Every finding on record at South Valley Post Acute Rehabilitation

Based on record review and interviews, the facility failed to designate a registered nurse (RN) to serve as the director of nursing (DON) on a full-time basis.Specifically, the facility did not designate an RN to serve as the DON on a full-time basis after the DON's RN license expired on [DATE]. Findings include:Record review, observations and interviews confirmed the facility corrected the deficient practice related to the facility's failure to designate a registered nurse (RN) to serve as the director of nursing on a fall time basis prior to the onsite investigation on [DATE] to [DATE]. The deficiency was cited as past non-compliance with a correction date of [DATE].I. Record reviewReview of the DON's RN license history revealed the license expired on [DATE].II. Staff interviewsThe nursing home administrator (NHA) and the regional clinical resource were interviewed together on [DATE] at 11:15 a.m. The NHA said the facility was notified on [DATE] by the facility's service center (staff external to the facility) that the DON's RN license on file was expired. The NHA said the DON attempted to renew the nursing license online and in person the following day ([DATE]) but was unable to. The NHA said the facility designed a facility RN charge nurse as the DON on [DATE]. The NHA said the facility created a plan of correction to address the issue. The NHA said the DON's license renewal date was monitored by the facility's service center and not the facility staff and the DON did not get a reminder email to renew her license.III. Plan of correctionThe NHA provided the facility's plan of correction on [DATE]. The plan of correction documented the following:Immediate action to correct the deficient practice:On [DATE] the facility was notified the DON's RN license had expired.On [DATE] the facility designated an RN charge nurse as the interim DON.Identification of other residentsOn [DATE] the facility began an audit to review work completed by the DON after [DATE] that included resident assessments and orders to identify residents who were or could have been affected; the schedule was reviewed for RN coverage; and, the regional clinical resource and the medical director reviewed the assessments and orders and found no concerns.Systematic changes The facility's human resources director will monitor the license renewal dates of facility licensed and certified staff including the DON's license. An annual reminder for RN license renewal was added to the facility's online training.MonitoringThe facility's human resources director will verify all licensed and certified facility employees have active licenses with [NAME] monthly. An annual reminder for RN license renewal was added to the facility's online training.IV. Facility follow upThe NHA provided the DON's updated RN license on [DATE] at 11:43 a.m. with an effective date of [DATE] (after the survey).

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection.Specifically, the facility failed to:-Ensure housekeeping staff followed proper cleaning techniques for cleaning and disinfectingresident rooms and high-frequency touched areas (call lights, door handles and handrails); and,-Ensure urinary catheter tubing and collection bag were handled in a sanitary manner for Resident #100. Findings include:I. Housekeeping failuresA. Professional referenceAssadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (July 2021) 113:104-114, was retrieved on 2/2/26 from https.//pubmed.ncbi.nlm.nih.gov. It read in pertinent part, High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (viruses or microorganisms that can cause disease). Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAI increase morbidity and mortality, prolonged hospital stays, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act a reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment.The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures,(revised 3/19/24) was retrieved on 2/2/26 from https://www.cdc.gov/healthcare-associatedinfections/hcp/cleaning-global/procedures.html?CDC_AAref_Val=https://www.cdc.gov/hai/preent/resource-limited/cleaning-procedures.html#cdc_generic_section_2-4-1-generalenvironmental-cleaning-techniques. It read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility.Common high-touch surfaces include: bed rails, IV (intravenous) poles, sink handles, bedsidetables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, controlpanels), call bells and door knobs.Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during terminal cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones) before patient toilets, within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions.B. Facility policy and procedureThe Routine Cleaning and Disinfection policy and procedure, revised November 2025, was received from the nursing home administrator (NHA) on 2/2/26 at 6:35 p.m. It read in pertinent part, It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Consistent surface cleaning will be conducted with a detailed focus on high touch areas to include, but not limited to, toilet flush handles, tray tables, call buttons, television remote, telephones, toilet seats, sinks and faucets, light switches, and door knobs.C. ObservationsDuring a continuous observation on 1/28/26, from 10:20 a.m. to 10:50 a.m., housekeeper (HK) #1 was observed cleaning rooms #315 and #310.HK #1 donned (put on) a new set of gloves, entered room [ROOM NUMBER] and began spraying Profect HP disinfectant into the sink in the common area between side A and side B of the room and on the raised toilet seat with handles. HK #1 removed the trash bags from the trash cans on both sides of the room and replaced them with new bags. HK #1 returned to his cart, removed his gloves and donned new gloves without performing hand hygiene in between. HK #1 grabbed two microfiber rags from a bucket containing a disinfectant solution, placed one on the sink in the common area, and used the other to begin wiping the bedside table of side A. HK #1 wiped the bedside table surface down to the legs of the table. -HK #1 did not disinfect high-touch areas such as the residents' call light or remotes for the