Every finding on record at South Lyon Medical Center

Based on clinical record review, interview and document review, the facility failed to document the specific needs the facility could not meet and attempts to meet the resident's needs when the facility declined to readmit a resident following an acute care hospitalization. This deficient practice had the potential for residents to be discharged from the facility without a safe discharge plan. Findings include:Resident #35Resident #35 was admitted was admitted to the facility on [DATE], with diagnoses including quadriplegia, abnormal posture, chronic pain, idiopathic constipation and anxiety.On 04/13/2026 the facility issued Resident #35 a 30-day involuntary discharge notice. The discharge notice documented the reasons for discharge included failure to pay, possession of marijuana, recording staff without consent and violation of behavior agreement.On 4/23/2026 a typed letter, written by the facility's administrator documented the facility rescinded the 30-day involuntary discharge notice until an appropriate and safe alternative placement could be secured.A Nursing Note dated 05/12/2026, documented Resident #35 approached the Registered Nurse (RN) and reported chest tightness, chills/diaphoresis, headache and abdominal discomfort. The RN assessed the resident's abdomen, abdomen noted to be soft and not distended. The resident reported generalized discomfort without visible signs of acute distress. The RN obtained vital signs and offered to transfer the resident to the local emergency room (ER) for further evaluation. The resident refused, stating the resident had been there multiple times and they had not done anything. The resident stated the resident preferred to go to another ER instead. The RN notified the Director of Nursing (DON). The DON informed the RN there were two options. First was to go to the local ER and have ER-to-ER transfer if needed, or the facility could give the resident a ride to another ER using the facility van, if the resident was stable/safe enough, with the RN to go with the resident. The options were presented to the resident, and the resident chose the second option.Around 12:40 PM, the nurse and resident arrived at an acute care hospital ER. The resident wheeled into the ER and checked in. The RN handed paperwork to the ER staff and told both the resident and the ER staff to call the facility with any questions. The RN explained to the resident the RN was returning to the facility.A Doctor's Note dated 05/12/2026, documented Resident #35 was transported to the ER per the resident's choice. Nursing assessment reviewed and demonstrated Resident #35 was medically stable for transfer. Resident #35 was offered evaluation in the local ER and declined. While out of the facility, the physician requested housekeeping take the opportunity to clean Resident #35's room. The resident declined on multiple occasions to have the room cleaned which posed an infection control concern. An administrative decision was made to not readmit Resident #35 to the facility and the justification for the Notice of Decision Not to Readmit was reviewed by the physician. On 07/30/2026 at 10:05 AM a Licensed Practical Nurse (LPN) confirmed Resident #35 was generally independent with activities of daily living but required catheter care and bowel care. The LPN stated Resident #35 exhibited impulsive and verbally aggressive behaviors at times but reported the facility was able to meet Resident #35's care needs.On 07/30/2026 at 11:20 AM the Social Services Designee (SSD) confirmed the involuntary discharge notice had been rescinded after the Ombudsman informed the facility there was insufficient support for the discharge. The Social Worker stated the facility continued extending the discharge while attempting to locate a safe alternative placement and acknowledged a hospital was not considered a skilled nursing placement. The Social Worker could not verify whether the original notice had been signed by the resident. The facility's Bed Hold Policy documented, In an effort to accommodate residents who are transferred to other facilities for more intense medical care, a bed hold will be placed on the resident's bed for a period of 7 days.The facility's Resident Rights Policy documented, the facility is required to provide residents transferred to a hospital written information regarding the facility's bed-hold policy and the resident's right to return to the facility.CPT 3040830Cross reference tags F550 and F628

Based on interview, clinical record review, and document review, the facility failed to ensure the safety of a resident with wandering behaviors when 1 of 13 sampled residents (Resident #9) eloped from the facility and staff failed to check all doors egressing to the outside when an audible door alarm was activated. The deficient practice had the potential for continued elopements from the facility resulting in injuries to the residents.Findings include:Resident #9Resident #9 was admitted to the facility on [DATE], with diagnoses including vascular dementia, unspecified severity, agitation, insomnia, and disorder of kidney and ureter, unspecified.A Facility Reported Incident (FRI) dated 06/02/2026, documented Resident #9 had eloped from an alarmed door of the facility. Resident #9 was found outside on the ground and complained of pain and was sent to the emergency room for evaluation.A Fall progress note dated 06/01/2026, documented Resident #9 had an unwitnessed fall after exiting the facility through the back hallway door. Resident #9 was found on the street out of the wheelchair with an abrasion to the left hand little finger and tenderness to the left lower extremity. The emergency room was called for physicians to examine Resident #9.A Communication progress note dated 06/02/2026, documented Resident #9 had sustained a ground level fall outside of the facility. Resident #9 had left leg pain and a computed tomography (CT) scan was completed. The CT scan impression showed an age indeterminate defect across the greater trochanter of the left proximal femur with fragments separated by less than four millimeters, possibly representing an acute or chronic fracture. Resident #9 verbally expressed pain when weight was applied to the lower left extremity.Resident #9's exit seeking care plan initiated on 06/29/2026, documented Resident #9 often exit seeks by opening and shaking exit doors. Interventions included taking Resident #9 to the porch or for short walks upon request.Resident #9's elopement care plan initiated 06/02/2026, documented Resident #9 had exited the facility through doors near the physical therapy department on 06/01/2026. Interventions included all staff being in serviced on door alarm response.The facility's internal investigation included statements from three employees working during Resident #9's elopement.Statement #1 dated 06/02/2026, documented an alarm sounding at approximately 8:10 PM. The employee checked two facility doors but failed to check the final door in the hallway. The employee reset the alarm and was unaware Resident #9 had eloped.Statement #2 dated 06/01/2026, documented at approximately 7:30 PM the door alarm sounded while the employee was assisting another resident. The employee rushed care and attempted to check the alarm status. The employee heard the alarm shut off and assumed the situation had been handled.Statement #3 dated 06/02/2026, documented during approximately the times of 7:30 PM to 8:00 PM, Resident #9 had eloped. The employee heard the alarm sound shut off. The employee assumed the situation had been addressed and did not follow up to verify resolution.On 07/30/2026 at 9:36 AM, the Chief Nursing Officer (CNO) explained Resident #9 was an elopement risk and attempted exit seeking behaviors daily. Staff had attempted stop strips across doors but were informed these could not be placed on emergency exits. Staff were required to keep Resident #9 within line of sight. The CNO verbalized on 06/01/2026, Resident #9 had eloped from the facility through the door next to the physical therapy department. Staff were not previously trained to check that door when alarms sounded. When the alarm sounded in the facility, staff checked the main door to the facility and the door next to activities. Staff did not observe anyone outside of those doors, assumed the issue was resolved, and deactivated the alarm. The CNO verbalized a passerby discovered Resident #9 outside next to a toppled wheelchair. Staff retrieved Resident #9 and sent the resident to the Emergency Room. The CNO explained reviewing camera footage on the night of 06/01/2026, and discovered Resident #9 had been outside for approximately 10 minutes before staff were able to locate the resident. The CNO verbalized all staff were in-serviced after the incident and instructed to check all three doors when the alarm sounded. On 07/30/2026 at 12:29 PM, a CNA explained Resident #9 had an increase in aggression several days prior to the resident eloping from the facility. The CNA could not recall an in-service training provided to staff; however, was able to recall being instructed to check all three doors every 30 minutes. When staff check the doors, the staff were to be checking to make sure alarms functioned and documented completion of the check in a binder located at the nursing station.On 07/30/2026 at 1:13 PM, a Licensed Practical Nurse (LPN) verbalized Resident #9 had weekly behaviors related to exit seeking behaviors. The LPN explained staff were required to check all the doors every 30 minutes; however, prior to the resident's elopement, staff were only checking two of the three doors if the alarm sounded. The LPN verbalized there was no formal system in place prior to the incident and confirmed because there was no formal system in place to check the doors, the resident eloped from the facility and experienced an injury. The facility policy titled Abuse Prevention last revised May 2023, documented neglect was the failure of a person who had a legal responsibility or a contractual obligation, or had voluntarily assumed responsibility to care for an older person, including failure to provide food, shelter, clothing, or services necessary to maintain the physical or mental health of that person. Abuse would be prevented by ensuring residents would be assessed and provided prevention methods to avoid abuse and neglect from occurring.FRI #3035419

Based on clinical record review, interview and document review, the facility failed to provide written notice of the facility's bed-hold policy to a resident and the resident's family member/legal representative upon transfer to an acute care hospital. This deficient practice had the potential to result in psychosocial harm to residents due to not being able to return to the facility and to the resident's previous room.Findings include:Resident #35Resident #35 was admitted was admitted to the facility on [DATE], with diagnoses including quadriplegia, abnormal posture, chronic pain, idiopathic constipation and anxiety.A Nursing Note dated 05/12/2026, documented Resident #35 approached the Registered Nurse (RN) and reported chest tightness, chills/diaphoresis, headache and abdominal discomfort. The RN assessed the resident's abdomen, abdomen noted to be soft and not distended. The resident reported generalized discomfort without visible signs of acute distress. The RN obtained vital signs and offered to transfer the resident to the local emergency room (ER) for further evaluation. The resident refused, stating the resident had been there multiple times and they had not done anything. The resident stated the resident preferred to go to another ER instead. The RN notified the Director of Nursing (DON). The DON informed the RN there were two options. First was to go to the local ER and have ER-to-ER transfer if needed, or the facility could give the resident a ride to another ER using the facility van, if the resident was stable/safe enough, with the RN to go with the resident. The options were presented to the resident, and the resident chose the second option.Around 12:40 PM, the nurse and resident arrived at an acute care hospital ER. The resident wheeled into the ER and checked in. The RN handed paperwork to the ER staff and told both the resident and the ER staff to call the facility with any questions. The RN explained to the resident the RN was returning to the facility. A Doctor's Note dated 05/12/2026, documented Resident #35 was transported to the ER per the resident's choice. Nursing assessment reviewed and demonstrated Resident #35 was medically stable for transfer. Resident #35 was offered evaluation in the local ER and declined. While out of the facility, the physician requested housekeeping take the opportunity to clean Resident #35's room. The resident declined on multiple occasions to have the room cleaned which posed an infection control concern. An administrative decision was made to not readmit Resident #35 to the facility and the justification for the Notice of Decision Not to Readmit was reviewed by the physician. On 07/30/2026 at 11:20 AM the Social Services Designee (SSD) confirmed residents generally received a 30-day discharge notice for involuntary discharges and confirmed the facility had rescinded Resident #35's discharge notice after the Ombudsman informed the facility there was insufficient justification to discharge Resident #35. The SSD verbalized the facility continued to seek appropriate placement for Resident #35 and a hospital was not considered a skilled nursing placement. The SSD acknowledged she could not verify whether the resident had signed the discharge notice that had been rescinded. The SSD could not confirm whether Resident #35 received written bed-hold notice at the time of his hospital transfer and was not able to provide documentation of the bed-hold notice. The facility policy titled Bed Hold Policy, documented, In an effort to accommodate residents who are transferred to other facilities for more intense medical care, a bed hold will be placed on the resident's bed for a period of 7 days.The facility policy titled Resident Rights, (revised December 2015) documented before a nursing facility transferred a resident to a hospital or allowed a resident to go on therapeutic leave, the facility was to provide written information to the resident and a family member or legal representative specifying the duration of the bed-hold policy under the State plan, if any, during which the resident was permitted to return and resume residence in the facility, as well as the facility's policies regarding bed-hold periods.CPT 3040830Cross reference tags F550 and F627

