DATE] at 2:22 PM revealed, at 2:30 AM, the nurse went to the Resident #1's room, and the resident was sitting in the wheelchair. The resident was encouraged to go to the bed and vitals signs were taken. At around 3:42 AM, the nurse went to Resident # 1's room again and Resident #1 stated that he was okay. At around 5:20 AM, Staff A entered Resident #1's room to provide a breathing treatment. Upon entering Resident #1's room Staff A observed that Resident #1 was not in bed, nor in the room. The bathroom door was noted to be closed. Staff A knocked on the door to gain the resident's attention and there was no response from the resident after three knocks on the door. Staff A opened the bathroom door and found Resident #1 in a sitting position with legs under buttock leaning to the right side facing the bathroom door with a white electrical extension cord around his neck. Upon assessment, the resident was noted to be unresponsive. CPR was initiated and 911 was called. Review of the resident's Care Plans revealed, Resident #1 was care planned for [CONDITION(S)] drug use adverse effects. Drug Class: Anti-anxiety. Approaches included, Notify MD immediately of any suicidal ideation, self-harming threats/ behaviors or threat of harm to others and delusions, hallucinations, disorganized behavior speech, lack of speech, lack of motivation, Report to MD (Medical Doctor) with follow up as indicated. The care plan was started on [DATE]. Resident # 1 was care planned for Behavior symptoms that indicated as behavior distress/socially inappropriate behavior .making sexual advances toward staff/resident, such as, but not limited to, touching/grabbing, and attempting to kiss others - The care plan was started on [DATE]. Resident # 1's care plan for Mood State revealed, Resident is exhibiting the following mood problem: Being fidgety and restless. The care plan was started on [DATE]. Review of the medication administration records revealed, Resident #1 was receiving [MEDICATION(S)] 15 milligram twice a day from [DATE] to [DATE] for anxiety. Review of the personal inventory possessions for Resident #1 revealed, two personal inventories for Resident #1; one was done on [DATE] with no items listed and the second was done on [DATE] with seven items listed and the list did not include an extension cord. On [DATE] at 12:13 PM, during an interview Staff C, a Certified Nursing Assistant (CNA) revealed, she remembered Resident #1. Staff C reported, on the day of the incident, Resident #1 came to the nurses' station using the wheelchair, and reported he was not feeling well. The nurse stated that it could be his blood pressure. The nurse checked his blood pressure and gave him medication. Staff C reported, the nurse always allowed Resident #1 to stay at the nurses' station. Resident # 1 was able to transfer from the wheelchair to his bed by himself. He had a roommate, but the roommate could not talk. Resident #1 never showed that he had depression. On the day of the incident, Resident #1 was found seated closer to the shower on the floor in the bathroom and the wheelchair was also in the bathroom. Staff C reported, that she saw the extension cord on the day of the incident, but she did not know if somebody brought the cord to the resident. Staff C reported, she did not know if the facility checked the objects brought by the family because she worked on the night shift. An attempt was made to interview Staff A, Registered Nurse (RN) on [DATE] at 12:41 PM and 1:14 PM and on [DATE] at 9:42 AM, voice messages were left and no return response was received. On [DATE] at 3:11 PM, during interview with Staff B, a Licensed Practical Nurse (LPN) by phone revealed, she no longer worked in the facility. Staff B explained, on [DATE] at 4:00 AM the floor nurse came to call her. Staff B stated, Resident #1 was found dead in the bathroom. Staff B stated, the Director of Nursing (DON) and 911 was called. Staff B stated, she checked the pulse, and there was no pulse and started CPR. Staff B stated, Resident #1 had [CONDITION(S)] on one side, he could walk and he could take a shower by himself. Staff B stated, Resident #1 tied the extension cord on the shower curtain bar. Staff B stated, she did not know where Resident #1 got the extension cord. Staff B stated, she did not know if the family brought the extension cord and if the facility checked the items brought by the family, because she was worked the night shift. Staff B added, Resident #1 did not have visitors at that time and she did not know if Resident #1 had any type of depression. Staff B explained, on the night of the incident, they did not have someone to supervise the shift and she was assigned to be the supervisor for the shift. On [DATE] at 3:51 PM, during an interview Staff D, CNA revealed, she remembered Resident #1. Staff D reported, Resident #1 was always quiet, not aggressive and did not show signs of depression. Staff D reported, Resident # 1 could not walk and used a wheelchair, he was able to get in and out of the bed by himself. Staff D reported, she never saw the extension cord before the incident and that the family came to visit him, but she did not know if somebody had to check the items that the family brought to the residents. On [DATE] at 11:47 AM, during interview with the previous Administrator/ Risk Manager and the current Administrator revealed, Resident #1 was found by the nurse in the bathroom with a white extension cord wrapped around his neck in a sitting position. The roommate was non interviewable and the roommate's responses were not consistent enough to be valid. The previous Administrator revealed, Resident #1 had visitors frequently. He had a psychiatric evaluation and the psychiatrist did not identify or notice any risk for self harm. The previous Administrator explained, he met with the family on the morning following the incident, the family was sad, but they were not surprised. The Administrator explained, there was no history of attempted suicide. The Administrator stated, Resident # 1's brother came to visit Resident #1 with other people. The extension cord that he used was not from the facility and it had to be a family member or a friend that brought the extension cord and gave it to the resident, because the residents are not supposed to have extension cords. The facility had an inventory list for each resident and, when the family brought any item it should be added on the inventory list. Resident #1 was very independent; he was alert and oriented. If something that was not safe and that should not be in the building, the nurse and CNA are required to notify maintenance, the Director of Nursing or the Administrator. Depending on what it is, they tried to not confiscate it, but they would call the family member to pick up the item. The administrator reported, extension cords are not allowed for life safety and for a situation like this. The family knew that he had an extension cord in the facility, but the Administrator could not figure out who brought the cord to him and the family members did not acknowledge that they brought it. The Administrator reported, he interviewed staff and they did not notice any signs and symptoms that showed that Resident #1 could do what he did. During the interview the Administrator reported, the facility did not have a Policy and Procedure in place to address residents having extension cords in their possession. On [DATE] at 9:11 AM, Staff L, CNA revealed, Resident #1 had an electric wheelchair, but she never saw the electric wheelchair being charged. In the mornings, he used to eat breakfast, take a shower and go outside. He could not walk. She had to help him to transfer from bed to the wheelchair. He had one side that was a little paralyzed and she thinks that it was the right side, but she was not sure. Staff needed to help him to take shower to clean his back. He never had a sign of depression. Staff L stated, she never saw the extension cord in the facility and she did not know where Resident #1 got the extension cord from. On [DATE] at 10:13 AM, during interview Staff O, LPN revealed, Resident #1 was very pleasant, he had no signs or symptoms of depression, he liked to take showers in the early mornings and take his breakfast afterwards. After he took his medications, he would go outside and talk with the other residents outside the building closer to the parking lot. Staff O, LPN stated, Resident #1's family came to visit and Resident #1 had an electric wheelchair that his family brought to him. Staff O stated, she never paid attention on how the wheelchair was charged because in the mornings it was already charged, but she thinks that he had a cord for his wheelchair, but she was not sure because she had not seen it. Staff O stated, Resident #1 was taking medication for depression, but it was not a high dose. She stated, he used to take Lorazepam and [MEDICATION(S)] and maybe the Lorazepam was discontinued and Resident #1 had no signs of side effects from the medication because he was not lethargic. On [DATE] at 11:18 AM, during an interview Staff M, CNA revealed, she had worked with Resident #1. He ate by himself, she helped him with taking a shower, he could transfer himself from the wheelchair to the bed, but she would watch him. She did not know if he had an extension cord inside his room. She did not know the color of the cord that he used. She did not know how he used to charge his electric wheelchair. On [DATE] at 2:22 PM, the current Administrator reported, the extension cord that Resident #1 used to commit suicide was white and Resident #1's motorized wheelchair had a battery and it was charged in the same system used by cell phones and Resident #1 plugged and charged his wheelchair by himself. On [DATE] at 10:29 AM, during a phone interview Resident #1's family member (brother) revealed, the resident was admitted to the facility about 6 years ago. The family member stated that during the visits leading up to the last days Resident # 1 behaved differently. The family member reported, Resident #1 had shortness of breath and he had lost his appetite and was anxious. The family member stated, he reported and complained about his brother a few times and the nurses came and placed oxygen, and he would get better, but they would not do anything else. The family member stated, he was in the facility the day before the incident happened Resident #1 was feeling better when he left, but the day after the facility called him to let him know about the incident. The family member reported, Resident #1 had an electric chair and a friend brought Resident #1 a white extension cord cable for him to charge the chair. The family member stated, the electric extension cord cable was white, and staff knew about the extension cord cable because it was visible from the door at the entrance of the room .The family member reported, the head of the bed had an electric outlet on the wall to the left side of