Every finding on record at Sierra Lakes Nursing & Rehabilitation Center

Based on observations, records reviewed and interviews, it was determined that the facility did not maintain adequate supervision to ensure a safe environment that is free from accident and hazards for 1 out of 5 residents sampled for accident hazards and supervision. On 04/28/2026, at approximately 6:20 PM, Resident #1 became dissatisfied with staff after being denied [brand] over-the-counter antacid medication that was not ordered by the physician. The resident #1 proceeded to light a cigarette in the hallway. Facility staff confiscated the cigarette and lighter and Resident #1 returned to her room unsupervised. Shortly thereafter, Resident #1 exited her room and informed staff that she had set her room on fire, and they needed to remove her roommate. The incident resulted from inadequate monitoring of Resident #1 during a supervised shopping trip on 04/22/2026, allowing her to acquire cigarettes and lighters that were brought into the facility without detection and a disregard for the facility's smoking policy. Subsequently, Resident #1 used one of these lighters to ignite a fire in her room creating the likelihood of serious injury, harm, impairment, or death of the facility's occupants. The findings included:Observational tour on 04/29/2026 starting at 10:00 AM of the facility's 3rd Floor [NAME] Unit revealed Resident #1's room had remnants of fire damage to the floor, bathroom and furniture; a bed in the room had a burnt mattress black in color. The windowpane was shattered/broken (Photographic Evidence Obtained). All the other rooms on the 3rd Floor [NAME] Unit showed no signs of damage. The 3rd Floor Dining Room had sixteen residents, (fourteen residents noted in beds and two residents sitting in chairs) there were five staff members in attendance. The 2nd Floor [NAME] Unit rooms were evacuated. The rooms and hallway were being dried by industrial type fans. The 2nd Floor Dining Room had twenty-three beds out of which nineteen residents were in bed and seven staff in attendance. Observation on the first floor revealed the smoking area attendant had cigarettes and lighters locked in a smoking cabinet, a book with the list of smokers, supervision requirement and who requires an apron. The aprons are stored in a closet in the smoking area.Review of the facility's policy and procedure titled Accidents and Incidents revisions dated 08/23, 04/29/2026 indicated:The facility will provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes:1. Identifying hazard(s) and risk(s).2. Evaluating and analyzing hazard(s) and risk(s).3. Implementing interventions to reduce hazard(s) and risk(s); and4. Monitoring effectiveness and modifying interventions when necessary.1. The facility will identify each resident at risk for accidents and/or falls and adequately plan care and implement procedures to prevent accidents.2. The facility will ensure each resident receives adequate supervision and assistance devices to prevent accidents.3. The facility will develop and implement an accident and incident reporting system that will report adverse incidents to the risk manager, or to his or her designee, within 3 business days after their occurrence.4. The reporting system will consist of:a. Report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required and take all necessary corrective actions depending on the results of the investigation.Review of the facility's policy and procedure titled Resident Leave revision dated 03/23 states: Resident Leave is defined as a patient leaving the grounds of the facility for a short period of time during the day. It is the Policy of the facility to provide residents with the ability to leave the facility grounds temporarily to engage in recreational activities.Policy Process and procedures:1. The physician will determine resident's ability to leave on pass.2. Residents/family will be informed of the facility's Resident Leave policy during the admission process and will be required to sign acknowledgement of the policy upon admission.3. Residents/responsible party must sign The Release of Responsibility for Leave of Absence form before leaving the facility.4. Residents must identify where they are going. During an interview on 04/29/2026 at 10:23 AM, the Director of Nursing (DON) reported that a call was received on 04/28/2026 at approximately 6:00 PM from Staff I, Registered Nurse (RN) and Unit Supervisor for the 3:00 PM to 11:00 PM shift to report that Resident #1 asked her assigned nurse, Staff D, Registered Nurse (RN), for [brand] antacid, and Staff D, RN, informed the resident she needed a physician's order to provide any new medication. Resident #1 became upset and cursed at the staff, then lit a cigarette in the hallway. Staff I, RN, confiscated the cigarette and lighter from Resident #1, and the resident returned to her room, cursing and spitting at staff. Moments later, she exited her room and announced, You better remove my roommate because I set the room on fire. Staff rushed into the room, observed smoke and fire, removed the roommate, closed the door, called 911, and evacuated the other residents to the dining room on the 3rd Floor [NAME] wing. Fire rescue arrived during the evacuation and helped staff move residents to a safe area in the dining room. Staff evacuated residents from the 2nd and 3rd Floor [NAME] Units. Staff kept all other residents in their rooms with the doors closed and followed fire protocols. The roommate (Resident #2) did not exhibit any signs or symptoms of respiratory distress, but the doctor ordered staff to send Resident #2 to the hospital for an overall assessment. On 04/29/2026 at approximately 10:30 AM the DON further revealed that when the police officers arrived at the facility on 04/28/2026, they interviewed Staff I, RN, and Resident #1. The resident stated that she bought cigarette lighters during a store outing with facility staff on 04/22/2026, knew she was not allowed to possess cigarette lighters. The police officers took Resident #1 to jail around midnight and charged her with several felonies, including attempted Felony Murder, Arson in the First Degree, and Battery touch/Strike as of 04/29/26 at 2:01 AM. On 04/29/2026, at approximately 10:35 AM, the Director of Nursing reported that smoking hours are between 7:00 AM and 11:30 PM. The smoking attendant manages the distribution of cigarettes and lighters, maintains a book listing the smokers and those requiring aprons. Record review of the facility's Policies and Procedures titled: Resident Smoking. Date Issued: 2/2020. Revised: 2/22/22 documented:Policy: This facility provides a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents in accordance to State and Federal regulations.Procedure: Smoking is prohibited in all areas except the designated smoking area. A Designated Smoking Area sign will be prominently posted.2. Safety measures for the designated smoking area will include, but not limited to:a. Protection from weather conditions (i.e. covered).b. Provision of ashtrays made of noncombustible material and safe design.c. Accessible metal containers with self-closing covers into which ashtrays can be emptied.d. Accessible fire extinguisher.e. Prohibition of oxygen use in the smoking area.f. Staff Supervision.3. No smoking signs will be maintained on the door or gate where oxygen is used or stored.4. Electronic cigarettes and vaping devices will be treated the same as any other smoking product.5. Residents and family members will be notified of this policy during the admission process, and as needed.6. All residents will be asked about tobacco use during the admission process, and in conjunction with the RAI Process.7. Residents who smoke will be further evaluated by the interdisciplinary team to determine additional safety interventions warranted.8. If a resident who smokes experiences any decline in condition or cognition, he/she will be reassessed for ability to smoke independently and/or to evaluate whether any additional safety measures are indicated.9. All safe smoking measures will be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking.I 0. Supervision will be provided as indicated on each resident's care plan.11. Family members or visitors that do not abide by this policy or the resident's plan of care will not be permitted to supervise resident's smoking.12. If a resident or family member does not abide by the smoking policy or care plan (e.g. smoking materials are provided directly to the resident, smoking in non-smoking areas, does not wear protective gear), the plan of care may be revised to include additional measures such as room searches, prohibited smoking, or even discharge.13. Smoking materials of residents who smoke will be maintained by nursing staff14. Residents will be allowed to smoke at designated smoking times.15. The interdisciplinary team, with guidance from the physician, will help to support the resident's right to make an informed decision regarding smoking by:a. Including the resident, family, and/or resident representative in discussions regarding the risks associated with smoking.b. Offering pharmacological and/or behavioral interventions to assist with smoking cessation.c. Providing educational materials regarding smoking and smoking cessation.d. Developing a safe smoking plan, or an individualized plan to quit smoking.16. Documentation to support decision making will be included in the medical record, including but not limited to:a. Resident's wishes, or those of the resident's representative.b. Assessment of relevant functional and cognitive factors affecting ability to smoke safely.c. Response to smoking cessation interventions.d. Compliance with smoking policy. On 04/29/26 at 8:21 PM, Staff C, a Certified Nursing Assistant who worked the 3:00 to 11:00 PM shift on the 3rd Floor East/West Unit, stated: On the evening of 04/28/2026, before the fire alarm started going off, I saw [Resident #1] in the hallway in her wheelchair. [Resident #1] told me, I put fire on the bed. I asked her, Are you for real? She replied, Yes, go check. She then went to the elevator in her wheelchair. I checked [Resident #1's] room and saw the bed close to the window on fire. I screamed, Help, fire, fire; the fire alarm started going off. Staff came to the room to help and pulled the roommate out of the room and closed the door. Record review of Resident #1's medical records revealed the resident was initially admitted to the facility on [DATE], readmitted on [DATE] and 04/09/2026. Clinical diagnoses included but not limited to: Unspecified Cerebral Infarction due to unspecified occlusion or stenosis of right cerebellar artery, Adjustment Disorder, Bipolar Disorder, Anxiety disorder, Schizophrenia, Mood Disorder due to known physiological condition, unspecified, Cocaine Abuse, uncomplicated. Resident # 1 was discharged on 04/29/2026.Record review of Resident #1's medical records revealed that on Saturday, 04/25/2026 the local police department removed Resident #1 from the facility for aggressive behavior and took her to a local hospital and the resident was readmitted to the facility later the same day.Review of Resident #1's Physician's Orders Sheet for April 2026 revealed the resident included but not limited to: Paroxetine Oral Tablet 30 Milligram (mg)-Give one tablet by mouth at bedtime related to Major Depressive Disorder. Clonazepam Tablet 1 mg-Give 1 tablet by mouth every eight hours for Anxiety related to Major Depressive Disorder, Trazodone Tablet 100 mg-Give one tablet by mouth at bedtime related to Schizophrenia and Oxycodone-Acetaminophen Tablet 10-325 mg-Give 1 tablet by mouth every four hours related to pain. Record review of Resident #1 's Discharge Return Anticipated Minimum Data Set (MDS) dated [DATE] documented in Section C for Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating the resident is cognitively intact and communicated her needs effectively. Section E for Behaviors documented verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) occur 1-3 days. Section GG for Functional Abilities documented the resident is dependent for care. Section H for Bowel and Bladder documented: Frequently incontinent of bowel and bladder. Section J for Health Conditions documented the resident received scheduled and as needed pain medications, no shortness of breath, no falls. Section N for Medications documented resident is taking anxiety, antidepressant, opioid, and antibiotic medication. Section O for Special Treatments and Procedures documented no special treatments received. Section P for restraints and Alarms documented none used. Section Q for Participation in Assessment and Goal Setting documented resident participated in assessment. Review of Resident # 1's most recent Smoking assessment dated [DATE] documented the resident is a dependent smoker that requires supervision.Interview on 04/29/2026 at 3:30 PM Staff Z, CNA/Smoking attendant revealed resident's cigarettes are kept in individually labeled lock boxes with their names and lighters in a separate lockbox. All the lockboxes are stored in a locked file cabinet with the smoking aprons which can only be accessed using the smoking attendant's key. When a resident comes to the smoking area if they are alert, they have the code to their individual lock boxes to retrieve their cigarettes only two cigarettes are allowed at a time. If the resident is not alert the attendant gives out the cigarettes. The attendant lights all cigarettes and supervises smoking for every resident.Review of Resident #1's Level I Preadmission Screening and Resident Review (PASRR) completed by the facility's Registered Nurse on 02/11/2026 documented Level II PASRR evaluation requested related to serious mental illness.On 02/25/2026 a Level II PASRR was completed by the authorized Mental Health Agency, Licensed Mental Health Counselor (LMHC). Based on the information provided for this review, Specialized Services were determined to not be needed as the patient did not appear to be at risk for inpatient hospitalization. It is recommended that the following rehabilitative services, of a lesser intensity than Specialized Services, are added or continued, on the patient's Comprehensive Person-Centered Nursing Care Plan: Psychiatric Medication Management. Individual Therapy and Substance Abuse Counseling/12 Step Program if available and if this is deemed needed by the multidisciplinary team and if available at the facility.Review of Resident #1's psychological consultations revealed the most recent consult was completed 04/22/2026 indicating: Resident's aggressive behaviors were explored and addressed. Interventions/techniques used Cognitive Behavioral Therapy, Motivational, Interpersonal, and Psychoeducational. The consultation documented the resident continued to have negative and irrational responses to facility staff. The consultation documented the resident was having excessive anger toward staff when she didn't receive her pain medication.Record review of Resident #1 's Care Plans Reference Date 01/20/2026 revealed the resident is at risk for drug related side effects due to use of psychotropic medications for the diagnosis of: Anxiety, Major Depressive Disorder, Insomnia, Bipolar Disorder, Schizophrenia, Psychosis uncomplicated, and Opioid abuse. Resident will remain free of drug related side effects through next review date. Interventions include- License Nurse to follow up behavior monitoring sheet. Medicate as ordered. Monitor behavior and mood every shift and document. Monitor for adverse side effects of drugs (lethargy, dizziness, increase in confusion, gait disturbance). Provide non-pharmacological interventions as needed. Report changes to MD as needed. Resident is a smoker. Resident will not suffer injury from unsafe smoking practices through the review date. Interventions include: The resident will not smoke without supervision through the review date. Instruct resident about smoking risks and hazards and about smoking cessation aids that are available. Notify charge nurse immediately if it is suspected resident has violated facility smoking policy.Resident has a serious mental illness per Preadmission Screening and Resident Review (PASRR) Level two (2) Resident will not require specialized services through next review date. Interventions include- Monitor resident's mood and/or behaviors for changes and need for specialized services. Offer Supportive Counseling, psychiatric and/or psychology services to address changes in mood and/or behavior. Provide Social Services support. Psychiatric Medication Management. Resident is displaying mood/behavior symptoms such as periods of restlessness/agitation, related to Anxiety. Constantly using the call light for the nurse multiple times after being seen. 02/07/2026 Verbally abusive behavior noted. Resident # mood/behaviors symptoms will be reduced through the next review date. Interventions include-Approach in a calm manner. Establish a trust relationship. Follow up psychiatric consult as needed. Give positive feedback for cooperating and efforts made. Monitor, report and document behavior. Resident is verbally aggressive and demanding towards staff and refuses redirection at times. Resident displays drug seeking behavior as reported by staff. Noted to fabricate stories about staff at times and calls police to report the staff. 