Based on interview, clinical record review, and document review, the facility failed to provide documented evidence a thorough investigation was conducted for incidents with the potential to indicate abuse and neglect for 3 of 4 Facility Reported Incidents (FRIs) investigated. This deficient practice had the potential for ongoing physical and/or psychosocial harm to residents due to allegations of neglect and abuse not being thoroughly investigated and documented to ensure appropriate protections were put in place to prevent future neglect and abuse.Findings include: Resident #9 Resident #9 was admitted to the facility on [DATE], with diagnoses including vascular dementia, unspecified severity, with agitation, insomnia, and disorder of kidney and ureter, unspecified. Resident #32 Resident #32 was admitted to the facility on [DATE], with diagnoses including type two diabetes mellitus with diabetic neuropathy, unspecified, essential (primary) hypertension, and chronic vascular disorders of intestine. FRI #2591438 submitted by the facility on 08/15/2025, documented the type of incident as physical abuse. The FRI Report documented a Licensed Practical Nurse (LPN) overheard Resident #32 yell out quit kicking me. The LPN observed Resident #9 seated a few feet away from Resident #32. Resident #32 had reported to the LPN Resident #9 had kicked the resident's leg three times. A Behavior Incident progress note dated 08/08/2025, documented Resident #32 was overheard yelling at Resident #9. Resident #32 was standing up, pointing a finger at Resident #9, yelling at Resident #9 to stop kicking Resident #32. The two residents were separated. No signs of injury or bruising were located on Resident #32. Resident #6 Resident #6 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including hemiplegia, unspecified affecting right dominant side, aphasia, and vascular dementia, unspecified severity, with other behavioral disturbance. FRI #2703876 submitted by the facility on 12/30/2025, documented Resident #6 was getting a brief change by a Certified Nursing Assistant (CNA). Resident #6 was being combative with the CNA during the brief change and had obtained a skin tear to the right hand. The resident had pointed to the resident's hand when asked, indicating the resident had scratched themselves causing the skin tear. A Skin/Wound Note dated 12/25/2025, documented Resident #6 was combative with staff during a brief change. During the brief change, Resident #6 had obtained a skin tear to the hand. The CNA had reported the skin tear to the Registered Nurse (RN). The RN had assessed the resident, located a skin tear, cleansed the skin tear, and applied barrier cream. Resident #28 Resident #28 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, unspecified and dementia in other disease classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Resident #8 Resident #8 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side and vascular dementia, moderate, with agitation. A final FRI report for FRI #3029831, submitted by the facility on 06/02/2026, documented Resident #28 was touching Resident #8's back in the dining room on 05/30/2026. Resident #8 motioned for Resident #28 to move away. When Resident #28 did not move away, Resident #8 slapped Resident #28 on the hand. On 07/30/2026 at 9:36 AM, the Chief Nursing Officer (CNO) could not provide documentation of the facility's investigation for FRI #2591438, FRI #2703876, and FRI #3029831. The CNO confirmed FRI initial and final reports were provided to the State Agency; however, the documentation of the facility's investigation into each FRI could not be located. The CNO verbalized the Assistant Director of Nursing (ADON) had been trained by the previous Director of Nursing (DON) on what to do and what to keep related to FRI investigations. The CNO verbalized the CNO had gone through the ADON's office and could not locate documentation of the investigations. The CNO could not recall the details into each investigation, how the conclusions were made for each FRI, and confirmed all investigations into FRIs needed to be documented with all information necessary to substantiate or unsubstantiate each FRI. On 07/30/2026 at 1:09 PM, the DON verbalized the ADON typically completed most of the investigations for FRIs. The DON confirmed the DON had participated in the investigation process in the past and verbalized an investigation would typically include interviews with staff, review of camera footage, completing additional interviews if information didn't align, coming to a conclusion based on the information and putting changes in place or providing education to staff based on the conclusion. The DON verbalized any interviews and observations completed as part of the investigation should have been written down, dated, and timestamped. The facility policy titled Abuse Prevention, approved 07/22/2026, documented residents would be free from abuse, neglect, mistreatment, exploitation of person or property and isolation. Any alleged, suspected or observed behaviors by staff or visitors which could be indicative of prohibited behavior would be immediately reported as outlined in this policy or as required by law. Alleged, suspected or observed abuse, neglect, mistreatment or exploitation would be reported immediately and an investigation begun. The initial report would be made to the charge registered nurse. The charge nurse would notify administrative staff of the problem. Administrative staff, including the CNO and the Director of Quality Management would be responsible to initiate and jointly conduct a thorough investigation into the situation reported. Documentation of the occurrence would be made in the nurses' progress notes. The report of alleged violation would be forwarded to the Director of Quality Management who was responsible to ensure all notifications, actions, findings and conclusions were documented. FRI #2591438, #2703876, and #3029831.

Based on interview, clinical record review, and document review, the facility failed to promote and protect a resident's right to be treated with respect and dignity and to make informed decisions when the facility declined to readmit the resident following an acute hospitalization. This deficient practice had the potential to result in psychosocial harm to the resident due to lack of lodging/place to live and services.Findings include:Resident #35Resident #35 was admitted was admitted to the facility on [DATE], with diagnoses including quadriplegia, abnormal posture, chronic pain, idiopathic constipation and anxiety. On 04/13/2026 the facility issued Resident #35 a 30-day involuntary discharge notice. The discharge notice documented the reasons for discharge included failure to pay, possession of marijuana, recording staff without consent and violation of behavior agreement. On 4/23/2026 a typed letter, written by the facility's administrator documented the facility rescinded the 30-day involuntary discharge notice until an appropriate and safe alternative placement could be secured. A Nursing Note dated 05/12/2026, documented Resident #35 approached the Registered Nurse (RN) and reported chest tightness, chills/diaphoresis, headache and abdominal discomfort. The RN assessed the resident's abdomen, abdomen noted to be soft and not distended. The resident reported generalized discomfort without visible signs of acute distress. The RN obtained vital signs and offered to transfer the resident to the local emergency room (ER) for further evaluation. The resident refused, stating the resident had been there multiple times and they had not done anything. The resident stated the resident preferred to go to another ER instead. The RN notified the Director of Nursing (DON). The DON informed the RN there were two options. First was to go to the local ER and have ER-to-ER transfer if needed, or the facility could give the resident a ride to another ER using the facility van, if the resident was stable/safe enough, with the RN to go with the resident. The options were presented to the resident, and the resident chose the second option.Around 12:40 PM, the nurse and resident arrived at an acute care hospital ER. The resident wheeled into the ER and checked in. The RN handed paperwork to the ER staff and told both the resident and the ER staff to call the facility with any questions. The RN explained to the resident the RN was returning to the facility. A Doctor's Note dated 05/12/2026, documented Resident #35 was transported to the ER per the resident's choice. Nursing assessment reviewed and demonstrated Resident #35 was medically stable for transfer. Resident #35 was offered evaluation in the local ER and declined. While out of the facility, the physician requested housekeeping take the opportunity to clean Resident #35's room. The resident declined on multiple occasions to have the room cleaned which posed an infection control concern. An administrative decision was made to not readmit Resident #35 to the facility and the justification for the Notice of Decision Not to Readmit was reviewed by the physician. On 07/30/2026 at 10:05 AM a Licensed Practical Nurse (LPN) verbalized Resident #35 was generally independent with activities of daily living but required catheter care and bowel care. The LPN confirmed Resident #35 exhibited impulsive and verbally aggressive behaviors at times but reported the facility was able to meet Resident #35's care needs. On 07/30/2026 at 11:20 AM the Social Services Designee (SSD) verbalized the Ombudsman informed the facility to rescind the 30-day involuntary discharge notice because there was insufficient justification to proceed. The Social Worker confirmed the facility continued extending the discharge while attempting to locate a safe alternative placement and confirmed a hospital was not considered a nursing facility placement. The facility policy titled Resident Rights, revised 12/2015, documented the facility was to permit each resident to remain in the facility and not transfer or discharge the resident from the facility unless: the transfer or discharge was necessary for the resident's welfare and the resident's needs could not be met by the facility, the transfer or discharge was appropriate because the resident's health had improved sufficiently so the resident no longer needed the services provided by the facility, the safety and/or health of individuals in the facility was endangered, the resident failed to pay for a say at the facility, or the facility ceased to operate. Residents were to be notified of the transfer or discharge and the reasons for the move in writing. Before a nursing facility transferred a resident to a hospital or allowed a resident to go on therapeutic leave, the nursing facility was to provide written information to the resident and a family member or legal representative that specified the duration of the bed-hold policy under the state plan, if any, during which the resident was permitted to the return and resume residence in the facility. The facility was to establish and follow a written policy under which a resident whose hospitalization or therapeutic leave exceeded the bed-hold period under the state plan, was readmitted to the facility immediately upon first availability of a bed in a semi-private room if the resident required the services provided by the facility and was eligible for Medicaid nursing facility services. CPT 304830.Cross reference tag F627 and F628.

Based on document review and interview, the facility failed to ensure an Infection Preventionist (IP) was employed by the facility at least part time each month from 12/27/2024 to 05/12/2025. This deficient practice had the potential to result in lapses in infection control and the Antibiotic Stewardship (ASP) program with potential for infections to spread throughout the facility and residents to be treated with ineffective antibiotics.Findings include: A facility document titled Payroll Status Form documented IP-1's last day of work at the facility was 12/26/2024. A facility document titled Payroll Status Form documented IP-2's first date of work at the facility was 05/12/2025. On 07/23/2025 at 8:42 AM, the Human Resource Manager (HRM) confirmed IP-1's last day of work at the facility was 12/26/2024, and IP-2's first day of work at the facility was 05/12/2025. The HRM verbalized to the best of the HRM's knowledge, there was not another individual who worked as an IP at the facility between 12/26/2024 and 05/12/2025. 07/23/2025 at 3:12 PM, the Chief Executive Officer (CEO) verbalized there were two additional employees at the facility with IP certification. The CEO confirmed the two additional employees had not worked in the role of the facility's IP including the antibiotic stewardship program, immunization, education of staff and residents, and surveillance of infection control practices throughout the facility. On 07/23/2025 at 3:13 PM, the interim Director of Nursing (DON) confirmed an IP had not worked at the facility from 12/27/2024 through 05/11/2025. The DON verbalized not having an IP working at the facility during this time span and the lack of oversight of the facility's Infection Prevention and Control Program and Antibiotic Stewardship Program could lead to increased infections throughout the facility.Cross reference with F881

Based on observation, interview, clinical record review, and document review, the facility failed to ensure the Facility Assessment (FA) was accurate and included nicotine dependence and addiction with the facility's common diagnoses and conditions. This deficient practice had the potential to result in facility staff not receiving adequate training on the care of residents with nicotine dependence and addiction diagnoses and the needs of those residents not being met. Findings include: During the entrance conference with the facility on 07/21/2025, a list of cigarette smokers (smokers) residing in the facility and the FA was provided by the facility. The list of smokers in the facility included five residents. The smoking location was designated off the outside patio accessed through the facility dining room. The Facility Assessment last reviewed March 2025, did not include nicotine abuse or addiction nor a list of the number of active or current substance abuse disorders. On 07/24/2025 at 8:37 AM, the Interim Director of Nursing (DON) verbalized the DON assisted with reviewing and completing the FA. The DON confirmed nicotine addiction was not identified on the FA as a diagnosis in the facility and the FA lacked documented evidence of the number of residents with active or current substance use disorders. The DON confirmed five residents in the facility were current cigarette smokers. The Centers for Disease Control and Prevention article titled Treatment of Substance Use Disorders, dated 04/25/2024, documented a substance use disorder was a treatable, chronic disease and could range in severity from moderate to severe. A substance use disorder could be applied to many types of drugs including tobacco (nicotine). The facility policy titled Facility Assessment Plan, undated, documented the FA would include the care required by the resident population considering the types of diseases and other pertinent facts present within the population.