the bed, the cable was placed on the left side behind the bed so that he could charge the chair on the right side. The family member stated, Resident #1 could get up and transfer himself from the bed to the chair and that he could connect the chair and could get up from the chair to the bed. He would not walk, but he could pull himself and transfer himself from the chair to the bed. The family member added, the staff knew about the electric cable because it was visible, and it was not something that was hidden and he never knew that he would use the extension cord to commit suicide and his brother never mentioned anything about suicide or any thought of suicide. On [DATE] at 10:58 AM interview with Resident #1's brother revealed, someone had given the extension cord to Resident #1 because he needed to charge the electric chair, but he did not know who gave the extension cord to him. He reported, Resident #1 had the electric chair for more than two years and stated, I bought him the chair, I assumed that everyone knew there was an extension cord because it was on top of the back of the bed and you could see it standing in front of the door of the room on the left side. The chair had a charger, but it did not reach the outlet, and someone facilitated the extension cord to him, but I do not know who it was. Resident #1's brother revealed, a nurse from the facility called him when it happened and told him that his brother expired, but did not tell me how. He stated he immediately went to the facility and the police was there. The brother stated, the nurse took me to another room and told me that my brother had expired but did not die of natural causes and that he hanged himself. He reported, the police did not let me go inside the room. The body was still in the facility when I went there. And the body was released to the forensics. He stated the autopsy results were not given to him and supposedly they were given to the resident's son. On [DATE] at 12:03 PM, during an interview with the Maintenance Director revealed, he has been working in the facility for [AGE] years. He checked the rooms every month to make sure that residents had no extension cord that it was not approved by the facility. He had been doing that before Resident #1 committed suicide. The Maintenance Director stated, he never saw an extension cord in Resident's #1 room before and he used to go to Resident #1's room frequently. The Maintenance Director stated, he did not know how Resident #1 charged his wheelchair. On [DATE], the facility's administrator submitted the facility's Immediate Jeopardy Removal Plan that included: - Corrective action included the facility modified its policy and procedure for the resident Valuables/ Personal Property policy on [DATE] to include items not allowed in the facility and the process the staff must follow if items are found in the resident's rooms. - All residents were assessed using a suicidal ideation risk assessment in Matrix on [DATE] Licensed Social Worker and Licensed Mental Health Consultant. - All residents were visited in their rooms on [DATE] and given an updated Resident Valuables/Personal Property Policy. All residents families, POA [Power of Attorney] or guardians were contacted via phone on [DATE] by facility staff to provide education on resident valuable/personal property policy which included items not allowed. - All staff were provided an in-service on the policy and procedure regarding items not allowed in the facility and how to provide care and services to residents displaying suicidal ideations. Inservices started on [DATE] and were completed on [DATE]. - Room audits were completed on [DATE] using the Audit of Unsafe Items in Resident Rooms form - Interdisciplinary team members (Quality Assurance and Performance Improvement (QAPI) team members) met [DATE] at 4:00 PM to discuss the event and formulated a plan of correction. - A Performance Improvement Plan (PIP) was formulated and approved with the Medical Director at an ad hoc QAPI meeting on [DATE]. - The Medical Director signed the ad hoc QAPI meeting on [DATE]. - Current rate education compliance all staff: 100 %. - A Root Cause Analysis completed. The facility's Immediate Jeopardy Removal Plan included an education plan which included: All staff will be educated during orientation on the policy and procudure for Resident Valuables/Personal Property. All staff will be inserviced yearly on the policy and procedure for reporting items not allowed in the facility and the reporting procedure. All staff will be educated on identifying and reporting suicide ideation on orientation. All staff will have yearly training on identifying and reporting suicidal ideations. All new residents and/or family members will be given the policy and procedure for Resident Valuables/Personal Property in their admission packet. Residents will be reminded during the monthly resident council meeting regarding items not allowed in the facility. On [DATE] during interviews with Staff O (LPN), Staff R (RN), Staff S (LPN), Staff T (CNA), Staff U (Social Service Assistant), Staff V (Physical Therapist), Staff W (Maintenance Worker), Staff X (CNA), Staff Y (CNA), Staff Z (CNA), Staff AA (LPN), Staff AB (CNA), Staff AC (Receptionist), Staff AD (Dietary Aide), Staff AE (Dietary Aide), Staff AF (Laundry), Staff AG (Housekeeping), Staff AH (Activity Department) from the day, evening and night shift revealed, they received in-services on how to report and monitor any changes in behavior, signs of depression or suicide and how to identify and care for residents that show suicidal ideations and what to do to prevent more incidents. Review of documentation for in-services provided revealed, All employees, family members and residents were informed and updated on the policy with the list of items that are not permissible in the facility and on how to identify harmful items. The facility had a Quality Assurance Performance Improvement (QAPI) meeting on [DATE]. The facility policy and procedures were modified to include all items not allowed in the facility and a room audit was conducted. On [DATE] at 1:39 PM during an interview with the Administrator and Director of Nursing (DON) revealed, as part of the immediate jeopardy removal plan they in-serviced all staff on how to identify signs of suicidal ideation, on how identify harmful items and how to response to the signs. They assessed all residents to see if they had any type of suicidal ideation or to harm themselves. The psychologist assessed all residents with a BIMS score of 14 or higher on the Suicide Risk Screening Tool. The facility informed all family members and residents of all updated lists of items that were not allowed in the facility. They had a QAPI meeting on [DATE] with the Heads of each Department. They created the removal plan for the team to implement. They implemented the policy on valuables and they specified the items that were not allowed in the facility and conducted room searches. The scope and severity of F600 was lowered to a (D) for No actual harm with a potential for more than minimal harm that is not immediate jeopardy as of [DATE]. The scope and severity was lowered as a result of the facility's Immediate Jeopardy Removal Plan and the implementation of the plan as of [DATE]. These actions were verified by the survey team through observation, record review and interviews, it was determined that the immediate jeopardy was removed on [DATE].

Based on record review and interviews the facility failed to implement policies and procedures to prevent neglect and self harm for one (Resident #1) out of three sampled residents as evidenced by Resident #1 was able to obtain an electrical extension cord and committed suicide using the extension cord. There were one hundred sixteen residents living in the facility at the time of the survey. The findings included: Review of the facility's Abuse, Neglect and Exploitation Policy and Procedure, revised on ,[DATE] revealed that neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or humiliate a resident(s). Review of the facility Resident's Valuables/ Personal Property Policy and Procedures, undated, revealed that All items brought to the facility by residents or representatives, shall be inventoried. All items must be brought to the nurse in charge to be added to the inventory. Any item determined to be unsafe to have at the facility with the potential to cause harm or potential harm to resident or others, will not be allowed in the facility. All electric items brought to the facility by residents or representatives shall be inspected by the maintenance staff and inventoried to include at the minimum: brand name, serial number, and dimensions. Review of the five-day report revealed that at approximately 5:20 AM on [DATE] the nurse (Staff A) entered Resident #1's room and noted that Resident #1 was not in bed. The nurse (Staff A) proceeded to check the bathroom and noted Resident #1 with an extension cord wrapped around his neck in a sitting position. Upon assessment no pulse, no respiration noted. Staff A called out for assistance, CPR (Cardiopulmonary Resuscitation ) initiated, 911 and MD (Medical Doctor ) notified, Emergency Medical Services (EMS) and law enforcement arrived in the building, unable to obtain pulse, respiration or blood pressure. Resident #1 was pronounced dead by the paramedics in the facility. Review of the face sheet for Resident #1 revealed an admission date of [DATE]. Clinical [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] for Resident # 1 indicated in Section C- Cognitive Patterns revealed a Brief Interview Mental Status (BIMS) of 13 out of 15, indicating Resident #1 was cognitively intact. For Section G limited assistance for bed mobility, transfer, walking in corridor, toilet use and personal hygiene and supervision on locomotion, eating (to setup). The MDS indicated that Resident #1 was on anti anxiety medication for 7 days per week. Review of weight records revealed on [DATE] Resident #1 weighed 148 pounds. Review of the Nursing Progress Notes documented by Registered Nurse (RN) , Staff A dated [DATE] at 2:22 PM revealed that at 2:30 AM, the nurse went to the Resident #1's room, and the resident was sitting in the wheelchair. The resident was encouraged to go to the bed and vitals taken. At around 3:42 AM, the nurse went to Resident # 1's room again and Resident #1 stated that he was okay. At around 5:20 AM, Staff A entered Resident #1's room to provide breathing treatment. Upon entering Resident #1's room Staff A observed that Resident #1 was not in bed, nor in the room. The bathroom door was noted closed. Staff A knocked on the door to gain the resident's attention and there was no response from the resident after three knocks on the door. Staff A opened the bathroom door and found Resident #1 in sitting position with legs under buttock leaned to the right side facing the bathroom door with a white