04/25/2026: Resident displayed verbal and physical aggression toward staff - Unable to be redirected. Involuntary psychiatric examination [Baker Act] order received and sent to hospital. 04/26/2026: Resident continues to be verbally aggressive with staff and calling police many times. 04/27/2026: Resident became increasingly agitated and exhibited destructive behavior on the unit. She damaged facility equipment, including telephones, a computer, and a fax machine. She also threw books onto the floor and overturned trash and laundry barrels in the hallway. Uneasy to redirect. Monitoring continues. Resident #1 will verbalize understanding of need to control verbally abusive behavior through the review date. Interventions include-Administer medications as ordered. Monitor/document for side effects and effectiveness. Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document Anticipate resident's needs and offer assistance as needed. Assess residents' understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Review of a Health Status Note dated 04/25/2026 time stamped 04:56 (4:56 AM) documented: At 3:00 AM Resident called the supervisor to the floor stating that this nurse refused to give her 12:00 AM meds, this nurse explained to her that the medication was administered with another staff as witness, just immediately the 911 arrived and made aware what happened and that the next dose is due at 4:00 AM which will be given to her as scheduled, the police assured her that her next dose will be given to her as scheduled and they left.Review of Health Status Note dated 04/25/2026 time stamped 05:22 (5:22 AM) documented: At 4:00 AM this nurse and supervisor went into the room and administered the 4:00 AM med, the resident refused to sign the paper again while in the room she threw down everything on her table on the floor and also threw the table at me but fortunately I moved back and the table landed on the floor. I walked out of the room and continued my work. Later while walking out from the pantry, she threw a bowl of water on this nurse my whole body was drained with water, she moved forward to the medication cart and threw everything on the floor. She picked up the laptop to throw on the floor when a staff quickly took it from her. The behavior continues, she brought her blue tooth speaker on the hallway and was playing music stating, I am going to wake everybody up. Few minutes later she came back to the medication cart and threw everything onto the floor again, including the cups by the side. Redirection with no effect behavior continues the resident was so aggressive at this time, very abusive, stating I hate you with passion and I pray you will be crushed before you get home today. At this time the supervisor called the police, and the resident was transferred to a local hospital for an involuntary psychiatric examination [Baker Act].Review of a Health Status Note dated 04/25/2026 timestamped 06:59 (6:59 AM) indicated: 6:30 AM resident was transferred to [local hospital]. She stated that: I will be back in 3 days Call placed to sister and message left. Call placed to MD and PA (Physician Assistant) made aware.Record review of Health Status Noted dated 04/25/2026 timestamped 08:10 (8:10 AM) indicated: The resident exhibited disruptive behavior, including making excessive noise, being verbally abusive toward staff, and physically aggressive (throwing water toward staff). The resident also contacted police regarding staff. Due to escalating behavior and safety concerns, the resident was placed under [NAME] Act and was transferred at 0610 (6:10 AM) to [local hospital] for further psychiatric evaluation and treatment. Staff maintained safety measures and followed facility protocol throughout the incident.Health Status Note dated 04/25/2026 timestamped 13:00 (1:00 PM) documented: Resident returned to facility from [local hospital] via stretcher accompanied by 2 ambulance attendants. Upon arrival, resident alert and oriented X4, vital signs stable, no acute distress observed. Review of Health Status Note dated 04/26/2026 time stamped 09:56 AM Note Text: Resident reports that during vital sign assessment at [local hospital] yesterday, a pulse oximeter was removed abruptly from her finger, causing pain. Resident now reports concern that the finger may be injured or possibly fractured. Resident's finger contracted and painful to touch, but there are no obvious sign/ symptoms of injury, MD made aware and gave order for x-ray, will continue to monitor. Review of a Behavior Note dated 04/27/2026 timestamped 00:18 (12:18 AM) Note Text: Resident was very aggressive and verbally abusive towards nurses and CNAs. stated that no one wants to help her with care even after getting care from CNAs. She told me that she will take her medication after coming from downstairs to smoke, then accusing writer not wanting to give her meds. Resident call police over 5 times, screaming and crying about medication after the facts that medication was given. She trying to destroy the place and call me stupid [inappropriate language]; resident redirected but doesn't care about anything but to curse everybody out by calling employees.bad names.Review of a Behavior Note dated 04/27/2026 timestamped 09:18 (9:18 AM) Note Text: Resident became increasingly agitated and exhibited destructive behavior on the unit. She damaged facility equipment, including telephones, a computer, and a fax machine. She also threw books onto the floor and overturned trash and laundry barrels in the hallway. Due to her escalating behavior and inability to de-escalate the situation safely, the police were contacted for assistance. At this time, the situation continues to monitor.Review of a Health Status Note dated 04/27/2026 timestamped 09:45 (9:45 AM) documented: Two Police officers arrived at facility and were informed of the situation, including the observed property damage and the resident's behavior. Officers were directed to resident's room, where they spoke to her directly. During the interaction, the resident provided information that appeared inconsistent with staff observations. While police officers were present, the resident's behavior de-escalated and she became calm. After completing their assessment, the officers provided staff with a contact card.Review of a Health Status Note dated 04/27/2026 timestamped 12:09 (12:09 PM) documented: On 4/27/26 at approximately 12:00 resident reported to writer that the 3rd floor Unit Manager, beat her up an pushed her wheelchair. Resident also reported that over this past weekend the supervisor cursed her and the facility lacks sufficient towels. A comprehensive investigation has been initiated. A skin assessment has been completed for [Resident #1] with no new findings. PCP (Primary Care Physician) notified. DCF (Department of Children and Families) notified; Psychology and Psychiatry notified: Police notified; Resident and staff interviews to be conducted.Review of a Health Status Note dated 04/27/2026 timestamped 14:55 (2:55 PM) documented: Law enforcement arrived at the facility at 2: 48 PM and resident refused officer. Officer stated to call back later to have another unit, and he is unable to get report because the resident is refusing to speak with him.Review of a Health Status Note Dated 4/27/2026 timestamped 20:32 (6:32 PM) documented: Police was called as a follow up of the morning incident. The police questioned the resident about the incident; case report card was given to the resident and one left with the writer. At this time no issues raised by the resident, quiet, cleaned and kept dry.Review of a nursing progress notes completed by Staff D, RN, dated 04/28/2026 timestamped 17:51(5:51 PM) documented: Resident put call light on, and I went to the room immediately, resident ask for medication that she has no order for. Resident informed that we have to get a doctor's prescription before administered to her. Resident started cursing out and threw her food tray on the floor. Supervisor was made aware and got involved promptly.Review of a Behavior Note completed by Staff I, RN dated 4/28/2026 timestamped 18:51(6:51 PM) documented: At approximately 6:00 PM, the resident displayed aggressive and disruptive behavior toward staff. Light up cigarette on the hallway, the writer tried taking it from her she began spitting at staff members and used verbally abusive language, including calling staff slave. During the interaction, the resident also intentionally spilled water on staff stating you [ .] redirection, but the resident continued to escalate. Thereby asking the staff to remove her roommate who was on oxygen out of the room because she going to burn the building, all of a suddenly we observed smoke coming out of the room. The resident is a danger to all staff and residents in the facility. she was unable to redirect. 911 called. MD and psychological Advanced Registered Nurse Practitioner (ARNP) notified, order given for an Involuntary psychiatric examination [Baker Act] the resident. Review of a Behavior Note completed by Staff D, RN dated 04/28/2026 timestamped 21:30 (9:30PM) documented: Resident observed in the hallway continued cursing, resident light up a cigarette to smoke in the hallway, cigarette removed by the supervisor, resident became more agitated, spit on the supervisor and returned to the room, new medication administered as ordered. Resident threw the remaining water at me. Shortly after, the resident wheeled in hallway and continued cursing out and stated, I put fire in the room, y'all better go get the resident out of the room Room checked by staff immediately and found the bed on fire. residents evacuated by the staff while fire rescue involved. Safety measures maintained, all residents evacuated and now resting comfortably in a safe place. Doctor, DON, Assistant Director of Nurse (ADON) and all the staff were notified. Monitoring continues.Review of Behavior Note completed by Staff I, RN on 04/29/2026 timestamped 00:40 (12:40 AM) documented: Resident left the facility via stretcher along with three local police officer to the hospital. Review of an Incident Note completed by the DON dated 04/30/2026 timestamped 12:29 PM documented: This note is a clarification of the events that occurred including the interventions for the resident on 4/28/2026 at approximately 6:05 PM, Resident is displaying disruptive behavior towards the staff using profanities and spitting at the staff members. Resident lit a cigarette in the hallway. Nursing Supervisor removed the cigarette and the lighter from the resident and explained she cannot have a lighter or smoke in the building. Resident cursed out the Supervisor and went to her room. Psych/NP was called and stated to have an Involuntary psychiatric examination [Baker Act] for the resident. At approximately 6:09 PM, Nurse entered the room and administered the [antacid] she requested. Resident accepted the [antacid] and used profane language to the staff member and threw a glass of water at the nurse. At approximately 6:18 PM, Resident exited her room approached the CNA and stated you need to go get the roommate out of the room because I just lit my mattress on fire because I want to burn this place down and continued using profanities towards the staff. Staff immediately removed the roommate from the room, the fire alarm sounded and sprinklers in the room turned on and extinguished the fire. Resident was placed on 1:1 (one to one observation). At Approx 6:30 PM, local Fire Department and Police Department arrived. Police Department was notified of the incident and taken to where the resident was with the staff member. Police Officers interviewed the resident who stated she purposely set the fire. Police Officers interviewed the staff and Nursing Supervisor who reported that the resident had been displaying negative behavior with use of foul language and throwing her food tray and water at staff and that earlier resident attempted to smoke inside the building and that the Supervisor removed her cigarette and lighter, resident returned to her room and a few minutes later reported to remove the roommate because she lit her mattress on fire. Police Officers placed the resident in their custody and assumed the 1:1 with the resident from this point on. At approximately 9:00 PM, Resident remains on 1:1 with Sherrif's Department. Medication was administered by the nurse. At approximately 11:00 PM, The CNAs provided care to the resident. Fluids provided to the resident. Resident remains with Sherrif Department. On 4/29/2026 at approximately 12:30 AM Resident was arrested and transported to jail via ambulance accompanied by Police Officers. Telephone interview on 04/30/2026 at 12:32 PM Staff D, RN who worked on the 3rd Floor [NAME] Unit, 3:00 PM to 11:00 PM shift stated: On 04/28/2026 I was assigned [Resident #1], I did rounds around 3:15 PM, the resident was in the smoking area downstairs. Shortly after my rounds [Resident #1] came on the unit, put the call light on in her room requesting to be changed out of her clothes, her assigned CNAs changed her, I administered medications to the resident. The resident received her dinner tray; I set up the food for the resident and left the room. Around 5:40 PM the call light in the resident's room was on again, I went to the room, the resident requested [brand antacid], I checked the resident's orders, she did not have an order for [brand antacid], I went to let the resident know that I needed to call the doctor to get an order for the [brand antacid]. The resident got upset and agitated, threw her food tray on the floor, and started cursing me out. I left the room and called my supervisor, (Staff I, RN). [Staff I, RN] came to the room, [Resident #1] started cursing at both of us using really bad words. [Staff I, RN] started calling the doctor to get the order for [brand antacid]. [Resident #1] then requested help to get in her chair from bed and wanted her hair bonnet fixed. Immediately after [Resident #1] wheeled her chair in the hallway by her room and lit a cigarette, [Staff I, RN] told her she cannot smoke in the hallway and took the cigarette from [Resident#1]. The resident threw the lighter at [ Staff I, RN] spat on her and kept cursing. [Resident #1] then wheeled her chair back into her room, approximately 4-5 minutes later I went in the room to give the resident [brand antacid] approved by the MD, [Resident #1] threw the water I gave her to take the medication on my clothes and told me, get out of my room and started cursing at me again. I w