Based on clinical record review, interview, and document review, the facility failed to ensure coordination of care between the facility and the dialysis center, a written contract and/or agreement with the dialysis provider, and a dialysis policy was developed for the care of a resident on dialysis for 1 of 13 sampled residents (Resident #2). This deficient practice had the potential to result in unmonitored and uncoordinated care for all residents on dialysis in the facility, and a preventable adverse event.Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including end stage renal disease and dependence on renal dialysis. A Comprehensive Care Plan included care plan initiated 07/22/2025, documenting Resident #2 required hemodialysis related to a diagnosis of end stage renal disease. A physician's order dated 04/25/2025, documented to take vital signs upon return from Dialysis on Mondays, Wednesdays, and Fridays one time a day. Resident #2's clinical record lacked documentation of an order for hemodialysis. The Dialysis and Nursing Home Handoff Communication Tool forms from May 2025 through July 2025, lacked documentation in the to be completed by dialysis section on the following dates:-05/02/2025.-05/23/2025.-05/31/2025.-06/02/2025.-06/06/2025.-06/11/2025.-06/16/2025. On 07/24/2025 at 9:14 AM, a Licensed Practical Nurse (LPN) verbalized Resident #2 was on dialysis and the [NAME] coordinated treatment with the dialysis center. The LPN explained the dialysis center provided all of Resident #2's care related to dialysis, including care of the fistula. The LPN verbalized the facility did measure vitals prior to dialysis appointments, however the dialysis center took responsibility for weighing the resident. The LPN verbalized if the LPN wanted to know the policy and procedures related to caring for a resident on dialysis, the LPN would reach out to the Interrem Director of Nursing (DON). On 07/24/2025 at 10:02 AM, the DON verbalized the facility did not have a contract with the dialysis center outlining roles and responsibilities of the dialysis center and the facility. The DON also verbalized the facility did not have a dialysis policy. The DON was unsure how staff would know how to care for residents on dialysis without a dialysis policy. On 07/24/2025 at 10:41 AM, the Chief Executive Officer (CEO) explained Resident #2 was the first and only resident on dialysis to be admitted to the facility. Resident #2's admission was discussed in depth at the monthly utilization review committee and was determined Resident #2 could be retained at the facility if the [NAME] took responsibility for the resident's transportation to and from the dialysis center. The CEO explained the facility was not responsible for any of the resident's care related to dialysis because the facility was not a dialysis center. The dialysis center took responsibility for the safety of the resident. The CEO explained confirmed there were no orders in Resident #2's clinical record for hemodialysis because the situation was treated the same as if the resident went home after a dialysis treatment. The facility was only responsible for taking pre and post treatment vitals. If there was a concern with the fistula site, the facility would refer the resident to the nephrologist at the Dialysis center. The CEO verbalized being unsure whether staff monitored the fistula site. On 07/24/2025 at 1:06 PM, the CEO explained the facility did not have a contract with the dialysis center because the facility would need to have a contract for everything, and the facility was not prepared to have a commitment over the resident's life. The CEO explained the facility was not involved with the dialysis center. The dialysis center took responsibility for the dialysis and the facility took responsibility of everything else while the resident was in the facility. The CEO verbalized being unsure what was expected of nursing staff for the care of residents on dialysis, what staff would monitor residents on dialysis for, and what information the facility received from the dialysis center. The CEO confirmed the incomplete Dialysis and Nursing Home Handoff Communication Tool form and verbalized being unsure whether staff reviewed the forms upon return to the facility. The CEO confirmed a contract with the dialysis center could assist in outlining responsibilities of the facility and the dialysis center to ensure coordination of care was implemented.

Based on interview and document review, the facility failed to ensure the facility had a full time Director of Nursing (DON). This deficient practice could have allowed all 27 residents residing in the facility on the affected date to go without proper assessments or certain cares Registered Nurses (RN), Licensed Practical Nurses (LPN), and Certified Nursing Assistants (CNA) perform and compromise the supervision of proper assessments and proper care due to lack of oversight. Findings include: On 07/21/2025, during entrance conference, the Chief Executive Officer (CEO) explained the current Chief Nursing Officer (CNO) was acting as the Interim Director of Nursing (DON) until the position was filled. The Facility Assessment, last reviewed 03/2025, documented the Skilled Nursing Facility required a DON and hours would be based off of the facility needs. The Staffing Schedule for the week of 07/13/2025 through 07/26/2025, documented the DON was working in the facility for 32 hours each week. On 07/24/2025 at 8:51 AM, the DON explained working for the facility a total of 40 hours each week and the time worked was split working for the hospital 80 percent (%) of the time and working for the Long Term Care 20% of the total time. The DON verbalized working eight hours per week for the facility and confirmed the facility did not have a full time DON.

Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident's Oxygen administration was documented in the resident's medication administration record (MAR) for 1 of 13 sampled residents (Resident #9). This deficient practice had the potential to result in unmanaged Oxygen saturation levels.Findings include: Resident #9 Resident #9 was admitted to the facility on [DATE], with diagnoses including chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease, unspecified. A physician's order dated 09/26/2023, documented to administer Oxygen (O2) via nasal canula (NC) at three liters per minute (LPM) as needed for shortness of breath. May remove as desired if breathing is comfortable. An Oxygen Saturations Summary Report documented an Oxygen flow of two LPM on the following dates:-On 07/06/2025 at 10:39 PM.-On 06/10/2025 at 8:22 PM.-On 06/09/2025 at 9:08 PM.-On 06/08/2025 at 8:03 PM.-On 05/01/2025 at 10:10 PM.-On 04/29/2025 at 8:13 PM. Resident #9's May, June, and July 2025 MARs lacked documentation Oxygen was administered on any day within the three-month time span. On 07/21/2025 at 9:53 AM, Resident #9 wore Oxygen via NC. Resident #9's oxygen concentrator was set to a flow of two LPM. On 07/21/2025 at 9:53 AM, Resident #9 verbalized the resident wore Oxygen all the time and often needed to gasp for air. Resident #9 verbalized believing Resident #9's Oxygen was supposed to be set at four LPM. On 07/21/2025 at 11:58 AM, Resident #9 wore Oxygen via NC. 07/23/2025 at 9:56 AM, a Licensed Practical Nurse (LPN) verbalized Resident #9's clinical record included a physician order for Oxygen at three LPM as needed to address difficulty breathing. The LPN explained Resident #9 wore the Oxygen continuously because the resident's Oxygen levels desaturated when not in use. The LPN verbalized the LPN did not document Resident #9's Oxygen administration anywhere in the electronic health record (EHR). On 07/23/2025 at 10:10 AM, Resident #9 wore Oxygen via NC. Resident #9's oxygen concentrator was set to a flow of two LPM. On 07/23/2025 at 10:10 AM, the LPN observed Resident #9's oxygen concentrator and verbalized the flow was set to right below two LPM. On 07/23/2025 at 10:21 AM, the Interim Director of Nursing (DON) verbalized the DON expected medication administration to be documented on the MAR at the time of administration. The DON confirmed Oxygen was considered a medication. The DON explained it was important to document as needed Oxygen administration to determine how often Oxygen was used and to assess whether the resident would benefit from alterations in the resident's medication regimen. The DON verbalized Resident #9 did not wear the Oxygen continuously, however did use Oxygen fairly often and had periodically observed the resident wearing the Oxygen. The DON confirmed Resident #9's May, June and July 2025 MARs lacked documented evidence of Oxygen administration on any day within the three-month time span. The DON verbalized the Oxygen administration should have been documented in the resident's MAR. 07/23/2025 at 11:26 AM, Resident #9 verbalized the resident did not touch the oxygen concentrator. All Oxygen was administered by the facility. The resident explained even if the resident wanted to change the resident's oxygen flow, Resident #9 would not know where to look or what to do. The facility policy titled, Administration of Medications, revised 01/2021, documented prior to administering any medications, the administering nurse was to consider the ten rights: right resident, right drug, right dose, right route, right time, right documentation, right client education, right to refuse, right assessment, and right evaluation. Chart all administered medication and treatments in the EHR within appropriate timeframes, and include all required information needed for the medication or treatment. Cross reference with F760.

Based on interview and document review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify a concern and ensure corrective action was implemented related to the lack of tracking and trending of infections and antibiotic use within the Antibiotic Stewardship Program (ASP). This deficient practice had the potential to result in unnecessary antibiotic use and the development of antibiotic-resistant organisms.Findings include: On 07/24/2025 at 3:11 PM, during the QAPI review with the Chief Executive Officer (CEO), the CEO verbalized the facility ceased tracking of infection prevention and control from August 2024 through May 2025, due to not having an Infection Preventionist on staff at the facility. The CEO explained as a result, the QAPI committee did not identify a concern related to the lack of antibiotic stewardship tracking for resident antibiotics. The facility policy titled, Quality Management Program, revised 06/2025, documented the performance improvement plan would address all systems of care and management practice. Performance measures known to jeopardize the safety of residents would be monitored. At a minimum, performance measures related to medication management and infection prevention and control would be monitored by the performance improvement committee. Cross reference with F881 and F882.