electrical extension cord around his neck. Upon assessment, resident noted unresponsive. CPR was initiated and 911 called. Review of Care Plans revealed Resident #1's was care planned for [MEDICAL CONDITION] drug use adverse effects. Drug Class: Anti anxiety. Approach included Notify MD immediately of any suicidal ideation, self-harming threats/ behaviors or threat of harm to others and delusions, hallucinations, disorganized behavior speech, lack of speech, lack of motivation, Report to MD with follow up as indicated. Started on [DATE]. Resident # 1 was care planned for Behavior symptoms that indicated as behavior distress/ socially inappropriate behavior .making sexual advances toward other staff/ resident, such as, but not limited to, touching/grabbing, and attempting to kiss others - Started on [DATE]. Resident # 1's care plan for Mood State revealed: Resident is exhibiting the following mood problem: being fidgety and restless. Started on [DATE]. Review of the medication administration records revealed Resident #1 was receiving [MEDICATION NAME] 15 milligram twice a day from [DATE] to [DATE] for anxiety. Review of the personal inventory possessions for Resident #1 revealed two personal inventories for Resident #1; one was done on [DATE] with no items listed and the second was done on [DATE] with seven items listed and did not include an extension cord. On [DATE] at 12:13 PM, during an interview Staff C, a Certified Nursing Assistant (CNA) revealed that she remembered Resident #1. On the day of the incident, Resident #1 came to the nurses' station using the wheelchair, stating that he was not feeling well. The nurse stated that it could be the blood pressure. The nurse checked his blood pressure and gave him medication. Staff C stated that the nurse always let Resident #1 stay at the nurses' station. Resident # 1 was able to transfer from the wheelchair to his bed by himself. He had a roommate but the roommate could not talk. Resident #1 never showed that he had depression. On the day of the incident Resident #1 was found seated closer to the shower on the floor in the bathroom and the wheelchair was also in the bathroom. Staff C stated that she saw the extension cord on the day of the incident but she did not know if somebody brought the cord to the resident. Staff C stated that she did not know if the facility checked the objects brought by the family because she worked on the night shift. Attempted to interview Staff A, Registered Nurse (RN) on [DATE] at 12:41 PM and 1:14 PM and on [DATE] at 9:42 AM, voice messages were left and no response received. On [DATE] at 3:11 PM, during interview with Staff B, a Licensed Practical Nurse (LPN) by phone revealed that she no longer worked in the facility. Staff B explained that on [DATE] at 4:00 AM the floor nurse came to call her. Staff B stated that Resident #1 was found dead in the bathroom. Staff B stated that the Director of Nursing (DON) and 911 was called. Staff B stated that she checked the pulse, and there was no pulse and started CPR. Staff B stated that Resident #1 had [MEDICAL CONDITION] on one side, he could walk and he could take a shower by himself. Staff B stated that Resident #1 tied the extension cord on the shower curtain bar. Staff B stated that she did not know where Resident #1 got the extension cord. Staff B, stated that she did not know if the family brought the extension cord and if the facility checked the items brought by the family, because she was worked the night shift. Staff B added that Resident #1 did not have visitors at that time and did not know if Resident #1 had any type of depression. Staff B explained that on the night of the incident, they did not have someone to supervise the shift and she was the supervisor. On [DATE] at 3:51 PM, during an interview Staff D, CNA revealed that she remembered Resident #1. Staff D stated that Resident #1 was always quiet, not aggressive and did not show signs of depression. Staff D stated that Resident # 1 could not walk and used a wheelchair, he was able to get in and out of the bed by himself. Staff D stated that she never saw the extension cord before the incident and that the family came to visit him, but she did not know if somebody had to check the items that the family bring to the residents. On [DATE] at 11:47 AM, during interview with previous Administrator/ Risk Manager and the current Administrator revealed that Resident #1 was found by the nurse in the bathroom with a white extension cord wrapped around his neck in sitting position. The roommate was non interviewable and the roommate's responses were not consistent enough to be valid. The previous Administrator revealed that Resident #1 had visitors frequently. He had a psychiatric evaluation and the psychiatrist did not identify or noticed any risk for self harm. The previous Administrator explained that he met with the family on the morning following the incident, the family were sad, but they were not surprised. The Administrator explained that there was no history of attempted suicide. The Administrator stated that Resident # 1's brother came to visit with other people. The extension cord that he used was not from the facility and it had to be a family member or a friend that brought the extension cord and gave it to the resident, because the residents are not supposed to have extension cords. The facility had an inventory list for each resident and, when family brought any item it should be added on the inventory list. Resident #1 was very independent; he was alert and oriented. If something that was not safe and that should not be in the building, the nurse and CNA are required to let maintenance, Director of Nursing or the Administrator know. Depending on what it is, they tried to not confiscate, but they will call the family member to pick up the item. Extension cords are not allowed for life safety and for a situation like this. The family knew that he had an extension cord in the facility, but the Administrator could not figure out who brought the cord to him and the family members did not acknowledge that they brought it. The Administrator reported that he interviewed staff and they did not notice any signs and symptoms that showed that Resident #1 could do what he did. On [DATE] at 9:11 AM, Staff L, CNA revealed that Resident #1 had an electric chair, but she never saw the electric chair being charged. In the mornings, he used to take breakfast, take a shower and he go outside. He could not walk. She had to help him to transfer from bed to the wheelchair. He had one side that was a little paralyzed and she thinks that it was the right side, but she was not sure. Staff he needed to help him to take shower in his back. He never had a sign of depression. Staff L stated that she never saw the extension cord in the facility and she did not know where Resident #1 got the extension cord from. On [DATE] at 10:13 AM, during interview Staff O, LPN revealed that Resident #1 was very pleasant, he had no signs or symptoms of depression, he liked to take showers in the early mornings and take his breakfast after. After he took his medications he would go outside and talk with other residents outside the building closer to the parking lot. Staff O, LPN stated that Resident #1's family came to visit and Resident #1 had an electric wheelchair that his family brought to him. Staff O, LPN stated that she never paid attention on how the wheelchair was charged because in the mornings it was already charged, but she thinks that he had a cord for his wheelchair, but she was not sure because she had not seen it. Staff O, LPN stated that Resident #1 was taking medication for depression but it was not a high dose. She stated that he used to take [MEDICATION NAME] and [MEDICATION NAME] and maybe the [MEDICATION NAME] was discontinued and Resident #1 had no signs of side effects of the medication because he was not lethargic. On [DATE] at 11:18 AM, during an interview Staff M, CNA revealed that she had worked with Resident #1. He ate by himself, she helped him with taking a shower, he could transfer himself from the wheelchair to the bed, but she was together watching him. She did not know if he had an extension cord inside his room. She did not know the color of the cord that he used. She did not know how he used to charge his wheelchair. On [DATE] at 2:22 PM the current Administrator reported, the extension cord that Resident #1 used to commit suicide was white and Resident #1 motorized wheelchair had a battery and it was charged in the same system used by cell phones and Resident #1 plugged and charged his wheelchair by himself. On [DATE] at 10:29 AM, during a phone interview Resident #1's family member (brother) revealed the resident was admitted to the facility about 6 years ago. The family member stated that during the visits leading up to the last days Resident # 1 behaved differently. The family member stated that Resident #1 had shortness of breath and he had lost his appetite and was anxious. The family member stated that he reported and complained about his brother a few times and the nurses came and placed oxygen, and he would get better but they would not do anything else. The family member stated that he was in the facility the day before the incident happened Resident #1 was feeling better when he left, but the day after the facility called him to let him know about the incident. The family member reported that Resident #1 had an electric chair and a friend brought Resident #1 a white extension cord cable for him to charge the chair. The family member stated the electric extension cord cable was white, and staff knew about the extension cord cable because it was visible from the door at the entrance of the room .The family member reported that the head of the bed had an electric outlet on the wall to the left side of the bed, the cable was placed on the left side behind the bed so that he could charge the chair on the right side. The family member stated that Resident #1 could get up and transfer himself from the bed to the chair and that he could connect the chair and could get up from the chair to the bed. He would not walk but he could pull himself and transfer himself from the chair to the bed. The family member added that the staff knew about the electric cable because it was visible, and it was not something that was hidden and he never knew that he would use the extension cord cable to commit suicide and his brother never mentioned anything about suicide or any thought of suicide. During an interview with the Administrator, the facility did not have a Policy and Procedure in place to address residents having extension cords in their possessions. When the Policy and Procedure related to extension in residents possessions the Administrator did not provide one and did not indicate if the facility was developing a Policy and Procedure to address residents' possession of extension cords in the facility.