Based on observations record review and interviews, the facility failed to maintain accurate narcotic accounting records, failed to record and implement narcotic disposal/wasting protocols in accordance with professional standards of practice for one (4th Floor East Cart) of four medication carts reviewed. As evidenced by Medication Monitoring Control Records for the 4th Floor East Cart were inaccurate when compared to the corresponding bingo cards and staff failed to have a witness before disposing narcotic. There were 160 residents residing in the facility at the time of the survey. The findings include:On 01/12/2026 at 5:51 PM, Staff Q, RN, revealed she was assigned to the 4th Floor East Cart and had completed giving all the 6:00 PM medications. A narcotic count review of the 4th Floor East Cart was conducted with Staff Q, RN and the following discrepancies were identified. Resident #76Tramadol-50 milligram (mg) tablet; Give 1 tablet every six hours for acute painMedication Monitoring Control Record Log on Hand documented:13 Bingo Card Medication Count =11 On 1/12/2026 at 5:58 PM, when asked about the discrepancy identified related to Resident #76's Tramadol-50 mg tablet ordered to be given every six hours for acute pain. Staff Q, RN stated: I gave it at 18:00 (6:00 PM) but I didn't sign. I am supposed to sign when I remove the medication. The patient dropped the medication on the floor, and I flushed it and I had to pull another one and give it, but I did not sign it. I should not have flushed it. I am going to let the supervisor know I should have had a witness to waste narcotic. Resident # 77Lacosamide 100 mg one tablet by mouth twice daily.Bingo Card Medication Count = 8Medication Monitoring Control Record Log documented amount on hand: 9 Resident # 103Lorazepam 0.5 mgBingo Card Medication Count =10Medication Monitoring Control Record Log documented amount on hand: 11 Resident # 34Oxycodone/APAP tablet 10-325 mg (Give one tablet by mouth every 4 hours as needed)Bingo Card Medication Count = 22Medication Monitoring Control Record Log documented amount on hand: 23 Resident # 11Lorazepam 1 mg tablet (one tablet by mouth twice daily)Bingo Card Medication Count =9Medication Monitoring Control Record Log documented amount on hand:10 Resident # 17Xanax (alprazolam) 1 mg tabletBingo Card Medication count =8Medication Monitoring Control Record Log documented amount on hand: 9 Resident #63Lorazepam 0.5 mg tablet _Give 0ne tablet by mouth at bedtime (9:00PM).Bingo Card Medication Count = 16Medication Monitoring Control Record documented amount on hand: 17 On 1/12/2026 at 6:05 PM for clarification Staff Q, RN was asked what time she had given the medications and again Staff Q, RN stated I give them at 1800 (6:00 PM).On 1/12/2026 at 6:10 PM, when Staff R, RN supervisor was informed of the identified concerns she stated: For wasted medication you are supposed to have a witness to sign off with before you flush the medication. The narcotic should be signed off in the book as soon as it removed. Another narcotic count was completed with Staff R, RN for the 4th Floor East Cart in the presence of Staff Q, RN and Staff R, RN acknowledged the identified discrepancies. The Director of Nursing, Assistant Director of Nursing, Regional Educator, and Regional Clinical Nurse, were also apprised of the identified pharmacy services concerns identified.Review of the facility's undated policy for Labeling, Medications Storage of drugs and Biologicals indicated: It is the policy of this facility to ensure that all medications and biologicals used in the facility will be labeled and stored in accordance with current state, federal regulations.

Based on observations, interviews and record review, the facility failed to store food under sanitary condition by ensuring 1) two reach-in refrigerators in the kitchen did not contain thermometers on the inside out of three reach-in refrigerators and 2) failed to ensure the proper washing of the dishes and utensils by not having an operable final rinse tank temperature gauge on the high temperature dish machine. This has the potential to affect 154 out of 160 residents who eat orally residing in the facility at the time of the survey.The findings included: 1) Record review of the Dietary Food Storage Policy and Procedure (no date written); Policy Statement-It is the policy of the facility to provide care and services related to the storage of food in the Dietary Department in accordance to State and Federal regulation; Procedure: 1) Refrigerated foods will be stored at the proper temperatures and 6) The use of a thermometer, which shows that the proper temperature is being maintained will be used.Observation of the initial kitchen tour on 1/12/26 at 8:33 AM with the Dietary Supervisor revealed the following: 1) Reach-in Refrigerator #2 temperature outside was 37 degrees F and for the inside temperature, there was no thermometer noted. The refrigerator is used for sandwiches, fruits and salads for the tray line and contained a bowl of shredded cheese (Photographic evidence submitted) and 2) Reach-in Refrigerator #3 temperature outside was 38 degrees F and for the inside, there was no thermometer noted. The refrigerator is used for the cook's preparation and contained mayonnaise, tuna salad, chicken salad, butters and creamers (Photographic evidence submitted).Interview with the Kitchen Supervisor on 1/16/24 at 8:36 AM. She stated, There is no thermometer kept on the inside of the reach-in freezer and refrigerator. We only use the temperature on the outside of the reach-ins.Interview with the Dietary Supervisor on 1/12/26 at 8:34 AM confirmed the reach-in refrigerator's #2 and #3 did not contain a thermometer on the inside. She revealed the thermometer should be in there.Review of the Reach-in Refrigerator #2 Temperature Log documented for the following: January 12, 2026 at 6:00 am, the temperature was 35.5 degrees F. Review of the Reach-in Refrigerator #3 Temperature Log documented for the following: January 12, 2026 at 6:00 am, the temperature was 33.6 degrees F. 2) Record review of the Dish Machine Temperature Log Policy and Procedure (no date written); Purpose: To ensure that dishware and utensils are sanitized effectively, the facility will monitor and document dish machine temperatures at every meal service in accordance with state and federal sanitation guidelines; Policy: Food and Nutrition Services staff will monitor and document the dish machine's wash and final rinse temperatures for each meal. Any discrepancies or equipment malfunctions will be addressed immediately to maintain sanitation compliance; Procedure: 2) At each meal service, dishwashing staff will: Observe and document the final rinse temperature, which must reach a minimum of 180 degrees F (for high-temp machines).Review of the manufacturer temperatures for high temperature dish machine operating temperatures were documented: Wash 150-160 degrees Fahrenheit (F); Pumped Rinse 160 degrees F and Final Rinse 180-195 degrees F.Observation of the high temperature dish machine on 1/14/26 at 8:47 AM with Staff A, Dietary Staff and the Dietary Supervisor revealed the wash dial was at 150 degrees F and the final rinse dial was at 162 degrees F. Staff A, Dietary Staff revealed the final rinse temperature should be at 180 degree F. Staff A, Dietary Staff placed several more trays with cups and dishes to be washed through the dish machine and the final rinse dial did not move, it stayed at 162 degrees F. Several more cycles were conducted and the wash dial stayed at 150 degrees F and the final rinse dial was at 162 degrees F. The Dietary Supervisor revealed the wash temperature should be at 180 degrees F. The Dietary Supervisor immediately stopped the dish machine and called the service tech company to come to the facility and service the dish machine (Photographic evidence submitted).Interview with the Dietary Supervisor on 1/14/26 at 11:08 AM. She stated, The technician came out today and the thermostat is burned out. He is bringing a new thermostat today. We are going to use disposable wear for lunch.Review of the Dish Machine Temperature Log documented for the month of January 2026 documented the wash temperature was 161 degrees F and the final rinse was 180 degrees F for breakfast, lunch and supper.Interview with the Dietary Supervisor on 1/15/26 at 8:11 AM revealed that a new thermostat was placed in the high temperature dish machine on yesterday and the temperature is at 180 degrees F now.Review of the Dish machine Repair Company Invoice dated 1/14/26 documented the following: Final rinse temp was not accurate (reading 160). Thermostat for final rinse was broken and burn (booster heater for final rinse). Thermostat was replaced and tested (temp 180).

Based on observations, record reviews and interviews, the facility failed to prevent accidents and hazards as evidenced by unsecured housekeeping carts on the Fourth Floor East and [NAME] Hallways. 2) Resident #77 was observed unattended in high positioned bed. 3) A hand sanitizer dispenser observed located directly above a light switch in the facility's conference room of the facility. There were 160 residents residing in the facility at the time of survey.The findings include. On 1/12/2026 at 9:51 AM an observation was made of an unattended housekeeping cart with key in the lock on the fourth-floor East hallway (photo evidence). Staff E, Housekeeping was immediately notified about identified concern and interviewed about facility's protocol for keeping the housekeeping cart secure. Staff E, Housekeeping stated, When I walk away from the cart I am supposed to keep the key in my pocket. I don't keep it locked while I'm working. I lock it when I go to break or go home and give the key to the boss. The surveyor requested to have the top section of the cart be opened and Staff C, Housekeeping opened it without a key, and several bottles of disinfectants were observed in the top section (photo evidence). Observation on 1/12/2026 at 10:08 AM on the fourth-floor [NAME] hallway, Staff D, Housekeeping exited a resident's room, opened the top section of the housekeeping cart without a key and placed a cleaning disinfectant spray bottle inside, then returned to the resident's room without locking the cart. On 1/12/2026 at 10:14 AM, an observation was made of an unattended housekeeping cart on the third-floor East hallway (photo evidence). Staff B, Housekeeping was observed in a resident's room; when the surveyor asked if the cart was locked, Staff B, Housekeeping opened the top section of the cart without a key, and the surveyor observed bottles with disinfecting chemicals. Observation on 1/12/2026 at 10: 30 AM, revealed an unattended housekeeping cart on the second-floor [NAME] side hallway. Staff C, Housekeeping was in a resident's room, and the surveyor asked housekeeping staff if the cart was locked. Staff C, Housekeeping opened the top section of the cart without a key. The surveyor asked Staff C, Housekeeping about facility's protocol for housekeeping carts and staff replied, I am supposed to lock the carts for the residents' safety. Interview on 1/13/2026 at 3:33 PM with the Housekeeping Director revealed there were seven housekeeping carts in the facility. Housekeeping worked 7:00 AM to 3:30 PM and 3:00 to11:30 PM and staff are to keep the housekeeping carts locked at all times when unattended to prevent residents from encountering the chemicals kept in the cart. On 1/12/2026 at 9:37 AM An observation was made of Resident#77 in bed with arms folded and the bed was in a high position. On 1/12/2026 at 9:38 AM Staff F, Certified Nursing Assistant (CNA), entered the room. The surveyor asked about the bed being left in a high position while no staff is present. Staff F, CNA replied, I left the bed high because I went to get the lifter. I am supposed to leave the bed down. On 1/12/2026 at 10:07 AM. the Restorative Nurse was notified about identified concern and stated, I will speak to the staff about this. Resident #77 was admitted on [DATE] and readmitted on [DATE] with diagnosis that included Seizures. Record review of The Annual Minimum Data Set (MDS) reference dated 12/8/2025 revealed Resident #77 had a Brief Interview for Mental Status (BIMS) score of 9 indicated moderate cognitive impairment and was dependent for all Activities of Daily Living (ADLS). Further review revealed Resident #77 was care planned on 01/06/2022 for at risk for falls related to: seizure disorder, impaired mobility, anemia, impaired vision, psychotropic drug use, aggressive behaviors at times. unaware of safety measures, history of falling, potential side effects of medications with Interventions/Tasks that included: Keep bed in lowest position. On 01/14/2026 at 10:21 AM, an interview with the Director of Nursing revealed staff are to keep the bed in a low position when leaving a resident's room to get assistance to transfer that resident. Observation on 01/12/2026 at 03:05 PM, one hand sanitizer dispenser that was fully operational was observed directly above a light switch in the facility's conference room. Interview on 01/14/2026 at 12:36 PM, the Maintenance Director and Maintenance Assistant stated The issue with the hand sanitizer dispenser occurred after the facility changed companies, maintenance staff were not present during installation.which resulted in the placement being missed. The inspector informed us of the three-foot requirement, and although we do not currently have a specific policy addressing this. The potential hazard identified was that sanitizer could have entered an outlet and caused the breaker to malfunction. Record review of facility's policy titled, Reporting Accidents and Incidents date issued 3/2020 revised 6/2023 revealed: PROCEDURE: The facility will ensure that: a. The resident environment remains as free from accident hazards as is possible.