Based on document review and interview, the facility failed to ensure the facility maintained an Antibiotic Stewardship Program (ASP) including tracking and trending of infections and antibiotic use from 08/2024 through 05/30/2025. This deficient practice had the potential to result in residents not receiving the correct or best antibiotic for infections resulting in prolonged or exacerbated infections and the spread of infections throughout the facility.Findings include:On 07/24/2025 at 2:46 PM, the facility was not able to provide documented evidence of an ASP, including tracking and trending of infections and antibiotic use between 08/2024 and 05/30/2025. On 07/24/2025 at 2:47 PM, the Infection Preventionist (IP) confirmed the IP had not been documenting data related to tracking and trending of infections and antibiotic use. The IP explained how the IP tracked infections and antibiotic use and monitored for trends but did not document the findings. The IP began working at the facility on 05/12/2025 and began to perform tracking and trending of infections and antibiotic use on 05/30/2025.On 07/24/2025 at 3:12 PM, the interim Director of Nursing (DON) confirmed the facility was not able provide documented evidence of an ASP, including tracking and trending between 08/2024 and 05/30/2025. The DON explained the concern with not having an ASP, including tracking and trending was the risk of increased infections throughout the facility.The facility policy titled Antimicrobial Stewardship Program last revised 12/2024, documented the ASP proactively monitored for the use of antimicrobial prescriptions. The IP summarized and kept records of the antibiotic use from electronic health records and laboratory data. The data included the culture site and organism, infection start date, antibiotic name, strength, date, duration, how the medication was administered, antibiotic sensitivity, and if the infection was a healthcare associated infection or a community acquired infection. The IP used the Long Term Care Infection Map to document all infections each month. The IP monitored and kept track of the communication from the clinical staff regarding infections and prescribed antibiotics, the Four Moments document including the antibiotic time out information, and resident/guardian education, signatures and dates.Cross reference with F865 and F882

Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident's Oxygen flow was administered per physician orders for a resident with chronic obstructive pulmonary disease for 1 of 13 sampled residents (Resident #9). This deficient practice had the potential to result in low Oxygen saturations and harm to the resident.Findings include: Resident #9 Resident #9 was admitted to the facility on [DATE], with diagnoses including chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease, unspecified. A physician's order dated 09/26/2023, documented Oxygen (O2) via nasal canula (NC) at three liters per minute (LPM) as needed for shortness of breath. May remove as desired if breathing is comfortable. An Oxygen Saturations Summary Report documented an Oxygen flow of two LPM on the following dates:-On 07/06/2025 at 10:39 PM.-On 06/10/2025 at 8:22 PM.-On 06/09/2025 at 9:08 PM.-On 06/08/2025 at 8:03 PM.-On 05/01/2025 at 10:10 PM.-On 04/29/2025 at 8:13 PM. On 07/21/2025 at 9:53 AM, Resident #9 wore Oxygen via NC. Resident #9's oxygen concentrator was set to a flow of two LPM. On 07/21/2025 at 9:53 AM, Resident #9 verbalized Resident #9 wore Oxygen all the time and often needed to gasp for air. Resident #9 verbalized Resident #9's Oxygen was supposed to be set at four LPM. 07/23/2025 at 9:56 AM, a Licensed Practical Nurse (LPN) verbalized Resident #9's clinical record included a physician's order for Oxygen at three LPM as needed to address difficulty breathing. The LPN explained Resident #9 wore the Oxygen continuously because the resident's Oxygen levels desaturated when not in use. The LPN verbalized the resident did not have a known behavior of changing the Oxygen flow on the resident's oxygen concentrator. The LPN verbalized the LPN measured Resident #9's Oxygen saturations once a day and ensured the oxygen concentrator was at the dose prescribed per physician's orders. On 07/23/2025 at 10:10 AM, Resident #9 wore Oxygen via NC. Resident #9's Oxygen concentrator was set to a flow of two LPM. On 07/23/2025 at 10:10 AM, Resident #9 verbalized the resident was struggling to breathe and requested an as needed breathing treatment. On 07/23/2025 at 10:10 AM, the LPN observed Resident #9's oxygen concentrator and verbalized the flow was set to right below two LPM. The LPN verbalized Resident #9's clinical record did not include a physician order for Oxygen titration. The LPN explained it was important for Resident #9 to have Oxygen at the prescribed level to prevent shortness of breath and hyperventilation. On 07/23/2025 at 10:21 AM, the Interim Director of Nursing (DON) verbalized the DON expected medications to be administered at the correct dose as outlined in the physician order. The DON confirmed Oxygen was considered a medication. The DON verbalized Resident #9 did not wear the Oxygen continuously, however did use Oxygen fairly often. The DON reviewed Resident #9's clinical record and confirmed the resident had a physician order to administer Oxygen at three LPM. The DON confirmed Resident #9's Oxygen Saturations Summary Report documented Resident #9 received Oxygen at two LPM, against the physician's order of three LPM. 07/23/2025 at 11:26 AM, Resident #9 verbalized the resident did not touch the oxygen concentrator. All Oxygen was administered by the facility. The resident explained even if the resident wanted to change the resident's oxygen flow, Resident #9 would not know where to look or what to do. On 07/23/2025 at 11:28 AM, the DON verbalized the DON would consider a medication administered at an incorrect dose to be a medication error. The facility policy titled, Administration of Medications, revised 01/2021, documented prior to administering any medications, the administering nurse was to consider the ten rights: right resident, right drug, right dose, right route, right time, right documentation, right client education, right to refuse, right assessment, and right evaluation. Cross reference with F842.

Based on observation, interview, clinical record review, and document review, the facility failed to ensure Transmission-Based Precautions (TBP) were implemented according to facility policy and Centers for Disease Control and Prevention (CDC) recommendations for 1 of 13 sampled residents (Resident #6). This deficient practice had the potential to increase risk of spreading infectious organisms throughout the facility.Findings include: Resident #6 Resident #6 was admitted to the facility on [DATE], with a diagnosis of methicillin resistant staphylococcus aureus (MRSA) infection, unspecified site. An aerobic bacterial culture report dated 03/27/2025, documented light growth of MRSA to the resident's left leg. A hospital Discharge summary dated [DATE], documented an order for contact precautions related to MRSA. A Comprehensive Care Plan included a care plan initiated 06/18/2025, documenting Resident #6 had a chronic fistula to the left inner knee related to chronic MRSA. An intervention initiated 04/06/2025, documented to instruct family, visitors, and caregivers to wear a disposable gown and gloves during physical contact with the resident. An intervention initiated 07/18/2025, documented contact precautions would be followed when providing treatment to the resident's wound. Resident #6's clinical record lacked documentation of an active order for contact precautions. On 07/21/2025 at 1:45 PM, the entrance of Resident #6's room lacked TBP signage and a Personal Protective Equipment (PPE) cart. On 07/21/2025 at 1:45 PM, Resident #6 verbalized Resident #6 had a staph (staphylococcus) infection in the resident's left inner thigh. On 07/23/2025 at 2:43 PM, Resident #6 verbalized staff wore gloves when providing wound care, transfer and dressing assistance, and food service. However, staff did not wear gowns or wear face masks at any point. On 07/23/2025 at 3:08 PM, a Certified Nursing Assistant (CNA) entered Resident #6's room, did not don PPE, provided snack service and pulled the blanket up to the resident's chest. The CNA washed their hands prior to exiting the resident's room. On 07/23/2025 at 3:11 PM, the CNA verbalized staff would don a gown and gloves prior to touching a resident or their environment for residents with MRSA. The CNA verbalized expecting a sign and PPE cart outside the room of a resident on TBP. The CNA verbalized being unaware Resident #6 had an active MRSA diagnosis and confirmed the CNA did not don PPE prior to entering Resident #6's room and touching the resident's environment. On 07/23/2025 at 3:15 PM, a Registered Nurse (RN) verbalized contact precautions were required for residents with confirmed or suspected contagious infections in order to prevent spread to residents and staff. Residents on contact precautions were to be given private rooms if available. The RN explained the Infection Preventionist (IP) was responsible for determining who would require TBP as well as ensuring signage and carts were present at room entrances. The RN confirmed Resident #6 was admitted to the facility with an active diagnosis of MRSA and described MRSA to be a highly transmissible infection. The RN confirmed a care plan indicating the use of contact precautions was included in Resident #6's clinical record. The RN verbalized the resident was not on contact precautions. On 07/24/2025 at 11:16 AM, the IP verbalized contact precautions were a type of TBP appropriate for residents with known or suspected infections of multidrug-resistant organisms (MDROs). Contact precautions required the use of gloves and gowns when caring for residents to protect both residents and staff. The IP would expect to see signage and carts available outside the rooms of residents on contact precautions. The IP verbalized the IP would expect residents with an active diagnosis of MRSA to be on contact precautions. The IP explained Resident #6 had an ongoing fistula with drainage and an active diagnosis of MRSA. The IP confirmed Resident #6 should have been on contact precautions. The facility policy titled Transmission Based Precautions, revised 08/2024, documented TBP was used for residents with a documented or suspected infection or colonization with highly transmissible pathogens. Contact precautions would be used for residents with known or suspected infections or evidence of syndromes that represent an increased risk for contact transmission. The facility followed CDC pathogen-specific recommendations. The CDC document titled 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, updated 09/2024, documented MDROs were generally defined as microorganisms which were resistant to one or more classes of antimicrobial agents. MDROs of concern included MRSA. Documented outbreaks in long-term care facilities were caused by various viruses and bacteria and could lead to substantial morbidity and mortality and increased medical costs. Prompt detection and implementation of effective control measures were required. Placement of a resident in a single room was preferred when there was concern about transmission of an infectious agent, including residents on contact and droplet precautions. Recommendations for residents infected or colonized with an MDRO judged as clinically important by the infection control program included contact in addition to standard precautions.

Based on observation, clinical record review, interview, and document review, the facility failed to ensure a resident with intellectual disabilities (Resident #20) was provided the necessary care and services to address the resident's scratching and picking at their arms and legs. This deficient practice had the potential to cause the resident preventable discomfort and placed the resident at risk of skin infections from scratching and picking at skin. Findings include:Resident #20 was admitted to the facility on [DATE], with diagnoses including traumatic subarachnoid hemorrhage with loss of consciousness status unknown, subsequent encounter, mild intellectual disabilities, and unspecified dementia, unspecified severity, with agitation.Resident #20's Comprehensive Care Plan documented a care plan related to communication. The care plan documented an alteration in communication related to intellectual disability, dementia. The interventions included determining the resident's communication methods and comprehension level and adapt communication techniques based on the resident's responses.Resident #20's Comprehensive Care Plan documented a care plan for the use of the medication hydroxyzine. The care plan documented the resident was prone scratching and picking at the resident's skin and causing bleeding. The care plan included interventions related to the adverse side effects of the medication.A physician's order documented to wash arms and apply lotion to both arms. Apply geri sleeves to both arms related to the resident picking and scratching. If geri sleeves were not available, may use tubi grip.A physician's order documented Hydroxyzine 25 milligram (mg) tabs, give 25 mg by mouth every eight hours as needed for itching, scratching causing bleeding, and picking at skin. The medication had a start date of 07/15/2025.Resident #20's Medication Administration Record for July 2025, documented the medication was given one time on 07/17 and 07/18/2025, and twice on 07/19/2025.A Communication with physician note dated 06/28/2025, documented Resident #20 had open areas and scratch marks to the left shin. Blood was noted on the resident's fingers from scratching and active bleeding was observed. There were multiple small, scattered broken spots.An Orders Administration Note dated 06/28/2025, documented Resident #20's right shin had scattered open spots.A Communication with Family note dated 07/15/25, documented Resident #20 documented Resident #20 was being given hydroxyzine for scratching and picking at both arms and both legs.On 07/21/2025 at 11:23 AM, Resident #20 had geri sleeves to both arms what appeared to be scratch marks could be seen on the resident's wrists.On 07/24/2025 at 8:38 AM, a Licensed Practical Nurse (LPN) verbalized Resident #20 wore geri sleeves to help prevent scratching and picking at the resident's skin.On 07/24/2025 at 8:42 AM, the LPN verbalized Resident #20 did not have the cognitive ability to ask for PRN medications and was not sure why the medication was ordered as a PRN medication. The LPN explained nurses would give the resident hydroxyzine if they noticed the resident scratching The LPN confirmed the resident was not capable of telling anyone when the resident was feeling itchy.On 07/24/2025 at 11:30 AM, the Chief Executive Officer (CEO) and the interim Director of Nursing (DON) verbalized they would like to defer resident questions to Registered Nurse (RN1) due to RN1 spent more time with the residents. The CEO and DON confirmed the preference to have questions deferred to RN1.On 07/24/2025 at 12:50 PM, RN1 verbalized RN1 was not sure why the Resident #20 had an order for PRN hydroxyzine rather than scheduled. RN1 explained nurses knew when Resident #20 needed a dose of Hydroxyzine when nurses observed the resident itching and scratching. The RN confirmed Resident #20 did not have the ability to ask for medications when needed.A facility policy titled Care of Residents with Intellectual and Developmental Disabilities dated 08/2022, documented Intellectual Disability (ID) was a disability characterized by significant limitations in intellectual functioning and adaptive behavior. The facility ensured the provision of appropriate and individualized care to residents with intellectual and developmental and intellectual disabilities.