Based on record review and interviews the facility to implement policies and procedures to prevent neglect and self harm for one (Resident #1) out of three sampled residents as evidenced by Resident #1 was able to obtain an electrical extension cord that subsequently committed suicide using the extension cord. There were one hundred sixteen residents living in the facility at the time of the survey. The findings included: Review of the facility's Abuse, Neglect and Exploitation Policy and Procedure, revised on ,[DATE] revealed that neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or humiliate a resident(s). Review of the facility Resident's Valuables/ Personal Property Policy and Procedures, undated, revealed that All items brought to the facility by residents or representatives, shall be inventoried. All items must be brought to the nurse in charge to be added to the inventory. Any item determined to be unsafe to have at the facility with the potential to cause harm or potential harm to resident or others, will not be allowed in the facility. All electric items brought to the facility by residents or representatives shall be inspected by the maintenance staff and inventoried to include at the minimum: brand name, serial number, and dimensions. Review of the five-day report revealed that at approximately 5:20 AM on [DATE] the nurse (Staff A) entered Resident #1's room and noted that Resident #1 was not in bed. The nurse (Staff A) proceeded to check the bathroom and noted Resident #1 with an extension cord wrapped around his neck in a sitting position. Upon assessment no pulse, no respiration noted. Staff A called out for assistance, CPR (Cardiopulmonary Resuscitation ) initiated, 911 and MD (Medical Doctor ) notified, 911 arrived in the building, unable to obtain pulse, respiration or blood pressure. Resident #1 was pronounced dead by the paramedics in the facility. Review of the face sheet for Resident #1 revealed an of admission date of [DATE]. Clinical [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] for Resident # 1 indicated in Section C- Cognitive Patterns revealed a Brief Interview Mental Status (BIMS) of 13 out of 15, indicating Resident #1 was cognitively intact. For Section G limited assistance for bed mobility, transfer, walking in corridor, toilet use and personal hygiene and supervision on locomotion, eating (to setup). The MDS indicated that Resident #1 was on anti anxiety medication for 7 days per week. Review of the Nursing Progress Notes documented by Registered Nurse (RN) , Staff A dated [DATE] at 2:22 PM revealed that at 2:30 AM, the nurse went to the Resident #1's room, and the resident was sitting in the wheelchair. The resident was encouraged to go to the bed and vitals taken. At around 3:42 AM, the nurse went to Resident # 1's room again and Resident #1 stated that he was okay. At around 5:20 AM, Staff A entered Resident #1's room to provide breathing treatment. Upon entering Resident #1's room Staff A observed that Resident #1 was not in bed, nor in the room. The bathroom door was noted closed. Staff A knocked on the door to gain the resident's attention and there was no response from the resident after three knocks on the door. Staff A opened the bathroom door and found Resident #1 in sitting position with legs under buttock leaned to the right side facing the bathroom door with a white electrical extension cord around his neck. Upon assessment, resident noted unresponsive. CPR was initiated and 911 called. Review of Care Plans revealed Resident #1's was care planned for [MEDICAL CONDITION] drug use adverse effects. Drug Class: Anti anxiety. Approach included Notify MD immediately of any suicidal ideation, self-harming threats/ behaviors or threat of harm to others and delusions, hallucinations, disorganized behavior speech, lack of speech, lack of motivation, Report to MD with follow up as indicated. Started on [DATE]. Resident # 1 was care planned for Behavior symptoms that indicated as behavior distress/ socially inappropriate behavior .making sexual advances toward other staff/ resident, such as, but not limited to, touching/grabbing, and attempting to kiss others - Started on [DATE]. Resident # 1's care plan for Mood State revealed: Resident is exhibiting the following mood problem: being fidgety and restless. Started on [DATE]. Review of the medication administration records revealed Resident #1 was receiving [MEDICATION NAME] 15 milligram twice a day from [DATE] to [DATE] for anxiety. Review of the personal inventory possessions for Resident #1 revealed two personal inventories for Resident #1; one was done on [DATE] with no items listed and the second was done on [DATE] with seven items listed and did not include an extension cord. On [DATE] at 12:13 PM, during an interview Staff C, a Certified Nursing Assistant (CNA) revealed that she remembered Resident #1. On the day of the incident, Resident #1 came to the nurses' station using the wheelchair, stating that he was not feeling well. The nurse stated that it could be the blood pressure. The nurse checked his blood pressure and gave him medication. Staff C stated that the nurse always let Resident #1 stay at the nurses' station. Resident # 1 was able to transfer from the wheelchair to his bed by himself. He had a roommate but the roommate could not talk. Resident #1 never showed that he had depression. On the day of the incident Resident #1 was found seated closer to the shower on the floor in the bathroom and the wheelchair was also in the bathroom. Staff C stated that she saw the extension cord on the day of the incident but she did not know if somebody brought the cord to the resident. Staff C stated that she did not know if the facility checked the objects brought by the family because she worked on the night shift. Attempted to interview Staff A, Registered Nurse (RN) on [DATE] at 12:41 PM and 1:14 PM and on [DATE] at 9:42 AM, voice messages were left and no response received. On [DATE] at 3:11 PM, during interview with Staff B, a Licensed Practical Nurse (LPN) by phone revealed that she no longer worked in the facility. Staff B explained that on [DATE] at 4:00 AM the floor nurse came to call her. Staff B stated that Resident #1 was found dead in the bathroom. Staff B stated that the Director of Nursing (DON) and 911 was called. Staff B stated that she checked the pulse, and there was no pulse and started CPR. Resident #1. Staff B stated that Resident #1 had [MEDICAL CONDITION] on one side, he could walk and he could take a shower by himself. Staff B stated that Resident #1 tied the extension cord on the shower curtain shower bar. Staff B stated that she did not know where Resident #1 got the extension cord. Staff B, stated that she did not know if the family brought the extension cord and if the facility checked the items brought by the family, because she was worked the night shift. Staff B added that Resident #1 did not have visitors at that time and did not know if Resident #1 had any type of depression. Staff B explained that on the night of the incident, they did not have someone to supervise the shift and she was the supervisor. On [DATE] at 3:51 PM, during an interview Staff D, CNA revealed that she remembered Resident #1. Staff D stated that Resident #1 was always quiet, not aggressive and did not show signs of depression. Staff D stated that Resident # 1 could not walk and used a wheelchair, he was able to get in and out of the bed by himself. Staff D stated that she never saw the extension cord before the incident and that the family came to visit him, but she did not know if somebody had to check the items that the family bring to the residents. On [DATE] at 11:47 AM, during interview with previous Administrator/ Risk Manager and the current Administrator revealed that Resident #1 was found by the nurse in the bathroom with a white extension cord wrapped around his neck in sitting position. The roommate was non interviewable and the roommate's responses were not consistent enough to be valid. The previous Administrator revealed that Resident #1 had visitors frequently. He had a psychiatric evaluation and the psychiatrist did not identify or noticed any risk for self harm. The previous Administrator explained that he met with the family on the morning following the incident, the family were sad, but they were not surprised. The Administrator explained that there was no history of attempted suicide. The Administrator stated that Resident # 1's brother came to visit with other people. The extension cord that he used was not from the facility and it had to be a family member or a friend that brought the extension cord and gave it to the resident, because the residents are not supposed to have extension cords. The facility had an inventory list for each resident and, when family brought any item it should be added on the inventory list. Resident #1 was very independent; he was alert and oriented. If something that was not safe and that should not be in the building, the nurse and CNA are required to let maintenance, Director of Nursing or the Administrator know. Depending on what it is, they tried to not confiscate, but they will call the family member to pick up the item. Extension cords are not allowed for life safety and for a situation like this. The family knew that he had an extension cord in the facility, but the Administrator could not figure out who brought the cord to him and the family members did not acknowledge that they brought it. The Administrator reported that he interviewed staff and they did not notice any signs and symptoms that showed that Resident #1 could do what he did. On [DATE] at 9:11 AM, Staff L, CNA revealed that Resident #1 had an electric chair, but she never saw the electric chair being charged. In the mornings, he used to take breakfast, take a shower and he go outside. He could not walk. She had to help him to transfer from bed to the wheelchair. He had one side that was a little paralyzed and she thinks that it was the right side, but she was not sure. Staff he needed to help him to take shower in his back. He never had a sign of depression. Staff L stated that she never saw the extension cord in the facility and she did not know where Resident #1 got the extension cord from. On [DATE] at 10:13 AM, during interview Staff O, LPN revealed that Resident #1 was very pleasant, he had no signs or symptoms of depression, he liked to take showers in the early mornings and take his breakfast after. After he took his medications he would go outside and talk with other residents outside the building closer to the parking lot. Staff O, LPN stated that Resident #1's family came to visit and Resident #1 had an electric wheelchair that his family brought to him. Staff O, LPN stated that she never paid attention on how the wheelchair was charged because in the mornings it was already charged, but she thinks that he had a cord for his wheelchair, but she was not sure because she had not seen it. Staff O, LPN stated that Resident #1 was taking medication for depression but it was not a high dose. She stated that he used to take [MEDICATION NAME] and [MEDICATION NAME] and maybe the [MEDICATION NAME] was discontinued and Resident #1 had no signs of side effects of the medication because he was not lethargic. On [DATE] at 11:18 AM, during an interview Staff M, CNA revealed that she had worked with Resident #1. He ate by himself, she helped him with taking a shower, he could transfer himself from the wheelchair to the bed, but she was together watching him. She did not know if he had an extension cord inside his room. She did not know the color of the cord that he used. She did not know how he used to charge his wheelchair. On [DATE] at 2:22 PM the current Administrator reported, the extension cord that Resident #1 used to commit suicide was white and Resident #1 motorized wheelchair had a battery and it was charged in the same system used by cell phones and Resident #1 plugged and charged his wheelchair by himself. On [DATE] at 10:29 AM, during a phone interview Resident #1's family member (brother) revealed the resident was admitted to the facility about 6 years ago. The family member stated that during the visits leading up to the last days Resident # 1 behaved differently. The family member stated that Resident #1 had shortness of breath and he had lost his appetite and was anxious. The family member stated that he reported and complained about his brother a few times and the nurses came and placed oxygen, and he would get better but they would not do anything else. The family member stated that he was in the facility the day before the incident happened Resident #1 was feeling better when he left, but the day after the facility called him to let him know about the incident. The family member reported that Resident #1 had an electric chair and a friend brought Resident #1 a white extension cord cable for him to charge the chair. The family member stated the electric extension cord cable was white, and staff knew about the extension cord cable because it was visible from the door at the entrance of the room .The family member reported that the head of the bed had an electric outlet on the wall to the left side of the bed, the cable was placed on the left side behind the bed so that he could charge the chair on the right side. The family member stated that Resident #1 could get up and transfer himself from the bed to the chair and that he could connect the chair and could get up from the chair to the bed. He would not walk but he could pull himself and transfer himself from the chair to the bed. The family member added that the staff knew about the electric cable because it was visible, and it was not something that was hidden and he never knew that he would use the extension cord cable to commit suicide and his brother never mentioned anything about suicide or any thought of suicide.