Based on observations, interviews and record review the facility failed to ensure the high temperature dish machine final rinse cycle was working properly. This has the potential to affect 154 out of 160 residents who eat orally residing in the facility at the time of the survey.The findings included:Record review of the Dish Machine Temperature Log Policy and Procedure (no date written); Purpose: To ensure that dishware and utensils are sanitized effectively, the facility will monitor and document dish machine temperatures at every meal service in accordance with state and federal sanitation guidelines; Policy: Food and Nutrition Services staff will monitor and document the dish machine's wash and final rinse temperatures for each meal. Any discrepancies or equipment malfunctions will be addressed immediately to maintain sanitation compliance; Procedure: 2) At each meal service, dishwashing staff will: Observe and document the final rinse temperature, which must reach a minimum of 180 degrees F (for high-temp machines).Review of the manufacturer temperatures for high temperature dish machine operating temperatures were documented: Wash 150-160 degrees Fahrenheit (F); Pumped Rinse 160 degrees F and Final Rinse 180-195 degrees F.Observation of the high temperature dish machine on 1/14/26 at 8:47 AM with Staff A, Dietary Staff and the Dietary Supervisor revealed the wash dial was at 150 degrees F and the final rinse dial was at 162 degrees F. Staff A, Dietary Staff revealed the final rinse temperature should be at 180 degrees F. Staff A, Dietary Staff placed several more trays with cups and dishes to be washed through the dish machine and the final rinse dial did not move, it stayed at 162 degrees F. Several more cycles were conducted and the wash dial stayed at 150 degrees F and the final rinse dial was at 162 degrees F. The Dietary Supervisor revealed the wash temperature should be at 180 degrees F. The Dietary Supervisor immediately stopped the dish machine and called the service tech company to come to the facility and service the dish machine (Photographic evidence submitted).Interview with the Dietary Supervisor on 1/14/26 at 11:08 AM. She stated, The technician came out today and the thermostat is burned out. He is bringing a new thermostat today. We are going to use disposable wear for lunch.Review of the Dish Machine Temperature Log documented for the month of January 2026 documented the wash temperature was 161 degrees F and the final rinse was 180 degrees F for breakfast, lunch and supper.Interview with the Dietary Supervisor on 1/15/26 at 8:11 AM revealed that a new thermostat was placed in the high temperature dish machine on yesterday and the temperature is at 180 degrees F now.Review of the Dish machine Repair Company Invoice dated 1/14/26 documented the following: Final rinse temp was not accurate (reading 160). Thermostat for final rinse was broken and burn (booster heater for final rinse). Thermostat was replaced and tested (temp 180).

Based on interview and record review, the facility failed to demonstrate an effective plan of action was implemented to correctly identify quality deficiencies in the problem area related to repeated deficient practices for F761 (Label/Store Drugs & Biologicals). These deficient practices have the potential to affect 160 residents residing in the facility at the time of the survey.The findings included: Record review of the facility's policy and procedures titled Quality Assurance and Performance Improvement (QAPI) Plan issued 6/10/2021 revealed Policy: It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Review of the facility's survey history revealed, during a recertification survey exit dated 07/18/2024 F761 Label/Store Drugs & Biologicals was cited.An interview with the Administrator on 01/15/2026 at 2:21 PM revealed the members of the QAPI team included the Medical Director, Administrator and all management team. Meetings are held monthly to discuss any concerns for each department and develop next plan for improvement; data was analyzed to determine which interventions are working or not.

Based on observations records reviewed and interviews, the facility failed to maintain a medication error rate of less than 5%. This consisted of nine (9) medication errors out of 88 opportunities, resulting in a medication error rate of 10.23%. Staff crushed medications together and administered them mixed in applesauce to Resident # 85; also identified were two omissions (Resident # 85 and Resident # 117) and one medication administered in the wrong dose form (Resident # 27). There were 160 residents residing in the facility at the time of survey. The findings include. Observation on 01/12/2026 at 9:34 AM of Staff N, Registered Nurse (RN) performing medication administration for Resident # 85 revealed physician ordered Zunveyl Oral Tablet Delayed Release, one tablet to be given two times a day for Alzheimer Disease was not available on the cart. Staff N, RN prepared and placed the following medications in a medication cup: one Aspirin 81 milligram (mg) chewable tablet, one Iron tablet 325 mg (Ferrous Sulfate), one Carvedilol 3.125 mg tablet, one Amlodipine 5 mg tablet, one Sinemet 25- 100 mg (Carbidopa- Levodopa) tablet and one Clopidogrel Bisulfate 75 mg tablet. Staff N, RN entered Resident #85's room identified resident.Staff N, RN placed the medications on the overbed table and left them unattended (Photographic evidence). Staff N, RN attempted to give the resident all the medications at once but was unsuccessful. Staff N, RN left the room with the medications and was observed at the medication cart where she placed and crushed all the medications together in a pill crusher pouch then mixed them together with applesauce in a medication cup, returned to the room and administered the medications. Review of Resident #85 clinical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses include but not limited to: Parkinsonism, Heart Failure unspecified, Alzheimer Disease, Dysphagia unspecified and schizoaffective disorder. Review of Resident #85's January 2026 Orders Summary Report revealed ordered medications included but not limited to: Aspirin 81 mg (milligram) Chewable Tablet: Give 1 tablet by mouth one time a day; Carvedilol Tablet 3.125 mg: Give 1 tablet by mouth two times a day for HTN (Hypertension); Amlodipine Besylate Tablet 5 mg: Give 1 tablet by mouth two times a day for HTN (Hypertension); Sinemet Tablet 25- 100 mg: (Carbidopa- Levodopa): Give 1 tablet by mouth three times a day for Parkinsons; Clopidogrel Bisulfate Tablet 75 mg: Give 1 tablet by mouth one time a day for Blood thinner, Iron Tablet 325 (65 Fe) mg (Ferrous Sulfate): Give 1 tablet by mouth one time a day for Supplement and Zunveyl Oral Tablet Delayed Release. (Benzgalantamine Gluconate) Give 10 mg by mouth two times a day related to Alzheimer's Disease. During an interview on 01/12/2026 at 9:59 AM, Staff N, RN acknowledged the identified concerns and revealed the Zunveyl Oral Tablet Delayed Release (Benzgalantamine Gluconate) 10 mg tablet will be ordered and should have been ordered in advance. Observation on 01/15/2026 at 8:02 AM of medication administration performed by Staff S, Licensed Practical Nurse (LPN) for Resident # 27 revealed Staff S, LPN prepared Multivitamin with Mineral one tablet from the facility's stock over the counter supply and administered it to the resident with other ordered medications. Clinical records revealed Resident #27 was admitted to the facility on [DATE]. Clinical diagnoses include but not limited to Alzheimer Disease. Review of the Electronic Health Record medication orders revealed an order for Multivitamin and Mineral Liquid (Multiple Vitamins-Minerals): Give 15 ml (milliliters) by mouth one time a day for Supplement. On 01/15/2026 at 8:25 AM during an interview and review of Resident # 27's medication orders Staff S, LPN acknowledged the wrong form of medication was administered. On 01/15/2026 at 9:11 AM during medication administration observation performed by Staff P, RN for Resident #117, physician ordered Losartan Potassium 25 mg oral tablet: give 2 tablets (50mg) one time a day related to Hypertensive Heart Disease without Heart Failure was not available in the medication cart. Staff P, RN informed the supervisor and checked the emergency kit and the automated medication dispensing machine, but the medication was not readily available. Clinical records revealed Resident #117 was admitted to the facility on [DATE], Clinical diagnoses included but not limited to Hypertensive Heart Disease without heart failure. Review of the facility's undated policy titled: Medication Preparation for Dispensing PROCEDURE: D. Medication Inspection. 1.Confirm that medication name and dose are correct. G. Prior to Medication Administration: 1. Verify each medication preparation that the medication is the RIGHT DRUG, at the RIGHT DOSE, the RIGHT ROUTE, at the RIGHT RATE, at the RIGHT TIME, for the RIGHT CUSTOMER. 2. Verify that the MAR reflects the most recent medication order

Based on observations, record review, and interviews, the facility failed to provide adequate activities of daily living (ADLs) care for one (Resident #71) out of three sampled residents. Resident #71 had long, uncleaned fingernails that dug into the skin on the palm of his hand. This deficiency increased the risk of self-injury and infection. There were 160 residents residing in the facility at the time of the survey. The findings include:On 01/12/2026 at 10:46 AM Resident#71 was observed seated in bed and expressed concerns regarding not getting his nails trimmed by staff. Observation revealed the resident's left hand was contracted with long fingernails digging into the palm of his hand (Photographic evidence taken). Record review revealed Resident #71 was admitted (re-entry) on 6/30/2025 clinical diagnosis included but not limited to: Spastic Hemiplegia Affecting Left Dominant Side and Epileptic Seizures.Review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident # 71 is cognitively intact, requires setup or clean-up assistance with eating, oral hygiene, upper body dressing, personal hygiene; requires supervision or touching assistance with toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear. Review of care plan with review start date 11/19/2025, target completion date 11/27/2025, and completed date 11/28/2025 revealed that: Resident #71 has a self-care deficit requiring staff assistance with ADLs secondary to encephalopathy (unspecified), spastic hemiplegia affecting left dominant side.epileptic seizures.Goal is for Resident #71's ADL needs to be met through the next review date. Interventions included allowing the resident to perform tasks at own pace, providing assistance only in areas of difficulty; setting up basic hygiene items within reach daily and as needed and showering as scheduled and as needed. Interview on 01/14/2025 at 01:20PM, Staff I, Certified Nursing Assistant (CNA) revealed nail care is primarily assigned to CNAs, although nurses may also cut residents' nails when necessary. On 01/14/2025 at 01:32PM, Staff J, CNA revealed CNAs are responsible for nail care, although there is a designated staff member assigned to cut nails and shave residents, if that staff member is off, it remains the CNAs' responsibility to provide this care and not wait for someone else. If a resident refuses nail care, the CNA must report it to the nurse. For residents with diabetes, CNAs only cut fingernails; toenail care is performed by podiatry.During an interview on 01/14/2025 at 01:50PM, Staff K, CNA stated that CNAs are responsible for cutting residents' nails and for cleaning the nail cutter before and after use. Documentation is not required; CNAs only need to notify the nurse if a resident refuses nail care. On 01/15/2025 at 10:51AM, an interview was conducted with Staff L, Registered nurse (RN). She stated that CNAs are responsible for cutting residents' nails. For residents with diabetes, podiatry performs toenail care. On 01/15/2025 at 11:01AM, an interview was conducted with Staff M, Registered nurse (RN) - unit supervisor. She stated that anyone can cut residents' nails, although there is usually a light-duty nurse assigned to this task. Review of the facility's Policy and Procedure titled Activities of daily living (ADLs) maintain abilities dated 03/2020 revealed that a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, a personal and oral hygiene.

Based on observations, interviews, and record review, facility failed to ensure a dignified dining experience for one (Resident #40) out of 11 sampled residents as evidenced by Resident #40's lunch tray was not served at the same time as other residents in the same dining table. On 01/12/2026 at 12:31 PM, lunch trays arrived at the third-floor dining room.On 01/12/2026 at 12:32 PM, staff began passing out meal trays to residents sitting at the first dining table.On 01/12/2025 at 12:35 PM, all residents in first dining table were served a meal tray except for Resident #40.On 01/12/2026 at 12:36 PM, staff began passing meal trays to residents sitting in second dining table.On 01/12/2026 at 12:44 PM, staff served meal tray to Resident #40 who was sitting at the first dining table.On 01/12/2026 at 1:21 PM, Restorative Nurse was notified about the dining concern and stated: When meal trays come out of the cart, all the residents who are sitting at one table should be served at the same time. There should not be any reason why all residents should not be served together.Record Review of a demographic sheet revealed Resident #40 was admitted on [DATE] and readmitted on [DATE] with diagnosis that included Muscle Wasting and Atrophy, Multiple Sites.Record Review of Quarterly Minimum Data Set (MDS) reference dated 12/30/2025, revealed Resident #40 had a Brief Interview for Mental Status (BIMS) of 3 indicating severe cognitive impairment and needed supervision or touching assistance when eating.Record Review of a Care Plan dated 12/17/2025, revised 12/19/2025 revealed Resident #40 was at risk for nutritional and or hydration deficits as evidenced by HTN, Dementia, Anxiety, Major Depressive Disorder with Interventions that included: encourage/assist to eat as needed.On 01/12/2026 at 1:27 PM, Staff H, Certified Nursing Assistant (CNA) stated: When serving meal trays, we always have to make sure that all residents sitting at a dining table are served together or at the same time.Record Review of facility's policy titled, Promoting/Maintaining Resident Dignity, dated 05/2020, revised 04/2023 revealed POLICY: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. COMPLIANCE GUIDELINES:All staff members are involved in providing care to residents to promote and maintain resident dignity and respect for residents' rights.