Based on observation, interview, record review, and document review, the facility failed to ensure 1 of 13 sampled residents (Resident #1) was provided medication for pain relief per the physician's order and failed to ensure medications prescribed for pain as needed (PRN) included the severity of pain the medication was prescribed for. This deficient practice had the potential to result in discomfort, prolonged or unmanaged pain and/or an adverse drug event.Findings include:Resident #1 was admitted to the facility on [DATE], with diagnoses including alcoholic cirrhosis of the liver without ascites, pain, unspecified, low back pain, unspecified, and age-related osteoporosis without current pathological fracture.A Physician's order dated 10/30/2024, documented to give Tylenol (acetaminophen) give 650 milligrams (mg) by mouth every four hours as needed for general discomfort for a pain level 1-4.The order did not specify the pain scale to used, such as 0-10, and did not include instructions regarding how much acetaminophen not to exceed (NTE) during a 24 time frame. (3,250 milligrams, (mg) of acetaminophen should not be exceeded during a 24 hour time frame)A Physician's order dated 06/28/2025, documented to give Percocet oral tablet 5-325 mg (oxycodone/acetaminophen), give one tablet by mouth every eight hours as needed for pain, unspecified. The order did not include instructions regarding the pain level (mild, moderate, severe) to administer the medication for and did not include a method for assessing the pain such as a numeric pain scale of 0-10. The order did not include NTE instructions for acetaminophen.Resident #1's Medication Administration Record (MAR) dated June 2025, documented from 06/01/2025 - 06/30/2025, Resident #1 was not administered Tylenol including when the resident reported a pain level of four.Resident #1's MAR dated June 2025, documented from 06/28/2025 - 6/30/2025, the resident was administered Percocet two times per day on 06/28/2025, and three times per day 06/29 and 06/30/2025. Percocet was administered for a pain level of four one time on 06/30/2025.Resident #1's MAR dated July 2025, documented the resident was not given Tylenol during July 2025, including for pain rated at 4.Resident #1's MAR dated July 2025, documented the resident was administered Percocet as follows:-07/01/2025 - 07/21/2025, Resident #1 was given Percocet two times per day for seven in 21 days. The resident was given Percocet three times per day for 14 times in 21 days.The MAR documented Resident #1 reported pain levels at four or less and was administered Percocet and not Tylenol as follows:-A pain level of zero was documented one time on 07/06/2025.-A pain level of one was documented one time on 07/02/2025.-A pain level of four was documented four times on 07/01, 07/20, 07/21, and 07/22/2025.Resident #1's Comprehensive Care Plan included a care plan initiated on 01/13/2025 for increased back pain related to chronic compression fractures. The care plan documented the resident had Computed Topography (CT). The CT found the resident had acute/sub-acute and chronic compression fractures, retropulsion of bone fragments causing stenosis of the spinal cord, and bilateral neural foramina.The resident reported chronic pain in the resident's left leg related to an old fracture with hardware. The resident had arthritis and plate in the right leg.The care plan documented to administer pain medications as ordered and keep the physician updated on effectiveness/ineffectiveness.On 07/21/2025 at 2:24 PM, Resident #1 verbalized the resident had chronic pain and the resident's pain was worse when it was cold. The resident verbalized the resident's room was always cold, especially at night. The resident explained the resident had back pain from compression fractures of the spine and the pain was often pretty bad.On 07/24/2025 at 8:11 AM, a Licensed Practical Nurse (LPN) verbalized pain was what ever the resident said it was. A numerical scale of 0-10 was used to assess residents pain.On 07/24/2025 at 8:14 AM, the LPN confirmed Resident #1's order for Tylenol included a pain rating of 1-4, and confirmed the resident's Percocet did not include parameters, such as a numerical scale.On 07/24/2025 at 12:26 PM, a Registered Nurse (RN) verbalized Resident #1 watched the clock and did not have the signs of pain you would expect to see. The RN acknowledged the resident had back surgery for compression fractures and had been on a lot of pain medications during this time.On 07/24/2025 at 12:38 PM, the RN confirmed Resident #1's order for Percocet was written for generalized pain and did not include a pain scale. The RN explained physician orders for PRN medications at the facility were sometimes entered for mild, moderate, or severe pain but did not include a pain scale to define what mild, moderate, and severe pain were on a pain scale. The RN verbalized not being familiar with setting parameters for PRN pain medications when there was more than one medication ordered for pain.On 07/24/2025 at 2:40 PM, the Interim Director of Nursing (DON) confirmed Resident #1's order for Percocet should have included parameters, and when the resident reported a pain of 4 or less, the resident should have been administered Tylenol per Physician's orders.On 07/24/2025 at 2:44 PM, the DON confirmed the expectation was orders containing acetaminophen would include instructions NTE acetaminophen as instructed by the physician.On 07/24/2025 at 2:46 PM, the DON explained the concern with not monitoring the amount of acetaminophen the resident was administered had the potential to lead to the resident receiving too much acetaminophen which could lead to liver issues and verbalized especially for Resident #1 due to the resident having a diagnosis of alcohol related cirrhosis of the liver.The Manufacturer's instructions/warning label for Tylenol/acetaminophen, documented NTE 3,250 mg of acetaminophen during a 24 hour period.The facility policy titled PRN Medication Administration dated 05/2023, documented PRN medications must have a complete physician order including specific indications (e.g., pain rated 5/10, anxiety, nausea) and the maximum daily dose or number of doses per 24 hours. PRN medications were administered per the prescriber's order and the nurse must verify absence of contraindication or duplicate therapies. The Interdisciplinary Team regularly reviewed PRN medication use during care plan meetings and pharmacy reviews. The DON or designee audited PRN usage patterns monthly for trends or potential overuse/misuse.

Based on observation, document review, and interview the facility failed to demonstrate effective administration by not ensuring the Chief Executive Officer (CEO) and the Chief Nursing Officer (CNO) adequately interpreted and implemented effective infection control protocols per the Centers for Disease Control and Prevention (CDC) guidance to effectively prevent the spread of COVID-19 (COVID) resulting in a wide spread outbreak of COVID amongst facility staff and residents. Findings include: A facility COVID tracking sheet documented between [DATE] and [DATE], 16 employees and 16 of 22 residents residing in the facility tested positive for COVID. (See Tag F880 for details). On [DATE] at 3:04 PM, the Chief Nursing Officer (CNO) confirmed the facility had a COVID outbreak in the facility around October or November. The CNO explained the rooms at the far end of the hallway had been used in the past to isolate residents with COVID. The residents would have been able to ambulate in the hallways without coming in contact with COVID negative residents due. The CNO explained the rooms were able to be separated from the rest of the facility by closing the firewall doors. However, the CNO explained an interim (travel) Director of Nursing (DON) verbalized to the CNO, the facility could not require residents to stay in their rooms. On [DATE] at 3:06 PM, the CNO confirmed the facility had not used the isolated pods due to the travel DON flat out saying they were the DON and they (the DON) had said no. The CNO verbalized unfortunately, they allowed the COVID positive residents to go to the dining room and this was how a lot of the residents became sick. On [DATE] at 3:08 PM, the CNO confirmed the DON was the CNO's subordinate. The CNO confirmed the CNO had the authority to instruct the DON regarding resident care and the functioning of the facility including the use of the rooms on the other side of the fire doors. The CNO confirmed the CNO should have instructed the DON to ensure COVID positive residents were isolated and did not intermingle with other residents and had failed to do so. On [DATE] at 3:10 PM, the CNO verbalized during the COVID outbreak staff attempted to get residents and visitors to wear mask. The CNO explained during the COVID outbreak staff wore surgical mask but as more employees and residents became infected with COVID, staff began to wear N95 respiratory mask. The rationale for the selection of source control was as the outbreak got larger, the facility decided it would behoove them all to wear N95 respirator mask to help prevent further spread. The CNO explained surgical mask were effective in the prevention of spreading COVID as long as the mask were not worn for too long of a period. On [DATE] at 3:12 PM, the CNO verbalized the Infection Preventionist (IP) working at the facility during the outbreak agreed with the use of surgical mask, but after speaking with the DON it was decided the facility should switch to N95 respirator mask. On [DATE] at 1:19 PM, the acting Long Term Care (LTC) Medical Director verbalized the facility had hired a physician to take over as the Medical Director for LTC. However, the physician's state licensure was taking longer than expected and around the first week of October, the Medical Director became involved with the facility's COVID outbreak and explained at this time there were approximately five COVID positive residents. The Medical Director verbalized during this time the facility had an interim (travel) Director of Nursing (DON) and the DON reviewed the facility's policies regarding COVID testing and quarantine. The Medical Director explained the facility's COVID policies were unclear regarding when to stop testing and there was confusions and debate amongst facility leadership. The Medical Director recalled reviewing CDC guidance with another physician and argued against 48 hour testing. The Medical Director confirmed testing was completed on residents and staff every 48 hours and believed this practice continued for a week or two. The Medical Director explained during past COVID outbreaks the facility was able to separate and isolate residents. Due to the amount of exposure which had already occurred, it was decided not to move residents around. The Medical Director confirmed Resident #12 was sent to an acute care hospital outside of the facility's hospital system and confirmed Resident #12 expired during the hospitalization. On [DATE] at 2:11 PM, the CNO confirmed the facility followed the Centers for Medicare and Medicaid (CDC) guidance. Cross reference with F880