Based on record review and interview the facility failed to prevent accident and hazards as evidenced by one (Resident #1) out of three residents sampled, was able to obtain an electrical extension cord that the facility was not aware of and subsequently committed suicide. The findings included: Review of the facility's Safety and Supervision of Residents, Accident hazards Policy and Procedures revealed the facility strives to make environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Review of the facility Resident's Valuables/ Personal Property Policy and Procedures, undated, revealed that All items brought to the facility by residents or representatives, shall be inventoried. All items must be brought to the nurse in charge to be added to the inventory. Any item determined to be unsafe to have at the facility with the potential to cause harm or potential harm to resident or others, will not be allowed in the facility. All electric items brought to the facility by residents or representatives shall be inspected by the maintenance staff and inventoried to include at the minimum: brand name, serial number, and dimensions. Review of the face sheet for resident #1 revealed date of admission on [DATE]. The [DIAGNOSES REDACTED]. Review of the Nursing Progress Notes dated [DATE] at 2:22 PM revealed that at 2:30 AM the nurse went to Resident #1's room. The resident was sitting in his wheelchair. Resident #1 was encouraged to go to the bed. Vitals taken. At around 3:42 AM, the nurse went to Resident #1's room again and the resident stated that he was okay. At approximately 5:20 AM, Registered Nurse (Staff A) entered the resident's room to provide breathing treatment. Upon entering the room, Staff A observed that Resident #1 was not in bed, nor the room and the bathroom door was noted closed. Staff A knock 3 times on the door and Resident #1 did not respond. Staff A upon opening the bathroom door observed Resident #1 in sitting position with his legs under his buttock leaned to the right side facing the bathroom door with an electrical extension cord around his neck. Upon assessment, Resident #1 was noted unresponsive. Cardiopulmonary Resuscitation was initiated and 911 called. The paramedics decal red Resident #1 deceased in the facility. Record review of the Minimum Data Set ((MDS) dated [DATE] for Resident # 1 documented in Section C- Cognitive Patterns revealed a Brief Interview Mental Status (BIMS) of 13 out of 15, indicating Resident #1 was cognitively intact. For Section G limited assistance was required for bed mobility, transfer, walking in corridor, toilet use and personal hygiene and supervision on locomotion, eating (to setup). Resident was on anti anxiety medication for 7 days per week and no antidepressant or anti psychotic. Review of the Resident #1's Care Plans revealed: - Care Plan for [MEDICAL CONDITION] Drug Use for adverse effects. Drug Class: Anti anxiety. Approach included Notify MD immediately of any suicidal ideation, self-harming threats/ behaviors or threat of harm to others and delusions, hallucinations, disorganized behavior speech, lack of speech, lack of motivation, Report to MD with follow up as indicated. Started on [DATE]. - Care Plan for Behavior symptoms as behavior distress/ socially inappropriate behavior . making sexual advances toward other staff/ resident, such as, but not limited to, touching/grabbing, and attempting to kiss others - Started on [DATE]. - Care Plan for Mood State. Resident is exhibiting the following mood problem: being fidgety and restless. Started on [DATE]. Review of the medication Administration revealed Resident #1 was receiving [MEDICATION NAME] 15 milligram (mg) twice a day from [DATE] to [DATE] for anxiety. Review of the Personal Inventory Possessions for Resident #1 revealed two Personal Inventory logs. One was dated [DATE] with no items listed and the second was dated [DATE] with seven items listed and did not include an extension cord. On [DATE] at 12:13 PM, during an interview Staff C, a Certified Nursing Assistant (CNA) revealed that she remembered Resident #1. On the day of the incident, Resident #1 came to the nurses' station in his wheelchair and reported that he was not feeling well. The nurse checked his blood pressure and gave him medication. Staff C added that the nurse always let Resident #1 stay at the nurses' station. Resident # 1 was able to transfer from the wheelchair to his bed by himself. He had a roommate but the roommate could not talk. Resident #1 never showed that he had depression. On the day of the incident Resident #1 was found seated close to the shower on the floor in the bathroom and the wheelchair was in the bathroom. Staff C stated that she saw the extension cord on the day of the incident but she did not know if somebody brought the cord to the resident. Staff C because she worked the night shift she does not know if the facility checked the items brought by the family. On [DATE] at 3:11 PM, during interview telephone interview Staff B, a Licensed Practical Nurse (LPN) revealed that she no longer worked in the facility. Staff B explained that on [DATE] at 4:00 AM the floor nurse came to call her because Resident #1 was found dead in the bathroom. Staff B stated that the Director of Nursing (DON) and 911 was called. Staff B stated that she checked the pulse, and there was no pulse and started CPR. Resident #1. Staff B stated that Resident #1 had [MEDICAL CONDITION] on one side, he could walk and he could take a shower by himself. Staff B stated that Resident #1 tied the extension cord on the bar for the shower curtain. Staff B stated that she did not know where Resident #1 got the extension cord. Staff B stated that she did not know if the family brought the extension cord and if the facility checked the items brought by the family, because she worked the night shift. Staff B added that Resident #1 did not have visitors at that time and did not know if Resident #1 had any type of depression. Staff B explained that on the night of the incident, they did not have someone to supervise the shift and she was the supervisor. Attempted to interview Staff A, Registered Nurse (RN) on [DATE] at 12:41 PM and 1:14 PM and on [DATE] at 9:42 AM messages left and no return call received from Staff A. On [DATE] at 11:47 AM, during interview with previous Administrator/ Risk Manager and the current Administrator revealed that Resident #1 was found by the nurse in the bathroom with a white extension cord wrapped around his neck in sitting position. The roommate was non interviewable and the roommate's responses were not consistent enough to be valid. The previous Administrator revealed that Resident #1 had visitors frequently. He had a psychiatric evaluation and the psychiatrist did not identify or noticed any risk for self-harm. The previous Administrator explained that he met with the family on the morning following the incident, the family were sad, but they were not surprised. The Administrator explained that there was no history of attempted suicide. The Administrator stated that Resident # 1's brother came to visit with other people. The extension cord that he used was not from the facility and it had to be a family member or a friend that brought the extension cord and gave it to the resident, because the residents are not supposed to have extension cords. The facility had an inventory list for each resident and, when family brought any item it should be added on the inventory list. Resident #1 was very independent; he was alert and oriented. If something that was not safe and that should not be in the building, the nurse and CNA are required to let maintenance, Director of Nursing or the Administrator know. Depending on what it is, they tried to not confiscate, but they will call the family member to pick up the item. Extension cords are not allowed for life safety and for a situation like this. The family knew that he had an extension cord in the facility, but the Administrator could not figure out who brought the cord to him and the family members did not acknowledge that they brought it. The Administrator reported that he interviewed staff and they did not notice any signs and symptoms that showed that Resident #1 could do what he did. On [DATE] at 9:11 AM, Staff L, CNA revealed that Resident #1 had an electric wheelchair, but she never saw the electric chair being charged. In the mornings, he used to take breakfast, take a shower and he go outside. She had to help him to transfer from bed to the wheelchair. He had one side that was a little paralyzed and she thinks that it was the right side, but she was not sure and he needed help to take shower in his back. He never had a sign of depression. Staff L stated that she never saw the extension cord in the facility and she did not know where Resident #1 got the extension cord from. On [DATE] at 10:13 AM, during an interview Staff O, LPN revealed that Resident #1 was very pleasant, he had no signs or symptoms of depression, he liked to take showers in the early mornings and take his breakfast after. After he took his medications he would go outside and talk with other residents outside the building closer to the parking lot. Staff O, LPN stated that Resident #1's family came to visit and Resident #1 had an electric wheelchair that his family brought to him. Staff O, LPN stated that she never paid attention on how the wheelchair was charged because in the mornings it was already charged, but she thinks that he had a cord for his wheelchair, but she was not sure because she had not seen it. Staff O, LPN stated that Resident #1 was taking medication for depression but it was not a high dose. She stated that he used to take [MEDICATION NAME] and [MEDICATION NAME] and maybe the [MEDICATION NAME] was discontinued and Resident #1 had no signs of side effects of the medication because he was not lethargic. On [DATE] at 11:18 AM, Staff M, CNA revealed that she had worked with Resident #1. He ate by himself, she helped him with taking showers, he could transfer himself from the wheelchair to the bed. Staff M stated that she did not know if Resident # 1 had an extension cord inside his room and she did not know how he charged his wheelchair. On [DATE] at 2:22 PM the current Administrator reported, the extension cord that Resident #1 used to commit suicide was white and Resident #1 motorized wheelchair had a battery and it was charged in the same system used by cell phones and Resident #1 plugged and charged his wheelchair by himself. On [DATE] at 11:18 AM, during interview with Staff M, CNA revealed that she used to work with resident #1 sometimes because she was floating in that floor. He was a good patient and nice. He ate by himself, she needed to help him to take shower, he could transfer himself from wheelchair to the bed, but she was together watching him. She did not know if he had an extension cord inside his room. She did not know the color of the cord that he used. She did not know how he used to charge his wheelchair. On [DATE] at 2:22 PM the current Administrator reported, the extension cord that Resident #1 used to commit suicide was white and Resident #1 motorized wheelchair had a battery and it was charged in the same system used by cell phones and Resident #1 plugged and charged his wheelchair by himself. On [DATE] at 10:29 AM, during a phone interview Resident #1's family member (brother) revealed the resident was admitted to the facility about 6 years ago. The family member stated that during the visits leading up to the last days Resident # 1 behaved differently. The family member stated that Resident #1 had shortness of breath and he had lost his appetite and was anxious. The family member stated that he reported and complained about his brother a few times and the nurses came and placed oxygen, and he would get better but they would not do anything else. The family member stated that he was in the facility the day before the incident happened Resident #1 was feeling better when he left, but the day after the facility called him to let him know about the incident. The family member reported that Resident #1 had an electric chair and a friend brought Resident #1 a white extension cord cable for him to charge the chair. The family member stated the electric extension cord cable was white, and staff knew about the extension cord cable because it was visible from the door at the entrance of the room .The family member reported that the head of the bed had an electric outlet on the wall to the left side of the bed, the cable was placed on the left side behind the bed so that he could charge the chair on the right side. The family member stated that Resident #1 could get up and transfer himself from the bed to the chair and that he could connect the chair and could get up from the chair to the bed. He would not walk but he could pull himself and transfer himself from the chair to the bed. The family member added that the staff knew about the electric cable because it was visible, and it was not something that was hidden and he never knew that he would use the extension cord cable to commit suicide and his brother never mentioned anything about suicide or any thought of suicide to him.