Based on observation, interview and record review the facility failed to maintain an effective pest control program so that the environment is free of flies. This was evident throughout the facility in the kitchen, conference room, second floor, third floor and fourth floor where resident's reside. This has the potential to affect the entire resident population (one-hundred and seventy-two residents) residing in the facility at the time of this survey. The findings included: Record review of the facility's policy titled Pest Control (issued date 3/2020) documented: Policy-It is the policy of the facility to maintain an effective pest control program that eradicates and contains common household pests and rodents; Definition of an Effective pest control program is defined as measures to eradicate and contain common household pests (flies); Policy Explanation and Compliance Guidelines: 1) Facility will maintain a written agreement with a qualified outside pest service to provide comprehensive pest control services on a regular and scheduled basis and 3) Facility will report issues that may arise in between scheduled visits with the outside pest service and treat as indicated. Observation of the facility's conference room on 7/15/24 at 7:35 AM revealed a swarm of flies in the conference room, flying around and landing on the tables. A fly repellent with a blue light was noted in the conference room. Observation during the initial kitchen tour on 7/15/24 at 8:08 AM with the Dietary Supervisor and the Registered Dietitian (RD) revealed flies were noted flying around the kitchen around the steam table and throughout the kitchen. A fly repellent with a blue light was noted in the kitchen. On 7/15/24 at 8:09 AM, interview with the Dietary Supervisor confirmed the flies in the kitchen. Observation of the second floor nurses' station on 7/16/24 at 8:58 AM revealed flies were flying and landed on the nurses' station. (Photographic evidence submitted) Observation of the second floor nurses' station on 7/17/24 at 7:35 AM revealed flies were flying and landed on the nurses' station. During observation of the lunch tray line on 7/17/24 at 11:39 AM revealed flies were noted in the kitchen, flying around the tray line. The flies were noted on top of the shelf on tray line and on the plate warmers. Dietary staff were observed fanning the flies away while on the tray line. (Photographic evidence submitted) On 7/17/24 at 11:41 AM, interview with the Dietary Supervisor confirmed the flies in the kitchen. On 7/17/24 at 2:05 PM, interview with the Regional Director of Maintenance. He stated, We are aware of the flies and have had the pest control company come out. On 7/17/24 at 2:28 PM, interview with the Administrator. She confirmed that the facility has a pest control contract and that the pest control company comes on a regular basis to the facility. On 7/17/24 at 2:47 PM, interview with the Director of Maintenance via Spanish translator. He revealed the pest control company comes to the facility every single week. They fumigate the whole building and when they come they do a specific area. Review of the Pest Control contract documented dated and signed on 6/05/24, with an effective date of 5/01/24; Contract covers American Roaches, [NAME] Banded Roaches, Oriental Roaches, Smoky [NAME] Roaches, German Roaches, House Ant, Rat/Mice. The contract did not list flies as a part of the interior pest control treatment. Review of the Pest Management Invoices dated from 1/02/24-6/04/24 revealed the facility had received pest control treatment.

Based on observation, interview and record review the facility failed to ensure lint screens were cleaned for two out of three dryers as evidenced by two out of three dryers lint screens observed full of lint. There were 172 residents residing in the facility at the time of the survey. The findings included: On 07/18/24 at 1:25 PM a Laundry Tour was conducted with the Housekeeping Director. The clean room contained three 87-pound capacity dryers. Two dryers were in progress and the lint screens were filled with lint. (photo evidence) When asked to view the lint log, the Housekeeping Director responded that the lint log was upstairs. On 07/18/2024 at 3:15 PM the surveyor was approached by the Housekeeping Director and given a lint log. Review of the Lint Log revealed July 18: 1:00 AM, 3:00 AM and 5:00 AM the log was not signed. The Housekeeping Director stated: The staff will sign for 1:00 AM, 3:00 AM and 5:00AM July 18 on July 19 overnight shift. Record review of the facility's Laundry Policy date implemented July 2020 Policy: The facility launders linens and clothing in accordance with current CDC guidelines to prevent transmission of pathogens. 10. Dryer filter will be checked, and lint removed every three hours while being used and PRN (as needed).

Based on observation, record review and Interview the facility failed to follow infection prevention protocol for one resident (Resident #118) out of seven sampled as evidenced by; the wound care nurse not wearing gown while providing wound care to Resident #118 who is under enhanced barrier precaution. There were 172 residents in the facility at the time of survey. The findings included: On 07/17/24 at 10:40 AM, during a wound care observation with the wound care nurse. The Licensed Practical Nurse (LPN wound care nurse performed wound care for Resident#118. Prior to wound care, the LPN wound care nurse donned gloves. Record review of demographic sheet for Resident #118 revealed an admitted [DATE] and readmitted [DATE] with diagnosis that included: Stage 4 Pressure Ulcer of right buttock and other site. Record review of Quarterly Minimum Data Set (MDS) dated [DATE] Section C (cognitive status) revealed a Brief Interview for Mental Status score of score 13 out of 15 indicated cognition was intact, Section GG (Functional status) revealed Resident #118 dependent for ADLs. Section H (bowel and bladder) revealed Resident #118 had an indwelling catheter. Section M (skin) revealed the resident had a 1 Stage IV unhealed pressure ulcer. Record review of CARE PLAN start date 10/16 /23 and revision date 5/10/24 revealed Resident #118 had a pressure injury on admission 10/16/2023 and interventions included: Enhanced based precaution (EBP) due to wounds and wound care as ordered. On 07/17/24 at 1:37 PM the LPN wound care nurse stated: [Resident #118] is under EBP due to his wound and catheter, and I did not wear a gown while performing wound care and that was a mistake. According to Protocol for EBP I should wear a disposable gown during wound care. Record review of the facility's Policy Enhanced Barrier Precautions issued 8/16/2022 revised 4/1/2024 Enhanced Barrier Precautions dated 8/16/2022 revised 4/1/2024 Policy: It is the policy of this facility that Enhanced Barrier Precautions, in addition to Standard and Contact Precautions will be implemented during high-contact resident care activities when caring for residents that have an increased risk for acquiring a multidrug resistant organism (MDRO) such as a resident with wounds, indwelling medical devices or residents with infection or colonization with an MDRO. Enhanced Barrier Precautions (EBP) consists of the use of gowns and gloves for high contact care activities which include but may not be limited to wound care: any skin opening requiring a dressing.

Based on observations and interview the facility failed to properly store and label medications in one medication room and one medication cart out of three medication rooms and seven medication carts reviewed as evidenced by an observation of an unlabeled vial and medication left unattended. There were 172 residents residing I the facility at the time of survey. The findings included: On 07/16/24 at 4:35 PM a review of a medication storage room on the second floor revealed a vial Labeled Lorazepam injection with no open date observed on the vial. On 07/16/24 at 4:45 PM Staff D, Registered Nurse (RN) stated: I counted the controlled medications with the off going nurse. I received the Ativan in the fridge. I did not notice there was not an open date. The vial should be labeled with an open date. On 07/17/24 at 8:47 AM on the second floor an observation was made of crushed medication in a transparent medicine cup unattended, on top of the middle medication cart. (photo evidence) 07/17/24 08:52 AM Staff F, Registered Nurse (RN) returned to medication cart and stated: It is not okay to leave the medication on top of the cart. The reason I left the medication unattended was because I went to call the other nurse to open the fridge. On 07/18/24 at 2:26 PM the Director of Nursing (DON) stated: All open vials of medications should be labeled with an open and expiration date. No medication should be left unattended. Record review of the facility's policy Labeling of Medications Storage of drugs and Biologicals dated 11/28/2019. Policy: It is the policy of this facility to ensure that all medications and biologicals used in the facility will be labeled and stored in accordance with current state, federal regulations. Policy Explanation and Compliance Guidelines: 9. Labels for multi-use vials must include: a. The date the vial was initially opened or accessed (needle-punctured); with specified timeframes for usage once opened that are outside of the manufacturers expiration date.

Based on observations and interviews, the facility failed to accurately reconcile two controlled medications on one medication cart out of seven medications carts reviewed. There were 172 residents residing I the facility at the time of survey. The findings included: On 07/17/24 at 12:52 PM on the 4th floor cart a controlled medication count was completed with Staff E, Licensed Practical Nurse (LPN) on the East medication cart. Two Medication Monitoring/ Control Records were inaccurate when compared to the corresponding bingo card. (photo evidence) On 07/17/24 at 12:52 PM Staff E, LPN stated: The correct procedure for signing out narcotics is to sign out the narcotic at the time it was given. I administered the medication to the resident but did not sign due to getting busy with other nursing tasks. On 07/18/24 at 2:26 PM the Director of Nursing (DON) stated: Nurses are to sign out controlled medications once it is popped out of the bingo card. Record review of the facility's policy: Controlled Substance Administration and Accountability date implemented June 2021. Policy: It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure. Policy Explanation and Compliance Guidelines: h. The Controlled Drug Record (or other specified form) serves the dual purpose of recording both narcotic disposition and patient administration.

Based on record review and interview facility failed to coordinate with the appropriate State authority to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) was completed in a timely manner for one resident (Resident #46) with a major mental disorder out of nine residents sampled as evidenced by Level I PASRR dated 2/19/24 omitted diagnosis of Schizophrenia, Bipolar disorder and Anxiety. There were 172 residents residing in the facility at the time of survey. The findings included: Record review of Preadmission Screening and Resident Review (PASRR) dated 2/19/24 Section I: PASRR Screen Decision-Making: Depressive Disorder and Psychosis was checked, Section IV: PASRR Screen Completion: No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required, signed on 2/19/24 by DON at the facility Record review of demographic sheet for Resident #46 revealed an admitted [DATE] with diagnoses that included Major Depressive disorder, Psychosis, Bipolar, Anxiety, and Schizophrenia. Record review of Admission Minimum Data Set (MDS) dated [DATE] Section A (Identification) revealed No level II PASRR Is the resident currently considered by the State process to have serious mental illness and/or intellectual disability or a related condition. Preadmission Screening and Resident Review (PASRR). Section I (active diagnosis) revealed Depression and Psychotic disorder. Further record review of electronic health record revealed a Significant Change MDS dated [DATE], Section I showed Anxiety disorder, Depression (other than bipolar), Bipolar Disorder, Psychotic disorder, and Schizophrenia. Section N indicated Antidepressant and Antipsychotic medications were received in the last 7 days. Section O indicated Psychological Therapy with total minutes of zero. Record review of Care Plan date initiated on 2/19/24 indicated R#46 was at risk for drug related side effects due to use of psychotropic meds for the diagnosis of Major Depressive Disorder and Psychosis. Interventions included: Notify Social Worker about any change in behavior pattern. Record review of physician orders revealed orders dated 4/26/24 for Quetiapine Fumarate Tablet 50 MG (milligrams) one tablet by mouth two times a day related to Psychosis and an order dated 6/18/22 for Lorazepam Tablet 0.5 MG one tablet by mouth every 12 hours for Anxiety. Record review of a Psychiatric Consult dated 2/19/24 revealed diagnosis of Major depression disorder. On 07/18/2024 at 11:24 AM, the Social Services Director stated, the process for completing PASSR is to evaluate all diagnosis upon admission, discuss in the morning meeting, and review current Level I to determine need for Level II. For residents who are currently residing in the facility we complete a resident review that includes clinicals and a Level I to determine if there is a need for a Level II to be sent to Kepro. The nurses are to update me about any new behaviors so I can ensure an accurate PASRR. For [Resident #46] I was notified last week by the resident's previous case worker via email about new diagnosis last week. I immediately completed a new PASSR and submitted it to Kepro for Level II determination on 7/16/24. Record review of an email given to the surveyor by the Social Services Director revealed a date of 4/8/2024 from case worker from a healthcare company regarding Resident #46, revealed a comprehensive care plan dated 4/1/24 that included diagnoses of Schizophrenia, Bipolar and Attention Deficit Hyperactivity Disorder Anxiety and Depression. Record review of the facility's Policy for PASRR dated 3/2021 Policy: It is the of the facility to assure that all residents admitted to the facility receive a Pre-Admission Screening and Resident Review, in accordance with State and Federal Regulations. Procedure: 5. A nursing facility must notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has a mental illness or intellectual disability for resident review.

Based on observation, record review and interview, the facility failed to protect residents' healthcare information on 3 out of 7 medication carts reviewed as evidenced by electronic health record screen were observed open and unattended. There were 172 residents residing in the facility at the time of the survey. The findings included: On 07/15/24 at 08:40 AM on the third floor an observation revealed an open electronic health record computer screen open and unattended with residents' information visible, on the [NAME] medication cart. On 07/15/24 at 08:44 AM Staff A, Licensed Practical Nurse (LPN) exited a resident's room and returned to the [NAME] medication cart and was approached by surveyor. Staff A, LPN stated: The computer has been having issues and when I walked away it was off but maybe when I plugged it in the screen came back on while; I was away from cart. I am supposed to lock my screen when I am away from the medication cart. On 07/16/24 at 9:26 AM; observation on the third floor the East medication cart was noted unattended, and the computer screen was open with residents' electronic health records information visible. On 07/16/24 at 9:35 AM Staff B, Registered Nurse (RN) exited a resident's room and returned to the East medication cart and was approached by surveyor. Staff B, RN stated: I have been employed at this facility for three months. The facility gives us training on the proper procedure concerning protecting residents' information by closing the computer screen when walking away from the medication cart. It was not locked because I went to check on a resident and didn't realize I left it open. On 07/17/24 at 9:51 AM; on the third-floor East medication cart, a medication administration observation was done with Staff C, LPN and an observation was made of an open electronic health record computer screen left open and unattended with residents' information visible. Staff C, LPN returned to cart stated: It is not okay to leave screen open when I am away from the medication cart. On 07/18/24 at 2:26 PM the Director of Nursing (DON) stated: The electronic medication administration screen should be closed when staff is away from the cart to protect residents' personal information. Record review of The facility's Policy HIPPA Security Measure dated 5/2024. Policy: It is the facility's policy to implement reasonable and appropriate measures to protect and maintain the confidentiality, integrity, and availability of the resident's identifiable information and or records that are in electronic format. 10. Technical safeguards will be implemented to allow access of EPHI only to those employees or software programs that have been granted access rights. C. Automatic logoff: electronic sessions will be terminated after a predetermined time of inactivity depending on the systems housed on the workstation.