Based on observation, record review, document review, and interview, the facility failed to ensure the Centers for Disease Control and Prevention (CDC) guidance and the facility's Infection Prevention and Control Plan (IPCP) were followed regarding the management of COVID-19 (COVID). This failure resulted in an outbreak of COVID within the facility resulting in 16 employees and 16 of 22 residents (Resident #14, #18, #4, #19, #9, #10, #3, #11, #16, #21, #15, #2, #5, #6, #17, and #12) becoming infected with COVID during September and [DATE]. Resident #12 was transferred to an acute care hospital for treatment of COVID symptoms the facility was not able to manage. Resident #12 expired during this hospitalization. Findings include: Employees An untitled and undated facility spread sheet utilized for tracking employee COVID status, documented during the months of September and [DATE], facility employees were tested for COVID as follows. -On [DATE], a consulting physician with a hire date of [DATE], tested positive for COVID and tested negative for COVID on [DATE]. The physician complained of a cough, stuffy/runny nose, and pain beginning on [DATE] and worked on [DATE]. The documentation indicated the physician was tested on day two and day five following the onset of symptoms. The spread sheet lacked documented evidence of additional testing and did not indicate when the employee could or did return to work. -On [DATE], a Dietary Aide with a hire date of [DATE], tested positive for COVID. The Dietary Aide tested negative on [DATE]. The Dietary Aide complained of sore throat and congestion starting on [DATE] and had worked all week while wearing a mask. The documentation indicated the Dietary Aide was tested on day four and day 10 following the onset of symptom. The spread sheet lacked documented evidence of additional testing and did not indicate when the employee could or did return to work. -On 09/30, 10/02, and [DATE], a Physical Therapist (PT) with a hire date of [DATE] tested positive for COVID. The PT tested negative on [DATE]. The PT called in sick on [DATE], and complained of a sore throat, runny nose, cough, and fever. The documentation indicated the PT was tested on day zero, day two, and day four, and day seven. The spread sheet lacked documented evidence of additional testing and did not indicate when the employee could or did return to work. -On 10/02 and [DATE], a Minimum Data Set (MDS) Coordinator with a hire date of [DATE], tested positive for COVID. The MDS Coordinator tested negative on [DATE]. The MDS Coordinator had complained of body aches and fever starting on [DATE]. The documentation indicated the MDS Coordinator was tested on day two, day four, and day seven. The spread sheet lacked documented evidence of additional testing and did not indicate when the employee could or did return to work. -On 10/02 and [DATE], Certified Nursing Assistant (CNA) with a hire date of [DATE], tested positive for COVID. The CNA tested negative on [DATE]. The CNA had complained of fever, sore throat, cough, body aches and gastrointestinal symptoms starting on [DATE]. The documentation indicated the CNA was tested on day two, day four, and day seven. The spread sheet lacked documented evidence of additional testing and did not indicate when the employee could or did return to work. -On 10/03, 10/04, and [DATE], an Aide with the hire date of [DATE] tested positive for COVID. The Aide tested negative on [DATE]. The Aide had complained of a runny nose, cough and sore throat starting on [DATE]. The CNA worked on 09/30 and [DATE]. The Aide was sent home on [DATE]. The documentation indicated the aide was tested on day two, day three, and day six. The spread sheet lacked documented evidence of additional testing and did not indicate when the employee could or did return to work. -On 10/05, 10/07, 10/09, and [DATE] an Assistant Housekeeping Supervisor with a hire date of [DATE] tested positive for COVID. The Housekeeping Supervisor tested negative on [DATE]. The housekeeper complained of having a hoarse voice on [DATE]. The documentation indicated the Housekeeping Supervisor was tested on day two, day four, day six, day eight, and day 11. The spread sheet lacked documented evidence of additional testing and did not indicate when the employee could or did return to work. -On 10/07 and [DATE] a Housekeeping Supervisor with a hire date of [DATE]. tested positive for COVID. The Housekeeping Supervisor tested negative on [DATE]. The Housekeeping Supervisor complained of a fever, headache, sore throat, cough, and a stuffy nose on [DATE]. The documentation indicated the Housekeeping Supervisor was tested on day two, day four, and day six. The spread sheet lacked documented evidence of additional testing and did not indicate when the employee could or did return to work. -On [DATE], a CNA with a hire date of [DATE] tested positive for COVID. The CNA tested negative for COVID on [DATE]. The CNA complained of fever, chills, body aches, runny nose, and headache starting on [DATE]. The documentation indicated the CNA was tested on day two and day four. The spread sheet lacked documented evidence of additional testing and did not indicate when the employee could or did return to work. -On 10/08 and [DATE] a CNA with a hire date of [DATE], tested positive for COVID. The CNA tested negative on [DATE]. The CNA complained of symptoms starting on [DATE]. The documentation indicated the CNA was tested for COVID on day three, day five, and day seven. The spread sheet lacked documented evidence of additional testing and did not indicate when the employee could or did return to work. -On 10/08 and [DATE], a Dietary [NAME] with a hire date of [DATE], tested positive for COVID. The Dietary [NAME] tested negative on [DATE]. The CNA complained of chills, aches, congestion, and a sore throat starting on [DATE]. The documentation indicated the Dietary [NAME] was tested on day two, day four, and day six. The spread sheet lacked documented evidence of additional testing and did not indicate when the employee could or did return to work. -On [DATE], a Housekeeper with a hire date of [DATE], tested positive for COVID. The Housekeeper tested negative on [DATE]. The Housekeeper complained of headache, sore throat, and runny nose starting on [DATE]. The documentation indicated the Housekeeper was tested on day two and day four. The spread sheet lacked documented evidence of additional testing and did not indicate when the employee could or did return to work. -On [DATE], a CNA with a hire date of [DATE], tested positive for COVID. The CNA tested negative on [DATE]. The CNA complained of a cough, headache, and runny nose starting on [DATE]. The documentation indicated the CNA was tested on day three and day five. The spread sheet lacked documented evidence of additional testing and did not indicate when the employee could or did return to work. -On 10/10 and [DATE] a CNA with a hire date of [DATE] tested positive for COVID. The CNA tested negative on [DATE]. The CNA complained of symptoms starting on [DATE]. The documentation indicated the CNA was tested for COVID on day two, day four, and day six. The spread sheet lacked documented evidence of additional testing and did not indicate when the employee could or did return to work. -On 10/14 and [DATE] a Licensed Practical Nurse (LPN) with a hire date of [DATE] tested positive for COVID. The LPN tested negative on [DATE]. The LPN complained of a sore throat and stuffy nose starting on [DATE]. The documentation indicated the LPN was tested on day two, day four, and day six. The spread sheet lacked documented evidence of additional testing and did not indicate when the employee could or did return to work. Additionally, an untitled and undated flow sheet documented on 09/282024 and [DATE], a Registered Nurse (RN) with a hire date of [DATE], tested positive for COVID. The RN tested negative on [DATE]. The RN complained of a cough and sore throat starting on [DATE] and was not scheduled to work until [DATE]. The documentation indicated the RN was tested on day three, day six, and day eight. The flow sheet lacked documented evidence of additional testing and did not indicate when the employee could or did return to work. The RN was not included on the facility's COVID testing spread sheet and was not included on the facility's employee list. On [DATE] at 3:24 PM, the Chief Nursing Officer (CNO) verbalized in the beginning of the COVID outbreak, staff wore surgical mask. The CNO confirmed surgical mask were worn, and explained the surgical mask were worn for no more than two weeks. The CNO verbalized during the beginning of the outbreak the Centers for Medicare and Medicaid Services (CMS) and the Infection Preventionist's (IP) instructions were followed. The CNO explained when an employee tested positive for COVID, the employee was not allowed to return to work until symptoms resolved and the employee tested negative for COVID. On [DATE] at 2:11 PM, the CNO confirmed the facility followed CDC guidance. On [DATE] at 2:44 PM, during a telephone interview, the Chief Executive Officer (CEO) confirmed the facility followed CDC guidance as much as possible and added the facility was stricter than CDC guidance. The CNO explained we can be stricter, and we have so much data we can show. The CEO confirmed employees and residents were tested every other day. A CDC memo titled Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 (COVID) Infection or Exposure to COVID, dated [DATE], documented health care workers with mild to moderate illness who were not moderately or severely immunocompromised could return to work after the following criteria was met: -At least seven days had passed since symptoms first appeared if a negative viral test was obtained within 48 hours prior to returning to work (or after 10 days if testing was not performed or if a positive test was obtained at days 5-7), AND -At least 24 hours had passed since the last fever without the use of fever reducing medications, AND -Symptoms such as cough and shortness of breath had improved. The return-to-work criteria for healthcare workers who were exposed to individuals with confirmed SARS CoV-2 infection included: -A series of three viral tests for COVID infection. Testing was recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. -All recommended infection prevention and control practices were to be followed, including wearing well-fitting source control, monitoring for fever or symptoms consistent with COVID, and health care workers were not to report to work when ill or if testing positive for COVID. Health care workers who have entered the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a National Institute for Occupational Safety and Health (NIOSH) approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). The facility policy titled Healthcare Personnel (HCP) with a COVID-19 Diagnosis or Exposure and their Return to Work revised on 04/2023, documented HCP with mild to moderate illness who were not moderately or severely immunocompromised could return to work after the following criteria was met: -At least seven days had passed since symptoms first appeared if a negative viral test was obtained within 48 hours prior to returning to work (or after 10 days if testing was not performed or if a positive test was obtained at days 5-7), AND -At least 24 hours had passed since the last fever without the use of fever reducing medications, AND -Symptoms such as cough and shortness of breath had improved. The return to work criteria for healthcare workers who were exposed to individuals with confirmed SARS CoV-2 infection included: -A series of three viral tests for COVID infection. Testing was recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. -All recommended infection prevention and control practices were to be followed, including wearing well-fitting source control, monitoring for fever or symptoms consistent with COVID, and health care workers were not to report to work when ill or if testing positive for COVID. The facility policy titled COVID-19: Source Control, revised 06/2024, documented source control options for HCP's included a NIOSH approved particulate respirator with N95 filters or higher, a respirator approved in other countries could be used if a NIOSH approved N95 was not available. A barrier face covering that met ASTM F3502-21 requirements including Workplace Performance and Workplace Performance Plus mask, OR a well-fitting facemask. A NIOSH approved particulate respirators with N95 filters or higher was recommended during the care of a patient with SARS-CoV-2 infection. Residents Resident #14 Resident #14 was admitted to the hospital on [DATE], with diagnoses including dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified severe protein-calorie malnutrition, and chronic obstructive pulmonary disease (COPD). A laboratory (lab) report documented Resident #14 tested positive for COVID on 10/012024. The report did not document any additional COVID testing. An untitled and undated facility COVID tracking spread sheet documented Resident #14 tested positive for COVID on 10/01, 10/03, 10/07, 10/09, and [DATE]. The resident tested negative on [DATE]. Resident #18 Resident #18 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type II diabetes mellitus with diabetic polyneuropathy, COPD, and unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A lab report documented Resident #18 tested positive for COVID on 10/02, 10/04, 10/06, and [DATE]. The resident tested negative on [DATE]. An untitled and undated facility COVID tracking spread sheet documented Resident #18 tested positive for COVID on 10/02, 10/04, 10/06, and [DATE]. The resident tested negative on [DATE]. Resident #4 Resident #4 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbance, and deficiency of other specified B group vitamins, and nutritional anemia, unspecified. A lab report documented Resident #4 tested positive for COVID on 10/04, 10/07, 10/09, and [DATE]. An untitled and undated facility COVID tracking spread sheet documented Resident #4 tested positive for COVID on 10/02, 10/07, 10/09, and [DATE]. The resident tested negative on [DATE]. Resident #19 Resident #19 was admitted to the facility on [DATE], with hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, essential (primary) hypertension, unspecified disorder of circulatory system, and adult failure to thrive. A lab report documented Resident #19 tested positive for COVID on 10/02, 10/04, 10/07, and 10/09. The resident tested negative on [DATE]. An untitled and undated facility COVID tracking spread sheet documented Resident #19 tested positive for COVID on 10/02, 10/04, 10/07, and 10/09. The resident tested negative on [DATE]. Resident #9 Resident #9 was admitted to the facility on [DATE], with diagnoses including multiple sclerosis, essential (primary) hypertension, and vitamin D deficiency, unspecified. A lab report documented Resident #9 tested positive for COVID on 10/02, 10/04, and [DATE]. The resident tested negative on [DATE]. An untitled and undated facility COVID tracking spread sheet documented Resident #9 tested positive for COVID on 10/02, 10/04, and [DATE]. The resident tested negative on [DATE]. Resident #10 Resident #10 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side. A lab report documented Resident #10 tested positive for COVID on 10/03, 10/07, and [DATE]. The resident tested negative for COVID on 10/02 and [DATE]. An untitled and undated facility COVID tracking spread sheet documented Resident #10 tested positive for COVID on 10/03, 10/07, and [DATE]. The resident tested negative for COVID on 10/02 and [DATE]. Resident #3 Resident #3 was admitted to the facility on [DATE], with diagnoses including alcoholic hepatic failure without coma, alcoholic cirrhosis of liver with ascites, essential (primary) hypertension, and unspecified protein-calorie malnutrition. A lab report documented Resident #3 tested positive for COVID on 10/04, 10/07, 10/09, and [DATE]. The resident tested negative for COVID on [DATE]. An untitled and undated facility COVID tracking spread sheet documented Resident #3 tested positive for COVID on 10/04, 10/07, 10/09, and [DATE]. The resident tested negative for COVID on 10/02 and [DATE]. Resident #11 Resident #11 was admitted to the facility on [DATE], and last readmitted on [DATE], with diagnoses including Alzheimer's disease, unspecified, essential (primary) hypertension, presence of cardiac pacemaker, and shortness of breath. A lab report documented Resident #11 tested positive for COVID on 10/04, 10/07, and [DATE]. The resident tested negative for COVID on 10/02 and [DATE]. An untitled and undated facility COVID tracking spread sheet documented #11 tested positive for COVID on 10/04, 10/07, and [DATE]. The resident tested negative for COVID on 10/02 and [DATE]. Resident # 16 Resident #16 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including COPD, type II diabetes mellitus without complications, polyneuropathy, unspecified. A lab report documented Resident #16 tested positive for COVID on 10/04, 10/07, 10/09, 10/11, 10/14, 10/16 and [DATE]. The lab report did not document a negative COVID test result. An untitled and undated facility COVID tracking spread sheet documented Resident #16 tested positive for COVID on 10/04, 10/07, 10/09, 10/11, 10/14, 10/15 and [DATE]. The resident tested negative for COVID on [DATE], prior to testing positive. The tracking spread sheet did not document any additional COVID test. Resident #21 Resident #21 was admitted to the facility on [DATE], with diagnoses including cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery, essential (primary) hypertension, acute respiratory failure with hypoxia, unspecified asthma, and dependence on long term (current) use of antibiotics. A lab report documented Resident #21 tested positive for COVID on 10/04 and [DATE]. The resident tested negative for COVID on 10/02 and [DATE]. An untitled and undated facility COVID tracking spread sheet documented Resident #21 tested positive for COVID on 10/04 and [DATE]. The resident tested negative for COVID on 09/23, 10/02 and [DATE]. Resident #15 Resident #15 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including hemiplegia, unspecified affecting right dominant side, essential (primary) hypertension, and vascular dementia, unspecified severity, with other behavioral disturbance. A lab report documented Resident #15 tested positive for COVID on 10/04, 10/07, 10/09, 10/11, 10/14, 10/16, and [DATE]. The lab report did not document a COVID negative test. An untitled and undated facility COVID tracking spread sheet documented Resident #15 tested positive for COVID on 10/04, 10/07, 10/09, 10/11, 10/14, 10/15, and [DATE]. The resident tested negative for COVID on [DATE], prior to testing positive. The tracking spread sheet did not document any additional COVID test. Resident #2 Resident #2 was admitted to the facility on [DATE], with diagnoses including vascular dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, disease of pancreas, unspecified, and essential (primary) hypertension. A lab report documented Resident #2 tested positive for COVID on [DATE]. The resident tested negative for COVID on 10/03 and [DATE]. An untitled and undated facility COVID tracking spread sheet documented Resident #2 tested positive for COVID on [DATE]. The resident tested negative for COVID on 10/03 and [DATE]. Resident #5 Resident #5 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side, hypertensive heart disease with heart failure, and occlusion and stenosis of unspecified carotid artery. A lab report documented Resident #5 was tested negative for COVID on 10/02 and [DATE]. The lab report did not document any additional COVID test. An untitled and undated facility COVID tracking spread sheet documented Resident #5 tested positive for COVID on 10/07, 10/09, 10/11, and [DATE]. The resident tested negative for COVID on 10/02, 10/03, and [DATE]. Resident #6 Resident #6 was admitted to the facility on [DATE], with diagnoses including pleural effusion, not elsewhere classified, adult failure to thrive, and chronic atrial fibrillation, unspecified. A lab report documented Resident #6 tested positive for COVID on 10/07 and [DATE]. The resident tested negative for COVID on 10/04, 10/11, and [DATE]. An untitled and undated facility COVID tracking spread sheet documented Resident #6 tested positive for COVID on 10/07 and [DATE]. The resident tested negative for COVID on 09/13, 09/18, 10/02, 10/04, 10/11, and [DATE]. Resident #17 Resident #17 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including acute respiratory failure with hypoxia, hypertensive heart disease with heart failure, acute on chronic diastolic (congestive) heart failure, type II diabetes mellitus with hyperglycemia, obstructive sleep apnea, and morbid (severe) obesity due to excess calories. A lab report documented Resident #17 tested positive for COVID on 10/11 and [DATE]. The resident tested negative on 10/02, 10/03, 10/09, and [DATE]. An untitled and undated facility COVID tracking spread sheet documented Resident #17 tested positive for COVID on 10/11 and [DATE]. The resident tested negative on 10/02, 10/03, 10/09, and [DATE]. Resident #12 Resident #12 was admitted to the facility on [DATE], and was last re-admitted to the facility on [DATE], with diagnoses including quadriplegia, unspecified, hydrocephalus, unspecified, hypotension, unspecified, respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia, unspecified severe protein-calorie malnutrition, and adult failure to thrive. A diagnosis of COVID was added on [DATE], and a diagnosis of pneumonia due to corona virus disease 2019 was added on [DATE]. A lab report documented Resident #12 tested positive for COVID on 10/06 and [DATE]. The resident tested negative for COVID on 10/02 and [DATE]. An untitled and undated facility COVID tracking spread sheet documented Resident #12 tested positive for COVID on 10/06 and [DATE]. The resident tested negative for COVID on 10/02 and [DATE]. A Health Alert note dated [DATE], documented Resident #12's oxygen saturating had begun to deteriorate to 88 percent (%). The resident's oxygen was increased to three liters per minute (LPM) with little effect and a physician was notified of the resident's condition. A Change of Condition note entered by a physician and dated [DATE] documented Resident #12 had a fever of 101.5 degrees Fahrenheit (F) on [DATE]. On [DATE], the resident had more of a cough and was tired. The resident's oxygen saturation had decreased to 88% on one LPM of oxygen. The oxygen was increased to three LPM and the resident's oxygen saturation remained at 88%. Resident #12 had received two nebulizer treatments while in the resident's regular room. Resident #12 was tested for COVID, and results were pending. The physician documented the physician believed the resident was COVID positive and planned to move the resident to a negative pressure room. The continued to document Resident #12's COVID test results had just come back positive, and the resident would be moved to a negative pressure room. A Health Status Note dated [DATE], documented Resident #12 was COVID positive and receiving antibiotics for pneumonia. A Health Status Note dated [DATE], documented Resident #12 was receiving oxygen at five LPM via nasal cannula and the resident's oxygen saturations were in the 60's. The resident did not want to go to the emergency room (ER) and requested to try a face mask for oxygen delivery. A face mask was applied and the resident's oxygen saturations increased to 75%. The resident agreed to be transferred to the ER. A Health Status Note dated [DATE], documented Resident #12's oxygen saturations remained in the 70's with oxygen being delivered at five LPM via face mask. The resident's heart rate was tachycardia in the 140's and the resident was transferred to the ER. On [DATE] at 3:04 PM, The Chief Nursing Officer (CNO) confirmed the facility had a COVID outbreak in the facility around October or November. The CNO explained the rooms at the far end of the hallway had been used in the past to isolate residents with COVID. The CNO explained the rooms were able to be separated from the rest of the facility by closing the firewall doors and residents would have been able to ambulate in the hallways without coming in contact with COVID negative residents. However, the CNO explained an interim (travel) Director of Nursing (DON) verbalized to the CNO, the facility could not require residents to stay in their rooms. On [DATE] at 3:06 PM, the CNO confirmed the facility had not used the isolated pods due to the travel DON flat out saying they were the DON, and they (the DON) had said no. The CNO verbalized unfortunately, they allowed the COVID positive residents to go to the dining room and this was how a lot of the residents became sick. On [DATE] at 3:08 PM, the CNO confirmed the DON was the CNO's subordinate. The CNO confirmed the CNO had the authority to instruct the DON regarding resident care and the functioning of the facility including the use of the rooms on the other side of the fire doors. The CNO confirmed the CNO should have instructed the DON to ensure COVID positive residents were isolated and did not intermingle with other residents and had failed to do so. On [DATE] at 3:10 PM, the CNO verbalized during the COVID outbreak staff attempted to get residents and visitors to wear mask. The CNO explained during the COVID outbreak staff wore surgical mask but as more employees and residents became infected with COVID, staff began to wear N95 respiratory mask. The rationale for the selection of source control was as the outbreak got larger, the facility decided it would behoove them all to wear N95 respirator mask to help prevent further spread. The CNO explained surgical mask were effective in the prevention of spreading COVID as long as the mask were not worn for too long of a period. On [DATE] at 3:12 PM, the CNO verbalized the Infection Preventionist (IP) working at the facility during the outbreak agreed with the use of surgical mask, but after speaking with the DON it was decided the facility should switch to N95 respirator mask. On [DATE] at 1:19 PM, the acting Long-Term Care (LTC) Medical Director verbalized the facility had hired a physician to take over as the Medical Director for LTC. However, the physician's state licensure was taking longer than expected and around the first week of October, the Medical Director became involved with the facility's COVID outbreak and explained at this time there were approximately five COVID positive residents. The Medical Director verbalized during this time the facility had an interim (travel) Director of Nursing (DON), and the DON reviewed the facility's policies regarding COVID testing and quarantine. The Medical Director explained the facility's COVID policies were unclear regarding when to stop testing and there was confusions and debate amongst facility leadership. The Medical Director recalled reviewing CDC guidance with another physician and argued against 48-hour testing. The Medical Director confirmed testing was completed on residents and staff every 48 hours and believed this practice continued for a week or two. The Medical Director explained during past COVID outbreaks the facility was able to separate and isolate residents. Due to the amount of exposure which had already occurred, it was decided not to move residents around. The Medical Director confirmed Resident #12 was sent to an acute care hospital outside of the facility's hospital system and confirmed Resident #12 expired during this hospitalization. On [DATE] at 2:11 PM, the CNO confirmed the facility followed CDC guidance. The CDC document titled Infection Control Guidance: SARS-CoV-s dated [DATE], documented during an outbreak of COVID, the approach to an outbreak investigation involved either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach was preferred if all potential contacts could not be identified or managed with contact tracing or if contact tracing failed to halt transmission Testing was completed for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing was recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This was typically at day 1 (where day of exposure is day 0), day 3, and day 5. If additional cases were identified, strong consideration was given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach, testing continued on affected unit(s) or facility-wide every 3-7 days until there are no new cases for 14 days. Cross Reference with F835