Based on observation, interview and record review the facility failed to ensure the provision of medication to meet the needs of each resident. This was evidenced by the failure to implement a procedure for acquiring, administering and monitoring the administration of medication in a timely manner for 1 of 1 sample residents ( Resident #1) who requires ongoing long term [MEDICAL CONDITION] and pain management treatment for [REDACTED]. The findings include: In an interview with Resident #1 on 9/2/2020 at 12:00 PM, the resident was observed sitting in a motorized wheelchair. She was alert, oriented and able to express her thoughts when questioned about her health status. The resident stated that she had a [DIAGNOSES REDACTED]. Resident #1 stated that the medications allows her to be comfortable, but at times she also relied on pain medication. She stated that she was very concerned since she had not been consistently receiving the prescribed [MEDICAL CONDITION] medications for months. Resident #1 stated that she had personally made phone calls to her Oncologist's office in an attempt to obtain the medications and she had discussed the situation with the facility management staff. Review of Resident #1's medical records indicated the resident medical [DIAGNOSES REDACTED]. The records indicated that Resident #1 is confined to a wheelchair and is unable to ambulate. The record further indicated that the resident is prescribed [MEDICATION NAME] for pain as needed. Review of Resident #1's Oncologist [MEDICAL CONDITION] plan/order dated on 1/13/2020 indicated the resident was ordered Revlimid ( Lenalidomide ) 10 milligram (mg) by mouth for a 28 day cycle, which consisted of a daily dose for 21 days and then off 7 days. The order indicated a continuous repeating cycle every 28 days. Additionally, the order indicated Resident #1 was to receive [MEDICATION NAME], given in a cycle of 40 mg orally daily for 4 days, Day 1-4 then off 4 days, Day 5-8. Then repeat the cycle, administering the medication on Day 9-12 and off Day 13-16 and then again administer on Day 17- 20 and off Day 21-24. The order indicated to repeat this medication cycle. Review of a nursing progress note for Resident #1, dated on 2/14/2020 indicated the resident visited her oncologist and had begun the [MEDICAL CONDITION] treatment of [REDACTED].#1 was complaining of a headache and the Oncologist ordered the medications to be held until a follow up appointment could be conducted on 2/21/2020. Review of Resident #1's February 2020 electronic Medication Administration Record [REDACTED]. Further view indicated no order to stop or restart the medication. Further review of the February 2020 MAR indicated [REDACTED]. Review of the February -March 2020 MAR indicated [REDACTED]. Further review of the electronic March 2020 MAR indicated [REDACTED]. Additionally, the March 2020 MAR indicated [REDACTED]. In an interview with the Director of Nursing on 9/3/2020 at 9:00 AM she provided documentation of nursing progress notes, which reflected contact with the resident's oncologist on 2/14/2020. The documentation indicated the next contact made was on 5/27/2020. Review of Resident #1's April 2020 electronic MAR indicated [REDACTED]. Review of Resident #1's May 2020 electronic MAR indicated [REDACTED]. Review of the facility nursing progress note dated on 5/27/2020 indicated a telemedical consultation between Resident #1 and Oncologist was conducted and no changes were made to the resident's medication orders. Review of Resident #1's Oncologist office note dated on 5/27/2020 indicated the resident was seen via telehealth. The note indicated Resident #1 remains on [DIAGNOSES REDACTED] medication regimen -Revlimid/ [MEDICATION NAME]. The note further indicated the facility nurse was requested to send recent blood work results for review and Resident#1 was to be seen again in 4 weeks. Review of Resident #1's June 2020 electronic MAR indicated [REDACTED]. The resident received the [MEDICATION NAME] medication only 4 days, on 6/1- 6/4/2020. Review of the nursing progress notes from June 2020 indicated no documentation of any notifications to the oncologist to discuss any missed medication doses. Review of Resident #1's Oncologist office note dated on 6/26/2020 indicated the resident was seen via telehealth. The note indicated Resident #1 remains on [DIAGNOSES REDACTED] medication regimen -Revlimid/ [MEDICATION NAME]. The note stated that the nursing home will send recent blood work results to the office and the resident was to continue on the medication regimen. Review of Resident #1's July 2020 electronic MAR indicated [REDACTED]. Review of the nursing progress notes for July 2020 revealed no documentation of any notifications to the Oncologist to discuss any missed medications. Review of Resident #1's Oncologist office note dated on 7/24/2020 indicated the resident was seen via telehealth. The note indicated Resident #1 remains on [DIAGNOSES REDACTED] medication regimen -Revlimid/ [MEDICATION NAME]. The note indicated Resident #1 was complaining of mild to moderate intermittent bone pain over the past few days. The note further indicted that Resident #1 had not taken her medication regimen for the past 2 weeks and was waiting for medication delivery from the pharmacy. The note indicated that the oncologist ordered a bone scan due to the resident's complaint of pain and the resident was to be seen for a follow-up visit in 2 weeks. Review of the facility nursing notes for August 2020 indicated no documentation of the bone scan being completed. The nursing notes indicated on 8/4/2020 the resident complains of pain that is not relieved by prescribed pain medications. The resident is transferred to the hospital for evaluation of abdominal pain and then readmitted back to the facility on [DATE], with treatment orders including abdominal ultrasound and [MEDICATION NAME] antibiotic therapy. In an interview with the Nurse Manager for Unit A on 9/2/2020 at 9:45 AM, she stated that Resident #1 had a [DIAGNOSES REDACTED]. The Nurse Manager stated that the Revlimid medication was supplied by an outside pharmacy, not the contracted facility pharmacy, and therefore when the Revlimid needed to be reordered, the Oncologist would be called each time to place an order with the specialty pharmacy. The Nurse Manager further stated that she was unaware of any specific procedure to procure/ receive specialty medications and there was no documentation of any contacts made to the Oncologist or the pharmacy in an attempt to refill the prescription. The Nurse Manager stated she was unaware that Resident #1 had not been consistently receiving her [MEDICAL CONDITION] treatments as ordered by the Oncologist. In an interview with the facility Consultant Pharmacist on 9/2/2020 at 2:25 PM, she was informed of the surveyor findings related to the procurement and administration of Resident #1's [MEDICAL CONDITION] medications. The Consultant Pharmacist stated that the Revlimid, most likely, was not available from the facility's contracted pharmacy and therefore the medication would need to be reordered on an as needed bases. She stated that she was aware that Resident #1 was prescribed Remlivid, but was not aware that the resident had not been administered the medication as prescribed. The pharmacist stated that since it was a specialty medication, she expected nursing documentation of when a refill order was placed and when the medication was received by the facility. She stated that the missed doses of Remlivid and [MEDICATION NAME] for Resident #1 should be investigated and a plan implemented to prevent this from re-occurring in the future. She stated that she would expect to see documentation of nursing notification to the Oncologist of any missed doses or concerns related to the prescribed [MEDICAL CONDITION] treatment. In an interview with Resident#1's Oncologist on 9/2/2020 at 3:20 PM, he stated that Resident #1 had the [DIAGNOSES REDACTED]. The Oncologist stated that the regimen was a continuous cyclical treatment consisting of Revlimid 10 mg by mouth for 21 days and then pause/ off for 7 days and then resuming the medication. The Oncologist stated that the [MEDICATION NAME] 40 mg was to be administered daily for 4 days, then paused for 4 days and resumed for 2 more cycles. The Oncologist was informed by the surveyor of the findings for numerous missed doses of the Revlimid and [MEDICATION NAME] over a 7 month period of time. The Oncologist stated that the treatment regimen should be given as ordered, and Resident #1 had a chronic [DIAGNOSES REDACTED]. The Oncologist stated that Resident #1 had informed him in July 2020 about missed medication doses and he had spoken directly with the facility nursing staff to address the reordering issue. The Oncologist stated that he had requested specific blood work to determine how Resident #1 was responding to her medication regimen, but he had not received the results for months. Review of the facility's policy on Administering Medications dated 12/2012 indicated that medications must be administered in accordance with the orders, including any required time frame. Review of the facility's Medication Utilization and Prescribing Clinical protocol dated 9/2012 indicated that the consultant pharmacist can help by reviewing facility medication usage patterns and trends and by intensifying medication reviews of individuals taking medications that present higher risks. In an interview with the Administrator and Director of Nursing (DON)on 9/2/2020 at 4:30 PM, the DON reviewed Resident #1's [MEDICAL CONDITION] medication orders dated 1/13/2020 for Revlimid and [MEDICATION NAME] and she stated that she was unaware that the medications required a continuous cyclical administration regimen. She stated that she had not contacted Resident #1's Oncologist to clarify any orders and was unaware that Resident #1 had not been consistently receiving her [MEDICAL CONDITION] medications as ordered. The Administrator stated that he recalled some discussion months ago about the procurement of the [MEDICAL CONDITION] medication, Revlimid for Resident #1 but he could not describe the facility's policy/ procedure for obtaining the medication. Both the Administrator and the DON stated they would immediately contact Resident #1's Oncologist and formulate a plan to correct any issues with procuring, administering and monitoring the administration of Resident #1's [MEDICAL CONDITION] medication regimen.