Based on record review and interviews, the facility failed to report an alleged abuse incident to the abuse registry for allegation of abuse for one (Resident #1, Resident #2) out of six residents reviewed for abuse. The findings included: Record review of the facility's policy titled, Abuse, Neglect and Exploitation protocol implementation date was on 10/2019, the policy documented: The facility will provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect and exploitation. Abuse means the infliction of injury with resulting physical harm, pain or mental anguish. Law enforcement is the full range of potential responders to elder abuse, neglect and exploitation including police sheriffs, detectives and public safety officers. A prompt thorough investigation will be conducted by the facility immediately. Policy Explanation and Compliance Guidelines: 1) The facility will develop and implement written policies and procedures that: a) Prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident property. VII. Reporting/Response of Abuse, Neglect and Exploitation: When abuse, neglect or exploitation is suspected: Immediately report all alleged violations to the Administrator, state agency, adult protective services and all other required agencies (law enforcement) within specified timeframes. Review of the Demographic Face Sheet for Resident #1 documented the resident was admitted on [DATE] with a diagnosis of chronic obstructive pulmonary disease, respiratory failure, anxiety disorder, major depressive disorder, schizophrenia, hypertension, emphysema, insomnia and blindness one eye. The resident was discharged from the facility on 4/10/23. Review of the Minimum Data Set (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 supervision with setup help only for adls (activities daily living). Review of the Physician's Order Sheets (POS) and Medication Administration Records (MAR) dated February 2023 for Resident #1 documented the resident was receiving the following medications: Quetiapine Fumarate 100mg (milligrams) tab (tablet) 200mg PO (by mouth) HS (at night) for schizophrenia; Zolpidem Tartrate 10mg tab 1 tab PO HS for insomnia; Percocet 5-325mg tab 1 tab PO every 8 hours PRN (as needed) for pain; -Trazodone HCL (hydrochloride) 50mg tab 1 tab PO HS for major depressive disorder and Divalproex Sodium DR (delayed release) 500mg tab 1 tab PO BID (twice a day) for other seizures. Review of Resident's #1 Psychotropic meds care plan dated 12/03/22 documented the resident was at risk for drug related side effects due to use of psychotropic meds for the diagnosis of: Depression, Insomnia, Schizophrenia, Psychosis; Goal: Resident will remain free of drug related side effects through next review date and Interventions: Medicate as ordered; Monitor behavior and mood changes. Review of the Demographic Face Sheet for Resident #2 documented the resident was admitted on [DATE] with a diagnosis of encephalopathy, diabetes mellitus, cerebral infarction, major depressive disorder, bipolar disorder, glaucoma, hypertension, anxiety disorder and psychosis. Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] for Resident #2 documented the resident's Mental Status (BIMS) Summary Score was 03, indicating severe cognitive impairment and he required supervision with setup help only for adls (activities daily living). Review of the Physician's Order Sheets (POS) and Medication Administration Records (MAR) dated February 2023 for Resident #2 documented the resident was receiving the following medications: Divalproex Sodium DR 500mg tab 2 tabs PO HS for seizures; Risperidone 0.5mg tab 1 tab PO BID for psychosis; Haloperidol 0.5mg tab 1 tab PO in the morning for psychosis and Mirtazapine 7.5mg tab 1 tab PO HS for depression. Review of Resident's #2 Psychotropic meds care plan dated 7/14/22 documented the resident was at risk for drug related side effects due to use of psychotropic meds for the diagnosis of: Anxiety, Major Depressive Disorder, Bipolar Disorder, Psychosis; Goal: Resident will remain free of drug related side effects through next review date and Interventions: Medicate as ordered; Monitor behavior and mood changes. Review of Federal Immediate Report dated 2/15/23 documented the following: Date/Time of Incident: 2/15/2023 3:15 PM; Type of Incident: Abuse; Who has been notified: Resident Representative, Abuse Registry; Law enforcement not notified; Description of Incident: On 2/15/23 at 15:20 a resident who is alert and oriented times three reported to staff when passing by room [ ] he observed [ ] Resident #2 on top of resident [ ] Resident #1 hitting him in his face. Residents were immediately separated from each other and placed on one to one supervision. [ ] Resident #2 states that he hit his roommate because he called him a [ ] and this made him upset. [ ] Resident #1 said he gave [ ] Resident #2 the tv remote control and he was called a [ ]. [ ] Resident #1 told to not call him a [ ] and went to his bed. [ ] Resident #2 climbed on top of [ ] Resident #1 and hit him. [ ] Resident #2 suffered no injuries and [ ] Resident #1 has scratches on his face with minimal bleeding. First aide was given. [ ] Resident #1 voiced no concerns for his safety and exhibits no change in behavior related to the incident. Administrator was notified. Residents placed on a one to one. Review of the Abuse Log dated February 2023-October 2023 documented the following: Dated 2/15/23, APS ID Date Called Time Called: 2/15/2023 6:15?, Accepted/Rejected: Answer Blank, Allegations: Resident to Resident. The abuse log dated for the incident on 2/15/23 documented the date, the time it was reported had a question mark and if the report was accepted or rejected, the answer was blank. All other abuse allegations on the abuse log were completed with the date, time, the person's name and ID (identification) number who took the report of the abuse and if the abuse report was accepted or rejected at the abuse registry. On 10/03/23 at 11:05 AM, interview with the Administrator/Abuse Coordinator. She stated, I called the abuse in because the abuse registry online was down. I don't have proof that the call was made. On 10/03/23 at 11:55 AM attempted to interview Resident #2 but the resident did not answer. On 10/03/23 at 12:13 PM via telephone with Administrator and local state abuse registry agency representative #1. She stated, I can't confirm or deny whether a call was received for abuse. I will transfer you to my supervisor. On 10/03/23 at 12:18 PM via telephone with Administrator and local state abuse registry agency supervisor representative #2. She stated, I can't confirm or deny whether a call was received for abuse. If an abuse report is accepted or rejected, it is put into the system. The Administrator was asked by the local state abuse registry agency supervisor representative #2 did she write down the person's name and ID number who took her report over the phone, and she stated, No, I didn't. On 10/03/23 at 1:10 PM interview with the Administrator/Abuse Coordinator. She stated, They were roommates at the time. [ ] Resident #1 called [ ] Resident #2 a [ ]. [ ] Resident #2 was on top of [ ] Resident #1 and started hitting him. Staff was walking by their room and saw them in action and broke them up. [ ] Resident #2 said he slapped the guy because he don't like the word. [ ] Resident #2 was sent to the hospital for aggressive behavior. [ ] Resident #1 said he didn't have any hard feelings but if he came back that he didn't want him to be his roommate. When [ ] Resident #2 came back they were placed in different rooms. [ ] Resident #1 was discharged to an ALF (assisted living facility). The administrator/abuse coordinator reported, I report abuse when I get them. Abuse is supposed to be reported in two hours. This was not reported to Law Enforcement.

Based on record reviews and interviews, the facility failed to implement their abuse and neglect policy as evidenced by staff failure to notify law enforcement that a crime had occurred against a resident this involved two (Resident #1, Resident #2) out of six residents sampled during the time of this survey. The findings included: Record review of the facility's policy titled, Abuse, Neglect and Exploitation protocol implementation date was on 10/2019, the policy documented: The facility will provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect and exploitation. Abuse means the infliction of injury with resulting physical harm, pain or mental anguish. Law enforcement is the full range of potential responders to elder abuse, neglect and exploitation including police sheriffs, detectives and public safety officers. A prompt thorough investigation will be conducted by the facility immediately. Policy Explanation and Compliance Guidelines: 1) The facility will develop and implement written policies and procedures that: a) Prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident property. VII. Reporting/Response of Abuse, Neglect and Exploitation: When abuse, neglect or exploitation is suspected: Immediately report all alleged violations to the Administrator, state agency, adult protective services and all other required agencies (law enforcement) within specified timeframes. Review of the Demographic Face Sheet for Resident #1 documented the resident was admitted on [DATE] with a diagnosis of chronic obstructive pulmonary disease, respiratory failure, anxiety disorder, major depressive disorder, schizophrenia, hypertension, emphysema, insomnia and blindness one eye. The resident was discharged from the facility on 4/10/23. Review of the Minimum Data Set (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 supervision with setup help only for adls (activities daily living). Review of the Physician's Order Sheets (POS) and Medication Administration Records (MAR) dated February 2023 for Resident #1 documented the resident was receiving the following medications: Quetiapine Fumarate 100mg (milligrams) tab (tablet) 200mg PO (by mouth) HS (at night) for schizophrenia; Zolpidem Tartrate 10mg tab 1 tab PO HS for insomnia; Percocet 5-325mg tab 1 tab PO every 8 hours PRN (as needed) for pain; -Trazodone HCL (hydrochloride) 50mg tab 1 tab PO HS for major depressive disorder and Divalproex Sodium DR (delayed release) 500mg tab 1 tab PO BID (twice a day) for other seizures. Review of Resident's #1 Psychotropic meds care plan dated 12/03/22 documented the resident was at risk for drug related side effects due to use of psychotropic meds for the diagnosis of: Depression, Insomnia, Schizophrenia, Psychosis; Goal: Resident will remain free of drug related side effects through next review date and Interventions: Medicate as ordered; Monitor behavior and mood changes. Review of the Demographic Face Sheet for Resident #2 documented the resident was admitted on [DATE] with a diagnosis of encephalopathy, diabetes mellitus, cerebral infarction, major depressive disorder, bipolar disorder, glaucoma, hypertension, anxiety disorder and psychosis. Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] for Resident #2 documented the resident's Mental Status (BIMS) Summary Score was 03, indicating severe cognitive impairment and he required supervision with setup help only for adls (activities daily living). Review of the Physician's Order Sheets (POS) and Medication Administration Records (MAR) dated February 2023 for Resident #2 documented the resident was receiving the following medications: Divalproex Sodium DR 500mg tab 2 tabs PO HS for seizures; Risperidone 0.5mg tab 1 tab PO BID for psychosis; Haloperidol 0.5mg tab 1 tab PO in the morning for psychosis and Mirtazapine 7.5mg tab 1 tab PO HS for depression. Review of Resident's #2 Psychotropic meds care plan dated 7/14/22 documented the resident was at risk for drug related side effects due to use of psychotropic meds for the diagnosis of: Anxiety, Major Depressive Disorder, Bipolar Disorder, Psychosis; Goal: Resident will remain free of drug related side effects through next review date and Interventions: Medicate as ordered; Monitor behavior and mood changes. Review of Federal Immediate Report dated 2/15/23 documented the following: Date/Time of Incident: 2/15/2023 3:15 PM; Type of Incident: Abuse; Who has been notified: Resident Representative, Abuse Registry; Law enforcement not notified; Description of Incident: On 2/15/23 at 15:20 a resident who is alert and oriented times three reported to staff when passing by room [ ] he observed [ ] Resident #2 on top of resident [ ] Resident #1 hitting him in his face. Residents were immediately separated from each other and placed on one to one supervision. [ ] Resident #2 states that he hit his roommate because he called him a [ ] and this made him upset. [ ] Resident #1 said he gave [ ] Resident #2 the tv remote control and he was called a [ ]. [ ] Resident #1 told to not call him a [ ] and went to his bed. [ ] Resident #2 climbed on top of [ ] Resident #1 and hit him. [ ] Resident #2 suffered no injuries and [ ] Resident #1 has scratches on his face with minimal bleeding. First aide was given. [ ] Resident #1 voiced no concerns for his safety and exhibits no change in behavior related to the incident. Administrator was notified. Residents placed on a one to one. On 10/03/23 at 11:55 AM attempted to interview Resident #2 but the resident did not answer. On 10/03/23 at 1:10 PM interview with the Administrator/Abuse Coordinator. She stated, They were roommates at the time. [ ] Resident #1 called [ ] Resident #2 a [ ]. [ ] Resident #2 was on top of [ ] Resident #1 and started hitting him. Staff was walking by their room and saw them in action and broke them up. [ ] Resident #2 said he slapped the guy because he don't like the word. [ ] Resident #2 was sent to the hospital for aggressive behavior. [ ] Resident #1 said he didn't have any hard feelings but if he came back that he didn't want him to be his roommate. When [ ] Resident #2 came back they were placed in different rooms. [ ] Resident #1 was discharged to an ALF (assisted living facility). The Administrator/Abuse Coordinator reported I report abuse when I get them. Abuse is supposed to be reported in two hours. This was not reported to Law Enforcement.