Based on interview and document review, the facility failed to ensure an allegation of neglect and abuse was reported to the State Agency (SA) within the required time frame for 1 of 22 sampled residents (Resident #18). This deficient practice could result in allegations of abuse not being investigated timely. Findings include: Resident #18 Resident #18 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type two diabetes mellitus with diabetic polyneuropathy and chronic obstructive pulmonary disease, unspecified. A Facility Reported Incident (FRI) was submitted to the SA on 11/27/2024, documenting an allegation of resident neglect and abuse by a Certified Nursing Assistant (CNA). The FRI documented the alleged incident occurred on 11/22/2024, and the Chief Nursing Officer (CNO) was notified of the allegations on 11/25/2024 by the long-term care unit secretary. On 01/29/2025 at 1:41 PM, the Director of Nursing Secretary (DON Secretary) verbalized the facility's abuse coordinator was the DON and all allegations of abuse were to be reported to the DON. The DON Secretary recalled an Observation Aide (OA) notified the DON Secretary of an allegation of resident neglect and abuse by a CNA. The DON Secretary verbalized the DON Secretary reported the allegation to the CNO as the facility did not have a DON at the time. The CNO was notified the same day the DON Secretary received the allegations from the OA. On 01/29/2025 at 2:25 PM, an Observation Aide (OA) recalled the OA was working in the evening on 11/22/2024. The OA recalled Resident #18 called out for help and verbalized the resident needed to be changed. Later in the shift, the OA observed from the hallway, Resident #18 had no brief on and was uncovered from the waist down. Resident #18 reported to the OA the CNA had come to change Resident #18's brief and had left without putting a brief on the resident or covering the resident. On 11/25/2024, the OA spoke to the DON Secretary about the incident and asked the DON Secretary how to contact the CNO to report it. The facility policy titled Freedom From Abuse (Residents, Patients), revised May 2021, documented abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish or the deprivation of goods or services necessary to attain or maintain physical, mental, and psychosocial well-being. Neglect was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Any person identifying signs of resident abuse or neglect were to immediately report to the charge nurse and the charge nurse would notify the DON and the Chief Risk Officer. The DON or the Chief Risk Officer would report suspected abuse to the SA within 24 hours. FRI #NV00072852