Based on observation, interview, and record review, the facility failed to provide the appropriate assessment to a resident after a 3-day old status [REDACTED].#159 suffered actual harm from the pain the resident experienced. This has the potential to affect one out of 59 residents on the Pain Management Program at the time of this survey. The findings included: Record review of the face sheet revealed, resident #159 was re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the telephone order for resident #159 dated 11/11/16 revealed, pain management consult with medical doctor for [DIAGNOSES REDACTED]. Record review of the telephone order for resident #159 dated 11/20/16 revealed, pain management consult with medical doctor. Record review of the Ear Nose & Throat (ENT) consultation for resident # 159 dated 11/28/16 revealed, history of gunshot wound to head on 06/2016. Record review of the consultation report for resident # 159 dated 12/1/16 revealed, status [REDACTED]. Record review of the telephone order for resident # 159 dated 2/24/17 revealed patient medically cleared for Cranioplasty surgery. Surgery scheduled for 2/28/17 needed to be in hospital for Cranioplasty. Record review of the hospital discharge medications for resident # 159 dated 3/3/17 at 4:55 PM revealed, the following pain medications: [REDACTED]. No other pain medications were listed. Record review of the initial admission assessment for resident # 159 dated 3/3/17 at 8:05 PM revealed, did the resident complain of pain upon admission: No was check marked. Skin warm and dry with discoloration. Patient post Cranioplasty surgery site to right parietal with blue thread and mid occipital with small opening with staples open to air. Mood alert, was check marked. Record review of the daily skilled note for resident # 159 dated 3/4/17 revealed, mental status alert and forgetful. Oriented to person checked, place and time not checked. Ability to hear was check marked. Pain on 3/4/17 at 6:09 am, none checked. Mild pain 1 checked, frequency no complaints of pain. Record review of the nursing assessment on 3/3/17 for resident # 159 revealed, the pain at 8:05 PM was listed as: had no complaints of pain on admission. Record review of the nursing assessment for resident # 159 dated 3/4/17 at 2:33 PM revealed, pain none checked. Location of pain - No. Pain score none. Record review of the pain assessment scale for resident # 159 dated 3/5/17 at 12:13 am, pain was none. Pain absence at this time. No complaints of pain. Record review of the pain assessment for resident # 159 dated 3/5/17 at 6:09 PM revealed, type of pain was none, location was no pain, pain score was none, no complaints of pain. Record review of the pain assessment for resident # 159 dated 3/5/17 at 8:39 PM revealed, pain intermittent headache, 3/10(pain scale) pain less than daily. Record review of the pain scale assessment for resident # 159 dated 3/6/17 at 3:05 am revealed, type of pain was none, location of pain was none, pain score was absent of pain, no complaints of pain. Record review of the pain assessment for resident # 159 dated 3/7/17 at 3:17 PM revealed, pain was intermittent with headache. Pain was 6 as moderate. Record review of the March 2017 Physician order [REDACTED].# 159 revealed, [MEDICATION NAME] 500 mg give 1 tablet via enteral tube every 4 hrs as needed for elevated temperature/headache. Record review of the Medication Administration Record [REDACTED]. Record review of the MAR for March 2017 for resident # 159 revealed, [MEDICATION NAME] 500 mg 1 tablet was given on March 5, 2017 and March 6, 2017. Record Review of the POS [REDACTED]. Record review of the MAR for resident # 159 dated 3/6/17 revealed, [MEDICATION NAME] 50 mg give 1 tab via enteral tube every 4 hrs as needed for pain was given on 3/6/17. Record review of the nurse's notes for resident # 159 dated 3/5/17 at 9:07 am revealed, resident complained of headache, pain scale of 3/10. Medicated as per medical doctor (MD) order. Will continue to monitor. Record review of the nurse's notes for resident # 159 dated 3/5/17 at 9:58 am revealed, resident # 159 lying down and denied pain. Medication was effective. Record review of the nurse's notes for resident # 159 dated 3/6/17 at 10:30 am revealed, resident # 159 complained of headache, was medicated with Tylenol. Will continue to monitor Record review of the nurse's notes for resident # 159 dated 3/6/17 at 11:28 am revealed, resident verbalized relief when assessed for pain. Record review of the nurse's notes for resident # 159 dated 3/6/17 at 2:35 PM revealed, resident # 159 complained of headache, medicated with Tylenol as ordered. Will continue to monitor. Record review of the nurses' notes for resident # 159 dated 3/6/17 at 4:49 PM revealed, received a call from nurse at doctor's office regarding resident # 159 daughter's concern that her mom was suffering in pain. She explained that resident # 159 was given [MEDICATION NAME] 500 mg twice on 7 am to 3 PM shift and the last time was at 2 PM. She was given [MEDICATION NAME] 50 mg at 3:15 PM and the daughter was asking for something more. It was explained that this was the first dose of [MEDICATION NAME] and it may take a little while to work and that they would give another dose of [MEDICATION NAME] at 6:30 PM. She still was not happy and she wanted more medication and it was explained to her, the doctor did not want to give her anything stronger due to her age and her medical condition. Record review of the pain care plan for resident # 159 updated 3/8/17 revealed, resident # 159 was at risk for alteration in comfort, pain related to multiple medical co-morbidities. Goal: Resident # 159 will have relief of pain within 1 hour of interventions. Interventions: Monitor for pain and report to medical doctor if pain was unresolved within 1 hour of worsening. Pain scale and assessment per facility protocol. Interview on 3/6/17 at 2:34 PM with family member A of resident # 159 revealed, she came from the hospital on [DATE]. She received over the counter Tylenol and was in tremendous pain. Family member A stated, resident # 159 had taken 2 pain medications before. Family member A had expressed concern about her pain medication. Family member A said R#159 received regular Tylenol on the weekend. Family member A said she was not sure which medication resident # 159 was discharged with. Observation on 3/6/17 at 2:43 PM of resident # 159 with family member A and the facility Administrator revealed, resident # 159 had a large scar to the right parietal area of her head with stitches and staples. Resident # 159 was in her room. The percutaneous endoscopic gastrostomy (PEG) tube feeding was infusing at 65 cc/hr (cubic centimeter/hour). Interview on 3/6/17 at 2:43 PM with resident # 159 in the presence of family member A and the Administrator in the resident's room revealed, when resident # 159 was asked about her current pain. Resident # 159 acknowledged that she was currently in pain. When resident # 159 was asked what her pain scale was from 1 (lowest) to 10 (highest) resident # 159 exclaimed: 10 and No one asked if it was working. When resident # 159 was asked about her pain level on the weekend. Resident # 159 reported, The same as it is now. When resident # 159 was asked to clarify using the scale of 1 to 10, resident # 159 had stated 10. Resident # 159 was asked which pain medication she received on the weekend. Resident # 159 replied, Tylenol and It was not working. Resident # 159 was asked if she told staff and resident # 159 reported, she had remembered telling someone she was in pain on the weekend. Interview on 3/6/17 at 3:17 PM with the nursing supervisor (Staff I), regarding resident # 159 revealed, she was last re-admitted on [DATE]. Her admission [DIAGNOSES REDACTED]. Resident # 159 had a history of [REDACTED]. Staff I explained, resident # 159 had a Cranioplasty which was brain surgery on 2/28/17. Staff I noted, resident # 159 was alert times 1 to 2. Staff I stated, resident # 159 could answer questions with yes or no and knew where she was, she thought she was in rehabilitation. Staff I noted, she came from the hospital with a discharge medication list, the admission nurse called the primary doctor on call to reconcile the medications upon re-admission. Staff I said, resident # 159 hospital readmission pain medication contained [MEDICATION NAME] 500 mg every 4 as needed (PRN). Staff I acknowledged, resident # 159 did not come with any other pain medications from the hospital. Staff I confirmed, resident # 159 knew when she was in pain. Interview on 3/6/17 at 3:25 PM with family member B of resident # 159 revealed, she was the proxy. Family member B noted, she was here on Saturday and Sunday. Family member B stated, resident # 159 came back to the facility on Friday 3/3/17. Family member B reported, she was here on Friday, Saturday and Sunday. The social worker stated, everything she was on in the hospital she would get here. Interview on 3/6/17 at 3:45 PM with staff I, the charge nurse regarding resident # 159 revealed, the pain management doctor ordered [MEDICATION NAME] 50 mg one tab via PEG PRN as needed every 4 hrs. Staff I noted, resident # 159 was just medicated with [MEDICATION NAME] 50 mg by her nurse. Observation and interview on 3/6/17 at 3:57 PM with family member A who was at the bedside of resident # 159 while the resident was sleeping revealed, resident # 159 received [MEDICATION NAME] at 3:20 PM. Interview on 3/9/17 at 5:05 PM with staff J, (Charge Nurse) revealed, R#159 was originally admitted on [DATE]. Her recent re-admission was on 03/3/17 for status [REDACTED].