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 as evidenced by failure to maintain refrigeration/freezer units in proper working order, failure to properly clean and sanitize food preparation and serving equipment, and failure to hold hot and cold foods at regulatory temperatures. The findings included: During the initial kitchen/food service observation tour conducted on 02/20/23 at 9:00 AM, accompanied with the Food Service Supervisor (FSS), the following were noted: (a) Observation of the walk-in freezer noted the entrance frame to have black organic matter and rust laden, and the door gasket was heavily torn. The door was also noted to have a heavy build-up of ice. Upon entering it was noted that the motor and fan were encased in ice. The motor was noted to be spraying ice throughout the unit. Cases of unidentifiable foods were noted to be covered and encased in ice. The surveyor requested to the FSS that foods be removed from the freezer and be located in alternate refrigeration units and requested that a licensed refrigeration vendor assess the refrigeration issue. (b) During the observation of the walk-in refrigerator it was noted that the internal motor unit was dripping condensation heavily onto foods located below the motor. It was also noted that the motor was spewing condensation onto other foods stored within the unit. Cases of foods were noted to be drenched in condensation. The surveyor informed the FSS that the foods located within the unit were becoming contaminated by the condensation. The surveyor requested to the FSS that foods be removed from the freezer and be located in alternate refrigeration units and requested that a licensed refrigeration vendor assess the refrigeration issue. (c) Observation of reach-in #1 refrigerator noted that the interior of the unit was pitting and the motor dripping condensation heavily. Foods located within the unit were noted to be wet with the dripping condensation. The surveyor requested that the unit not be utilized until repairs could be made. (d) Observation of food preparation skillets (frying pans = 9) were noted to be covered in a thick layer of carbon. The surveyor informed the FSS that the carbon could possibly result in food contamination when the pans a heated. The surveyor requested that the skillets/pans be discarded as soon as possible. (e) Observation of the [brand] industrial food chopper and blender was reported by the FSS to be clean and ready for use however, further observation noted approximately an inch of fluid in the bottom of the unit. The surveyor informed the FSS that the unit must be turned upside down after cleaning/sanitizing and air dried prior to next use. The surveyor requested that the unit not be used until it is properly cleaned, sanitized, and internal dried. (f) Observations of the kitchen noted 3 cleaning rags left on food preparation and serving surfaces. The surveyor requested that the rags be store in a chemical sanitizing solution when not in use. (g) A container located within the reach-in #2 refrigerator was noted to have a yellow food substance. The container was dated 02/15/2023 and did not contain documentation of what the food was. The FSS stated that she thought the food was pudding, however, should have been discarded with 72 hours. (h) The utility drawer observed contained food portioning equipment. Further observation noted that the serving spoons and scoops were placed in all directions and not placed in a sanitary manner to ensure that staff would handle only by the handles. The surveyor requested that the serving utensils be rewashed and sanitized and placed in the drawer in a sanitary manor. (i) Observation revealed Staff G had three packed bags on foods. Upon further investigation it was revealed that the 3 bags contained sandwiches for residents leaving the facility for medical appointments. The bags were noted to contain egg salad sandwiches (2) and cheese sandwich (1) It was revealed that the perishable sandwiches were to be transported with the residents were not in an insulated container with commercial ice packs to ensure that the sandwiches maintained the regulatory 41 degrees F or below. Staff G stated that the sandwiches would be transported at room temperature in a zip lock bag. (j) Observation of the commercial slicer revealed the unit was not properly cleaned after the last use. The unit was noted to have areas of dried food matter around the blade's exterior and base. The surveyor requested that the unit be properly cleaned and sanitized prior to the next use. 2) During a second observation tour of the main kitchen on 02/21/2023 at 7:00 AM, accompanied with the FSS, the following were noted: (k) Food temperatures were taken by the Food Service Supervisor with the facility's calibrated bayonet food thermometer. The results of the temperature testing revealed that hot foods were not being held at the regulatory temperature of 135 degrees Fahrenheit (F) or higher and cold foods were not being held at the regulatory temperature of 41 degrees F or below. The following was noted: Waffles (40 portions) = 110 degrees F Pancakes (40 portions) = 115 degrees F Orange Juice (50 - 4-ounce portions) = 55 degrees F Thickened Orange Juice (10 - 4-ounce portions) = 50 degrees F (l) During the observation it was noted that the walk-in freezer, walk-in refrigerator, and reach in refrigerator continues to drip condensation and spray and spew condensation and ice throughout the units.

Based on observations and interviews conducted the facility failed to provide a safe, clean, comfortable, and homelike environment, as evidenced by unclean, disrepair, unkempt environment to include floors, ceilings, bathrooms and furniture. There were 178 residents residing in the facility at the time of the survey. The findings included: During the environment tour conducted on 02/21/2023 at 1:00 PM with the Administrator, Director of Housekeeping, and Corporate Maintenance Director, the following were noted: First Floor: Observation of the main hallway to the Smoking Area, revealed approximately 20 feet of the handrails located on the south side were noted to be loose and falling from the wall. Observation of elevator #2 revealed a large hole in the floor that could be a potential trip hazard to residents and anyone entering the elevator. Second Floor: Observation revealed the entire floor around and behind the second-floor nurses' station to be soiled, stained, and black in color. Observation of the second floor East Wing: The ceiling frame was noted to be rust laden. The second floor dining room had six large windows that were clouded over with a waxy substance and view to outside could not be seen by residents. Observation of the second floors' Community Shower room [ROOM NUMBER]: The toilet seat was detached and falling off the toilet bowl, and the shower stall grout was stained and black in color. Observation of Community Shower room [ROOM NUMBER]: The metal ceiling frame was rust laden, and the floor was soiled and stained. Observation on the second floor Hallway revealed the handrails were detached from the walls between rooms #225 to #227. Observation of room [ROOM NUMBER] revealed the exterior of the 2 room chairs were heavily worn. The room floor was soiled and stained, the privacy curtain (A bed) was soiled and stained, and 1 of 2-bathroom lights was not working. Observation of room [ROOM NUMBER] revealed the Room floor was soiled and stained. During observation of room [ROOM NUMBER], it was noted that the room floor was soiled and stained, the exterior of the 2 overbed tables were worn and wood exposed, and the privacy curtain (A bed) was soiled and stained. Observation of room [ROOM NUMBER] revealed the floor soiled and stained, a large area of the vinyl floor was becoming detached from floor. Observation of room [ROOM NUMBER]: The exterior of the tube feeding pole (A bed) was noted to be soiled and stained, the exterior of the 2 overbed tables were heavily worn with wood exposed, there was a large hole in the wall behind B bed, the room chair exteriors were heavily worn. Observation of room [ROOM NUMBER] revealed the footboard (A bed) was heavily worn with sharp wood exposed and the exteriors of the 2 overbed tables were worn and in disrepair. Observation of room [ROOM NUMBER] revealed the privacy curtain (A bed) was soiled and stained, the vinyl room floor was detached from the floor, and the exterior of the bathroom entry door was damaged and in disrepair. Observation of room [ROOM NUMBER]: The base boards were detached from the room walls, the exterior of the 2 room chairs were heavily worn, and the exterior of the entry door for the bathroom was damaged and in disrepair. Observation of room [ROOM NUMBER]: The privacy curtain (A bed) was soiled and stained, the base boards were falling off from the room walls, the exterior of the bathroom door was damaged and in disrepair, and 1 of 2-bathroom lights not working. Observation of room [ROOM NUMBER]: The armrest of the electric wheelchair (A bed) was heavily worn and torn and in need of replacement (resident requested replacement), the exterior of bathroom entry door was damaged and in disrepair, the base boards in the room were detached from the room wall, and there was no overbed light cord (B bed). Observation of room [ROOM NUMBER]: The privacy curtain was soiled and stained and the exterior of the overbed table (1) was heavily worn, and wood exposed. Observation of room [ROOM NUMBER]: The privacy curtain (1) was soiled and stained, the overbed table was heavily worn wood exposed. Observation of room [ROOM NUMBER]: The privacy curtain (a bed) was too short to flow around the bed and could not ensure privacy. Observation of room [ROOM NUMBER]: A large area of the ceiling in the room had peeling paint and was in disrepair. Observation of room [ROOM NUMBER]: The exterior of the 2 overbed tables were rust laden, and no television cable reception for A bed. Third Floor: Observation of the third-floor dining room revealed six large windows that were clouded over with a waxy substance and view to outside could not be seen by residents. Observation of the third-floor community shower room [ROOM NUMBER], noted the toilet seat not secured to toilet, and 1 of 3 room lights mot working. Observation of the third-floor community shower room [ROOM NUMBER]: The bathroom handrail was detached and falling from the wall in the shower stall, and the room entry door was noted to have large bolts protruding through door that could cause potential injury to residents. Fourth Floor: Observation of the fourth-floor dining room revealed, six large windows that were clouded over with waxy substance and view to outside could not be seen by residents. Observation of room [ROOM NUMBER]: The room floor was soiled and stained, the bathroom floor was soiled and stained, there was a large bolt protruding from the bottom of the bathroom door that was a potential accident hazard to the residents. Observation of room [ROOM NUMBER]: Bathroom light 1/2 was not working, the privacy curtain (A bed) was soiled and stained, and the exterior bathroom door was damaged and in disrepair, Observation of room [ROOM NUMBER]: The exterior of room entry door was damaged and in disrepair, the exterior of the bathroom door was damaged and in disrepair, the 2 overbed tables were heavily worn with wood exposed. On 02/21/2023 at approximately 2:00 PM following the environment tour the findings were again confirmed with the Administrator. It was stated that staff are failing to report the housekeeping/maintenance issues on the Maintenance Logbook that are located at all 3 nurses stations.