Based on observation, document review, and interview the facility failed to demonstrate effective administration by not ensuring the facility's influenza (flu) and pneumonia (PNA) vaccination program included 1) screening residents for eligibility to receive the vaccines, 2) the provision of education related to the risk and benefits of the vaccines to residents and/or the resident's representative preventing the resident or the resident's representative from making an informed decision regarding the vaccines, 3) a process for determining/selecting the correct PNA vaccine for each resident per the Centers for Disease Control and Prevention (CDC) guidance. This failure resulted in substandard quality of care. Findings include: Influenza Vaccine The facility lacked documented evidence 23 of 26 residents eligible or potentially eligible to receive a flu vaccine were screened for eligibility to receive a flu vaccine and lacked documented evidence education related to the 2023/2024 flu vaccines was provided to the resident or the resident's representative (Resident #4, #16, #10, #24, #11, #15, #19, #6, #13, #5, #23, #1, #3, #22, #21, #9, #7, #20, #18, #12, #26, #17 and #8). The facility administered Flu vaccines to the residents as follows: -8 of 26 residents eligible to receive a flu vaccine declined vaccination (Resident #11, #19, #13, #23, #3, #9, #18, and #12. The residents' clinical records lacked documented evidence the residents were screened for eligibility to receive a flu vaccine and the residents and/or residents' representatives were provided education regarding the 2023/2024 flu vaccines prior to declining vaccination resulting in the resident not having the opportunity to make an informed decision. -5 of 26 residents (Resident #24, #22, #7, #17 and #8) clinical records lacked documented evidence the residents were screened to determine eligibility to receive a flu vaccine and were provided education regarding the 2023/2024 flu vaccines prior to signing consents and prior to the administration of a 2023/2024 flu vaccine. This failure resulted in the residents not having the opportunity to make an informed decision prior to being administered a 2023/2024 flu vaccine and put residents at risk of having adverse reactions to the flu vaccine related to risk factors identified during the screening process. -3 of 26 residents (Resident #16, #20 and #26) clinical records lacked documented evidence the residents were screened for eligibility to receive a flu vaccine, education regarding the 2023/2024 flu vaccine was provided, and consent was given by the resident or the residents representative prior to administering a flu vaccine to the residents. This failure resulted in the residents not having the opportunity to make an informed decision and either consent to receive or decline to receive a flu vaccine prior to being administered a 2023/2024 flu vaccine. The lack of screening for eligibility put the residents at risk of having adverse reactions to the flu vaccine related to risk factors identified during the screening process. 6 of 26 residents (Resident #10, #15, #6, #5, #1 and #21) clinical records documented consents were signed to receive a flu vaccine during the 2022/2023 flu season. The residents' clinical records lacked documented evidence the residents were screened for eligibility to receive vaccination with a 2023/2024 flu vaccine, the resident or the resident's representative were provided education regarding the 2023/2024 flu vaccines, and consent for vaccination with the 2023/2024 flu vaccine was obtained prior to administering a 2023/2024 flu vaccine to the residents. This failure resulted in the residents not having the opportunity to make an informed decision and either consent to receive or decline to receive a flu vaccine prior to being administered a 2023/2024 flu vaccine. The lack of screening for eligibility put the residents at risk of having adverse reactions to the flu vaccine related to risk factors identified during the screening process. 1 of 26 residents (Resident #4) was screened for eligibility to receive a flu vaccine with a hospital consent form. The screening/consent form included a section with an acknowledgement of receipt of a Vaccination Information Sheet (VIS) and an acknowledgement the resident reviewed the information on the back of the form. The form documented the VIS provided to the resident was dated 08/06/2021. The form documented the vaccine administered to Resident #4, Fluad manufactured by Seqirus, was to be given to individuals 65 and older only !!!! and Resident #4 was 61 YOA. A Food and Drug Administration package insert titled Fluad Quadrivalent - Seqirus Incorporated, dated March 2023, documented the Fluad vaccine was approved for use in individuals [AGE] years of age or older and was not approved by the FDA for people under the age of 65. The facility policy titled Influenza Vaccination, revised 12/2023, documented influenza vaccination was the primary method for preventing influenza and it's severe complications. Therefore, vaccination against influenza was offered to residents. Upon admission residents were assessed for recent and past flu vaccination, and flu vaccines were administered to residents annually thereafter. The healthcare professional administering the vaccine obtained a signed consent from the resident or resident representative at the time of admission or prior to the next flu season. Residents were routinely vaccinated, unless contraindicated, at one time, annually, before the influenza season. Residents and/or the resident representatives were provided a copy of the most current VIS regarding the flu vaccine the resident was to be given. Residents were screened for history of Guillain-Barre Syndrome, and for severe allergic reaction to a previous dose, vaccine component, and egg protein. A flu vaccine was not to be administered to residents exhibiting signs and symptoms of moderate or severe acute illness, with or without fever. The facility referred to current Advisory Committee on Immunization Practices (ACIP) recommendations for special circumstances such as immunosuppression, immunodeficiencies, corticosteroid therapy and organ transplantation. Pneumonia Vaccine The facility lacked documented evidence 26 of 26 residents eligible or potentially eligible to receive a PNA vaccine were screened for eligibility to receive a PNA vaccine and lacked documented evidence education regarding the PNA vaccine the resident was eligible to receive was provided to the resident or the resident's representative (Resident #4, #27, #16, #10, #24, #11, #15, #14, #19, #6, #13, #5, #23, #2, #1, #3, #22, #21, #9, #7, #20, #18, #12, #26, #17, and #8). The facility administered PNA vaccines to the residents as follows: -13 of 26 residents (Resident #4, #16, #10, #24, #11, #15, #19, #6, #13, #5, #23, #1, #3, #22, #21, #9, #7, #20, #18, #12, #26, #17 and #8) eligible or potentially eligible to receive a PNA vaccine declined vaccination The residents' clinical records lacked documented evidence the residents were screened for eligibility to receive a PNA vaccine and the residents and/or residents' representatives were provided education regarding the PNA vaccines prior to declining vaccination resulting in the resident not having the opportunity to make an informed decision. -7 of 26 residents' clinical record included a signed consent requesting to receive vaccination with a PNA vaccine (Resident #2, #21, #8, #7, #22, #24, and #10). The residents' clinical record lacked documented evidence the resident was screened for eligibility to receive a PNA vaccine, education was provided related to the PNA vaccine the resident was eligible to receive, and the PNA vaccine was administered to the resident. The facility policy titled Pneumococcal Polysaccharide Vaccination, last revised 10/2017, documented because pneumococcal disease was known to lead to serious infections in the resident population and was proving to be resistant to antibiotics, the facility provided vaccination against pneumococcal disease to prevent the spread of infection. PPSV protected against multiple types of pneumococcal bacteria and was offered to the resident population. Residents were screened for severe allergic reactions after a previous dose of PPSV and consent was obtained from the resident or the resident's representative/guardian. Residents or the resident's representative/guardian were provided with information regarding potential reactions and a copy of the most current VIS. Copies of the VIS were obtained from the CDC website. Documentation in the residents clinical record included the date of administration, amount and dosage given, reactions to the vaccine. The policy was last revised in 2017, and documented the sole reference was titled CDC, Morbidity and Mortality Weekly Report (MMWR), Prevention of Pneumococcal Disease: Recommendations of the Advisory Committee on Immunization Practices (ACIP), volume 46/No. RR-8, dated 04/04/1997. The reference included a weblink, but the link indicated the page could no longer be found. The guidance in the policy was outdated and did not include the CDC's most recent guidance regarding the selection and administration of pneumococcal vaccines.