# 159 was alert times 1 (name) to 2 (name and place) and was a retired nurse. Staff J noted, resident # 159 knew the milligrams and frequencies of medications. Staff J mentioned, resident # 159 was retired from the hospital. Staff J stated, resident # 159 was incontinent of bowel and bladder and was total care with PEG (percutaneous tube). Staff J reported, resident # 159 had a history of [REDACTED]. Staff J reported, resident # 159 had a Cranioplasty where the surgeon had removed part of her skull with reinsertion to be done later. Staff J noted, her incision was on the right parietal area extending from the forehead to back of the ear. Resident # 159 had stitches and 2 staples which were open to air. Staff J reviewed the re-admission hospital medications dated 3/3/17 for resident # 159 and noted Tylenol 500 mg PRN Q 4 hrs. Staff J confirmed, resident # 159 was not readmitted with any other pain medications. Staff J stated, the charge nurse would reconcile and call the attending medical doctor upon admission of a resident. Staff J noted, resident # 159 had a history of [REDACTED].? Staff J acknowledged, that there was no PRN Tylenol 500 mg listed as given on the MAR for resident # 159 on 3/3/17 Friday and Saturday 3/4/17. Staff J stated, the pain assessment was done on admission, a daily assessment every shift, throughout the shift and before and after the PRN pain medication. Staff J noted, normally it would be a concern to her if a resident was post-operative brain surgery 3-days with only a PRN Tylenol order because she was a resident advocate and wanted to ensure that the residents were comfortable. Staff J stated, she spoke to the nurse of the neurosurgeon at the hospital and because of resident #159's past medical history they didn't want to over sedate her. Staff J confirmed, resident # 159 could tell if she was in pain or not. Staff J exclaimed, She is one of us, a retired nurse. Record review of the facility's policy titled, Pain and Management revised March 2015 revealed, Purpose: The main purpose of this procedure are to help the staff identify pain in the resident and to develop interventions that are consistent with the resident's goals and needs and that address the underlying cause of pain. General guidelines. 1. The pain management program is based on the facility-wide commitment to resident comfort. 2. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. 3. Pain is a multidisciplinary care process that includes the following: A. Assessing the potential for pain; B. Effectively recognizing the presence of pain; C. Identifying the characteristics of pain; D. Addressing the underlying cause of pain; E. Developing and implementing approaches to pain management; F. Identifying and using specific strategies for different levels and sources of pain; G. Monitoring for the effectiveness of interventions H. Modifying approaches as necessary. 4. It is important to recognize cognitive, cultural, familial or gender-specific influences on the resident's ability or willingness to verbalize pain. 5. Conduct a comprehensive pain assessment upon admission to the facility. 6. Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain.

Based on record review and interview the facility failed to ensure each resident receives adequate supervision and assistance to prevent accidents while assisting with activities of daily living. This was evident for 1 of 6 sampled residents (resident #1). Findings include: Record review of resident #1's quarterly Minimum Data Set (MDS) with an assessment date of 07/20/13 revealed, under Functional Status, the resident is totally dependent for transfers with two-person assist and totally dependent for bathing with one-person physical assist. Review of resident #1's care plan for falls dated 11/08/12 revealed problem, "(Resident's name) is at risk for falls and fall related injuries related to: history of falls, impaired vision, use of psychotropic medication and pain medication; extensive assistance with ADL." There were 17 interventions noted including, "#13. Two staff members for transfers." Review of the Personal Care Record dated August 2013 documents total care for bed bath and shower; range of motion is also total care. The resident care card does not address support needed during ADLs. Review of the Restorative Observation dated 07/20/13 documented the resident is totally dependent for bathing and transfer. One person assist for bathing and two person assist for transfers. Record review of the nurses notes on 08/17/13 revealed at 9:25 am, the nurse was called into the resident's room by assigned Certified Nursing Assistant (CNA). The resident noted to be on the floor in supine position with right foot internally rotated and left foot externally rotated. When questioned, the assigned CNA replied resident was about to slide off the shower chair, attempted to catch her up and I eased her down to the floor. Patient transferred to ... Medical Center via stretcher. Review of the hospital records consultation of 08/18/13 revealed an x-ray of the right and left ankle and foot and a Computed Tomography (CT) scan of the right and left ankle were performed. Impression: 1. Left acute on chronic distal tibia/fibula pilon fracture, 2. Right acute distal tibia/fibula shaft fracture. Review of the documentation for resident #1 revealed, the date and time of the incident as 8/17/13 at 9:30 am. It occurred in room 126 B. According to the report, "The certified nursing assistant called for help, upon entering the resident's room, the resident was found in supine position lying on the floor. There was no loss of consciousness. On assessment it was observed that the Rt (right) foot was internally rotated and the left externally rotated. When asked what happened, the CNA stated that resident slid off the shower chair as she was doing morning care. The staff attempted to catch her and lowered her to the floor instead. The resident was questioned as well but did not respond verbally only moaned." Interview with CNA B on 9/4/13 at 11:03 am revealed on 8/17/13, she was on her unit in room 122. She heard someone yell there was a patient on the floor. She went outside and went to the room. Resident #1 was on the floor and the shower chair was close by. She moved the shower chair. She then went back to her resident. The nurse (Nurse A) came into the room. Interview with Nurse A on 9/4/13 at 3:28 pm revealed, on 8/17/13 she heard someone scream her name very loudly. She got to the room and saw the resident on the floor. She asked CNA A what happened and was told resident #1 fell and slid down to the floor. When she assessed resident #1, she discovered one leg was internally rotated and one was externally rotated. She called 911. When 911 came they did an evaluations and sent the resident to the hospital. Nurse A stated she thought resident #1's legs were broken based on what she saw. She had worked with the CNA before and did not have issues with residents under that CNA's care. She stated, she attended an in-service after the incident and that the facility trains its employees upon hire regarding resident transfers and fall prevention. Review of the listing of current Certified Nursing Assistants (CNAs) against those who signed in-service sheets revealed 47 out of 75 total CNAs had not attended the in-services regarding fall prevention/resident transfers as of 9/4/13. Interview with the Assistant Director of Nursing (ADON) on 9/4/13 at 3:03 pm revealed in-services were provided regarding falls and fall prevention but are still ongoing. Not all the staff has participated. She indicated the in-services would be finished this month. Review of in-service documentation provided on 9/5/13 for in-services provided on 9/4/13 and 9/5/13 revealed the facility had in-serviced an additional 18 CNAs on fall risk and prevention and safe transfers. Telephone interview with resident #1's assigned Certified Nursing Assistant (CNA) on 09/05/13 at 11:06 am revealed, on Saturday 08/17/13 she transferred the resident from the bed to the shower chair by herself, like she always does. She took the resident to the shower room and gave her a shower. She then took the resident back to her room and started to dress her. She noticed the resident shaking and moving and sliding off the chair so she grabbed her between her shoulders to prevent the fall but, she could not put her back in the chair and the resident fell to the floor. At that time, the resident from the other bed, resident #7, came in so she asked her to call for help. Interview with resident R#7 on 09/05/13 at 11:55 am revealed, she was coming back to her room and when she entered, she saw the CNA and resident #1 on the floor next to the resident ' s bed. " She is a big woman that resident." The CNA asked me to call for help. Interview with the DON on 9/5/13 at 4:36 pm revealed she came to the conclusion that CNA A had transferred resident #1 from the wheelchair to the bed by herself and dropped the resident causing the multiple fractures. She explained the facility conducted in-services with the staff regarding safe transfers and will do so quarterly. They started on 8/20/13 and it is ongoing. They are going to do a plan of action in which falls upon transfer will be analyzed and tracked. According to the DON, as of 9/4/13, 72% of the staff CNAs were in-serviced. She said that as of this date, 9/5/13, all the CNAs are trained. Record review of the facility's undated policy and procedure titled, "Safety During Manual Transfers" revealed it only addressed transfers from bed to chair. It did not address transfers prior to or after bathing such as wheelchair to shower chair or shower chair to wheelchair.