Based on medical record review, facility staff and hospital staff interviews, and review of the pulse-oximeter Operator's Manual, policy, review of the Interim for suspected of positive for COVID-19, policy, and review of the Coronavirus prevention, policy, the facility failed to 1) ensure to a shared pulse-oximeter used on visitors, staff and residents for screening, that persons fingers were cleaned, to prevent the risk for transmission of COVID-19; 2) failed to ensure that staff was aware of the necessary precautions to take for Resident #2 who was exposed to COVID-19 from Resident #1 who tested positive; 3) failed to implement isolation precautions to control or prevent the potential spread of COVID-19, and failed to accurately complete the Skilled Nursing Facility (SNF) to Hospital COVID-19 patient transfer-communication form, to alert the receiving hospital staff, that Resident #2 was exposed to COVID-19, and 4) failed to ensure the infection control surveillance tool, used to track residents on contact isolation was completed accurately. The Infection Control Nurse was unable to determine after review of the tracking tool utilized, the specific residents listed on contact isolation, or the associated diagnoses. These failures occurred during a COVID-19 pandemic, and had the potential to affect all residents that resided at the facility. The facility census was 179. It was determined the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents. The Immediate Jeopardy was related to 480.80 Infection Control. The Administrator, Vice President of Clinical Services, Infection Control Nurse, Unit Manager (4th Floor), and Licensed Practical Nurse Supervisor (4th Floor) were made aware that Immediate Jeopardy existed on April 2, 2020 at 8:53 p.m. The Director of Nursing was not present onsite during the Immediate Jeopardy notification. Immediate Jeopardy was removed on April 3, 2020 at 2:00 p.m., after an acceptable removal action plan was received and further observations, staff interviews, policy review and review of training's to verify the immediate corrective action taken. The facility remained out of compliance at a lower scope and severity of E at F880. The findings include: 1. On 04/01/2020 at 9:00 a.m., upon entry into the facility, the receptionist while screening visitors, did not clean the finger of the visitor, before or after use of the pulse-oximeter device. During an interview on 04/01/2020 at 10:01 a.m., the receptionist confirmed that she used the same pulse-oximeter on visitors, staff and residents, throughout the day. The receptionist stated, she did not clean visitors, staff or residents fingers, before or after use, to minimize the risk for transmission of COVID-19. The receptionist acknowledged that she was aware that there was a current COVID-19 pandemic. During an interview on 04/02/2020 at 4:10 p.m., the Vice President of Clinical Services (VPCS) stated, she expected visitors, staff and residents' fingers to be cleaned, according to the manufactures instructions. During a phone interview on 04/03/2020 at 12:01 p.m., the Director of Nursing (DON) stated she expected the staff to follow the manufacture's instructions, when using the shared device on visitors, staff or residents. Review of the pulse-oximeter manufacture's instructions, revealed, .Clean the finger being tested using alcohol before and after each test . 2. Review of Resident #1's medical record revealed, the resident resided in the same room with Resident #2, prior to (Resident #1) hospitalization on [DATE]. Review of the nurses notes for Resident #1 dated 03/31/2020, revealed, .0700 (7:00 AM) resident appears lethargic .1000 (10:00 AM) resident noted lethargic .1055 (10:55 AM) resident is leaving to [MEDICAL TREATMENT] in stable condition accompanied by two transporters .10 pm resident was transferred to (name of hospital) from [MEDICAL TREATMENT] center due to fever and pneumonia in ICU (intensive care unit) . Further review of Resident #1's laboratory results dated [DATE], revealed, coronavirus detected. During an interview on 04/02/2020 at 3:57 p.m., Nurse Manager (4th floor) and Licensed Practical Nurse (LPN) Supervisor (4th floor), confirmed they were not aware upon starting their work shift, for 1st shift, on 04/02/2020 of any coronovirus concerns for Resident #s 1 and 2. The LPN Supervisor also confirmed that she was not aware of any concerns on 04/01/2020. During an interview on 04/02/2020 at 6:00 p.m., the Administrator and the Infection Control Nurse (ICN) acknowledged awareness, that the hospital notified the facility on 04/01/2020, that Resident #1 tested positive for COVID-19. Both the Administrator and ICN confirmed they did not verify isolation precaution, was implemented for Resident #2, nor verified if the direct care staff, were made aware of Resident #1's status, and Resident #2's exposure to COVID-19. Telephone interviews conducted with direct care staff on 2nd shift and 3rd shift confirmed, that staff was not aware Resident #2 was exposed to COVID-19, nor did the staff observe personal protective equipment (PPE) outside Resident #2's door, or signage posted on the door. During an interview on 04/02/2020 at 6:18 p.m., the Registered Nurse Supervisor (RNS) who worked 3pm - 11pm on 04/01/2020, stated, he was not aware of any COVID-19 concerns with Resident #s 1 and 2 on 04/01/2020. The RNS indicated that he did not observe any posted door signage or isolation equipment setup, outside Resident #2's room, throughout his work shift on 04/01/2020. During an interview on 04/02/2020 at 4:10 p.m., the VPCS stated, she expected direct care staff, to have been notified, related to Resident #s 1 and 2 health status, and the facility's coronavirus policy followed. During a telephone interview on 04/03/2020 at 12:01 p.m., the DON stated, she expected effective communication to have occurred, so staff was made aware of Resident #s 1 and 2 status/exposure, so the necessary safety precautions, could have been taken. Review of the coronavirus prevention policy, dated 03/18/2020, revealed, .The facility will emphasize on prevention efforts on early recognition of suspected cases or contact with cases. The nursing staff will be aware of some common exposures and how to protect themselves and the residents . 3. Review of Resident #2's medical record revealed, the resident was transferred via ambulance service, to the hospital per physician order [REDACTED]. Further review of the SNF (skilled Nursing Facility) to Hospital COVID-19 Transfer Communication Tool revealed, the form was not completed accurately. The form read, .8. Has the patient been in contact with anyone who has tested positive for COVID-19? No . Review of the .Resident Hospital Transfer and Discharge Summary . dated 04/02/2020, revealed, Resident #2 was transferred from the SNF to the hospital for .low grade fever (temperature) . There was no other communication on the form that reflected Resident #2 was exposed to COVID-19. During a telephone interview on 04/02/2020 at 3:57 p.m., accompanied by the Administrator, ICN, VPCS, Nurse Manager (4th floor) and LPN Supervisor (4th floor), the hospital Associate Nurse Manager (ANM) stated Resident #2 was in route back to the facility. The facility staff observed from the first floor conference room window, that the resident had arrived back at the facility via ambulance, and was in progress of being transported, back into the facility. The ANM stated the facility did not communicate to the hospital the resident was exposed to COVID-19. The ANM indicated, if the facility staff had communicated such information, it was likely, that the hospital physician, would have proceeded with COVID-19 testing, prior to discharging the resident, back to the skilled nursing facility. During an interview on 04/02/2020 at 4:10 p.m., the VPCS stated, she expected the SNF transfer form to have reflected Yes that the resident was exposed, to someone who tested positive for COVID-19. During a telephone interview on 04/03/2020 at 12:01 p.m., the DON stated she expected the SNF transfer to hospital form to be completed correctly. During an interview on 04/03/2020 at 1:52 p.m., LPN #1 stated, she was not aware that Resident #2 had been exposed to COVID-19, nor was she aware Resident #1 tested positive for COVID-19. Therefore, she marked No on the SNF transfer form to the hospital, on 04/02/2020 (date the form was completed). LPN #1 also confirmed she did not recall, any door signage posted on Resident #2's door or PPE outside the door. Review of the coronavirus prevention policy, dated 03/18/2020, revealed, .Prior to transfer, emergency medical services .the receiving facility should be alerted to the resident's diagnosis, and precautions to be taken including placing a facemask on the resident during transfer . 4. On 04/02/2020 at 6:33 p.m., the ICN stated, that she had not included any residents as of 04/01/2020, on her surveillance tracking form related to COVID-19, nor residents that required isolation precautions. Further review of the ICN surveillance-tracking tool, revealed, the ICN was unable to identify or clarify unknown residents listed on the antibiotic report for contact isolation, for September 2019, and the associated diagnoses. The ICN stated she needed to develop a better plan of tracking residents, for future reference. During a telephone interview on 04/03/2020 at 12:01 p.m., the DON stated, she expected the surveillance-tracking tool to reflect the residents and their diagnosis, and why contact precaution was required. Review of the interim policy for suspected or positive for COVID-10 revised, 03/30/2020, revealed, .The facility will emphasize on prevention efforts on early recognition of suspected cases or symptomatic residents or staff. The facility will implement control measures to minimize the spread of the COVID-19 in the facility from an outbreak . The facility provided an acceptable removal action plan on April 3, 2020 at 12:40 p.m., that read: At 4:10 PM Resident #2 was immediately placed in isolation upon return from the hospital on [DATE] by the Unit manager assisted by the ADON. The isolation sign was placed at the door. The PPEs cart which contains mask, gowns, gloves was placed at the door by the Unit Charge Nurse. At 4:15 PM call was placed to the by physician by the nurse assigned to resident #2. At 5:00 PM, The physician was notified that the resident return to the facility from the hospital by the nurse. MD was made aware that the resident was exposed to COVID_19 from his roommate prior to his discharge to the hospital. MD ordered to transfer the resident back to the hospital. On 4/3/2020 approximately 5 AM the nurse on the 4th floor spoke ER nurse who explained to her that resident has no symptoms and will be transfer back to the facility. Resident returned to the facility around 11 AM. Resident remains on Isolation pending COVID-19 test result. The staff was made aware that resident remains on isolation to use their PPEs. At 5 PM Staff on the 4th floor was reeducated to have the resident wear a mask during transfer and to notify the EMS and the hospital about the resident's exposure. Education was complete nursing supervisor and ADON. The staff was also educated by Unit Manager and ADON regarding placing the Isolation sign at the door and have the cart with the PPEs at the door. PPEs including gown, mask and gloves. On 4/2/2020 8:30 PM - 12 Midnight the active residents at the facility were evaluated for signs and symptoms of COVID-19 by the ADON, Nursing supervisor and MDS coordinators. Vital signs were taken including oxygen saturation. The Nursing supervisor, ADON, MDS Coordinators, Infection Control Nurse were educated by the Vice-President of clinical services regarding the facility infection control policy. Any resident noted to be suspected, symptomatic will be placed in isolation. The Nurssing staff is to be notified immediately of any suspected, symptomatic confirmed case of COVID-19. Prior to transfer, emergency medical services and the receiving facility should be alerted to the resident's diagnosis, and precautions to be taken including placing a facemask on the resident during transfer. At 8:45 PM, Administrator, Infection Control Nurse, Vice-President of Clinical Services validated and observed the resident with possible Exposure in isolation with Isolation sign, and the chart with PPEs at the door. 1-On 4/2/2020 at 9 PM, The Administrator, ADON, Infection Control Nurse and the 3-11 supervisor were immediately re-educated by the Vice-President of Clinical Services on the requirement to promptly notify the staff of any residents tested positive, suspected or exposed to COVID-19, the isolation precautions and appropriate Protective Equipment such as gloves, gown and mask when entering the resident's room. Contact, droplet precaution is to be implemented for any resident suspected, symptomatic or positive for COVID-19 to prevent the potential spread of COVID-19 and alert persons. At 9 PM Staff working on 3-11 shift were made aware by nursing supervisor of the suspected or exposed residents to Covid-19. At 11 PM, 11-7 were made aware of the suspected or exposed residents to COVID-19 by the ADON & Nursing Supervisor and the Administrator. At 11 PM in-serviced provided by the Corporate MDS Coordinator and the Vice President of Clinical serviced to the 3-11 and the 11-7 nursing staff. Infection Control Protocol including PPEs and Isolations precautions were reviewed with the staff. Resident on isolation will be documented in 24 hr report and communicate to the incoming shift during report. In-services will be provided in every shift by the ADON, Staff development nurse, Unit Manager and unit supervisor 2- On 4/2/2020 between 10:30 PM 11:30 PM Education provided by the Corporate MDS Director to the staff regarding the fully implementation of contact droplet precautions for as a measure to prevent the potential spread of Covid-19. The Signage will be at the door indicated the resident is on isolation, to see the nurse prior entering the room. The cart with the PPEs will be by the door to include the gloves, masks and gowns. Competencies completed on 3-11 and 11-7 staff on how to properly Donning and Doffing PPEs. Education and Competencies will be conducted on every shift to ensure the staff is in-serviced on this component of the infection control protocol. Facility infection control policy, the interim policy for residents suspected, symptomatic and positive for COVID-19. Reeducation of transmission-based precautions Personal Protective Equipment (PPEs). 3- On 4/2/2020 between 10:30 Pm and 11:30 PM, reeducation provided to licensed nurses by the Vice-President of Clinical Services and the Corporate Director of MDS regarding how to correctly complete the SNF to Hospital COVID-19 communication transfer form to convey to the receiving hospital staff resident. Prior to transfer, emergency medical services and the receiving facility should be alerted to the resident's diagnosis, and precautions to be taken including placing a facemask on the resident during transfer. Transfer form to the hospital will be complete accurately to reflect any resident symptomatic or suspected for COVID-19. Education provided on the step to properly complete the form. Around 11:45 PM Teachable moment will be provided to the nurse who incorrectly complete the transfer form for resident #2 by the Vice-president of Clinical Services . Education will be continued every shift before the staff starts working to ensure they are educated to properly. The ADON, Administrator, Vice-President of Clinical Services will ensure the ongoing education and validate staff receive the education. The Unit Manager, supervisor, ADON, Vice-president will conduct review of discharge resident record to ensure on going compliance. 4. on 4-2-2020 at 11:30 PM reeducation provided by the vice-president of Clinical Services and the Corporate Director of MDS to the 3-11 and 11-7 nursing staff regarding the procedure to ensure shared pulse oximeter used for visitors and residents finger for COVID-19 screening finger is cleaned according to the manufactures instructions to prevent potential spread of COVID-19. The individual fingers to be cleaned with alcohol and The pulse oximeter to be cleaned before and after each use. Competencies with return demonstration conducted with the 3-11 & 11-7 nursing staff verified by the Vice-president of Clinical Services and the Corporate Director of MDS. Facility will continue re-education and competency every shift to ensure staff is reeducated prior starting their shift to ensure compliance to the infection control policy and prevent spread of infection. DON, ADON, Staff development/infection control nurse, Regional Director of Clinical Services, Vice-President of Clinical Services, Corporate MDS Director will monitor compliance. The Manufacturer's instructions concord Oximeter was obtained by the administrator on 4-1-2020 at 11 AM regarding the cleaning instruction. The education was provided the staff screening the visitors and the employees by the staff development. Cleaning the finger tip pulse oximeter: use medical alcohol to clean the silicone touching the finger inside of oximeter. Also clean the finger being tested using alcohol before and after each use. The ADON, Unit Managers, Nursing Supervisors, Vice-President of Clinical Services, DON and Regional Director of Clinical Services will monitor the process for compliance. 5- On 4-2-2020 at 6 PM, the Vice-President of Clinical Services developed a new tool to be used to track residents who are on contact isolations and be able to identify residents associated with the [DIAGNOSES REDACTED]. New residents with infection or new antibiotic order will be entered into the log by the infection control log and document accurately. The infection control log will be reviewed by the Regional Director of clinical service or Vice-President of Clinical Services weekly to ensure the facility is properly tracked the infection in the facility. On 4-2-2020 at 11 PM the administrator called the department of health for notification of resident#2 exposure to COVID-19. No one was available to take the call. Recorder responded a message to call in the morning. On 4-2-2020 at 11 PM The Medical Director was notified by the Administrator of the survey Immediate jeopardy and the Plan of action for removal. The plan was discussed with the ADON, DON, Nursing supervisor, MDS coordinator, Vice-president of Clinical Services, Vice-President of Operations. On 4/3/2020 at 5 AM Ad Hoc Quality Assurance members present Social services Director, Business office Director, Human Resources, Assistant DON, Vice-President of Clinical Services, Vice-president of Operations, Corporate Director of MDS, Infection Control Nurse, Maintenance Director, Housekeeping Director, Activity Director, MDS Coordinator. The Meeting chaired by the administrator. Medical director, Regional Director of Clinical Services and Director of Nursing participated via phone. The Vice-president of Clinical services, Vice-president of Operations, Regional Director of Clinical services, Corporate Director of Operations, Director of Nursing and Facility administrator are assigned to monitor the Plan of Action for compliance. Alleged Removal Date of Immediate Jeopardy: April 3rd, 2020. Validation of the removal plan was completed on April 3, 2020 at 2:00 p.m., after the survey team verified corrective actions taken by the facility had been implemented. This included observations, staff interviews, policy review and review of training's to verify the immediate corrective actions were in place.