residents residing on either side of the room.HK #1 returned to his cart, removed his gloves and donned new gloves without performing hand hygiene. HK #1 began using the microfiber rag on the sink to begin wiping the top of the sink, then the inside of the sink basin, then along the countertop. HK #1 returned to his cart, removed his gloves and donned new gloves without performing hand hygiene. HK #1 grabbed another microfiber rag from the disinfectant bucket and placed it on the toilet seat. HK #1 grabbed a toilet brush from inside a bathtub in the room and used it to scrub the toilet bowl before setting it back down into the bathtub. -HK #1 did not disinfect the toilet brush after use. HK #1 did not return the toilet brush to an appropriate vessel to prevent further cross-contamination.HK #1 used the microfiber rag to wipe the toilet seat, then used another rag to wipe the inner rim of the toilet, then the toilet seat, then the toilet lid and flusher handle. HK #1 then disposed of the microfiber rags, removed his gloves and donned new gloves without performing hand hygiene. HK #1 placed a dry mop head onto the mop on side A, pushed the mop to side B, then swept the entire room moving from side B to side A before sweeping the debris into the room's doorway. HK #1 removed the dry mop head, swept up and disposed of the debris, and removed the dry mop head. HK #1 took a wet mop head out of a bucket containing a disinfectant solution , placed the mop head onto the floor in side A and pushed it into the bathroom to begin mopping the bathroom. HK #1 then removed the mop head and disposed of it, grabbed another mop head from the disinfectant solution bucket and began mopping side A. HK #1 removed the mop head and disposed of it, grabbed another mop head from the disinfectant bucket and placed it on the floor of side A before pushing it to side B. HK #1 then mopped the entirety of side B, mopped back through parts of side A, mopped part of the floor in side B, then mopped up through side A to the doorway of the room. HK #1 removed the mop head and disposed of it before replacing the dry mop head onto the mop. HK #1 used the dry mop head to dry the floors in side B then side A. HK #1 removed the dry mop head, removed his gloves and performed hand hygiene.-HK #1 failed to mop the two sides of the room separately.At 10:38 a.m. HK #1 donned new gloves, entered room [ROOM NUMBER] and spoke with the residents residing in the room. HK #1 grabbed a spray bottle of Profect HP disinfectant and sprayed the sink and toilet seat with the cleaner. HK #1 collected the trash on Side B of the room and discarded it, disposed of his gloves, performed hand hygiene and donned a new pair of gloves. HK #1 grabbed two microfiber rags from the disinfectant bucket and used one of the rags to clean the inside of the sink, then the top of the sink and the countertop. HK #1 then used the other microfiber rag to clean the toilet seat, then the underside of the seat, then the inner rim of the toilet. HK #1 grabbed a toilet brush kept beside the toilet in the bathroom, scrubbed the inside of the toilet bowl, and returned the toilet brush back to the container. -HK #1 did not disinfect the toilet brush after use.HK #1 returned to his cart, removed his gloves and donned a new set of gloves without performing hand hygiene. HK #1 placed a dry mop head onto the mop and began sweeping side B then side A. HK #1 removed the dry mop head, grabbed a broom and swept the debris from the floor into a dustpan and disposed of it. HK #1 removed his gloves, performed hand hygiene and donned new gloves. HK #1 grabbed a mop head from the disinfectant bucket, placed it on the floor in side A and pushed it into the bathroom to begin mopping the bathroom. HK #1 removed the mop head, grabbed a new mop head and placed it on the floor in side A, then pushed it to side B and began mopping side B. HK #1 finished mopping side B, and with the same mop head continued mopping side A. HK #1 removed the mop head, grabbed a new mop head, placed it on the floor on side A and pushed into side B, then mopped from side B to side A. -HK #1 failed to mop the two sides of the room separately.D. Staff interviewsThe housekeeping supervisor was interviewed on 1/29/26 at 2:00 p.m. The housekeeping supervisor said the housekeeping staff began cleaning rooms first by knocking and waiting a few minutes before letting the resident know housekeeping was there to clean their room. The resident would reply and tell the staff member if they could come in or not. The housekeeping supervisor said the housekeeper would then start cleaning the room by spraying disinfectant spray on the residents' call lights, sink, doorhandles, bed remotes, and on the bathroom surfaces. The housekeeping supervisor said the housekeeper would then retrieve rags from a bucket containing the same disinfectant solution, and use the rags to clean the tables and remote controls, the sink, and the toilet, with each surface getting its own color rag. The housekeeping supervisor said the disinfectant had to remain on the surface for two minutes. The housekeeping supervisor said the housekeeping staff should use one mop head for each separate side of the room, and one mop head to mop the bathroom.The housekeeping supervisor said the toilet was always cleaned last. The housekeeping supervisor said the housekeeping staff should clean the toilet starting from top to bottom, and should clean the seat of the toilet last. The housekeeping supervisor said the housekeeping staff should be folding the rag over as they were cleaning the toilet so a fresh side would be touching the surface. The housekeeping supervisor said the toilet brushes were kept in a container in the residents' bathroom. The housekeeping supervisor said the toilet brush should not be left in the resident's bathtub.The housekeeping supervisor said the housekeeping staff needed to sanitize their hands between each glove change.The infection preventionist (IP) was interviewed on 1/29/26 at 2:31 p.m. The IP said toilet brushes should be stored on the housekeeper's cart, and not stored in the resident's bathtub. The IP said the housekeeping staff should clean from cleanest to dirtiest, and work starting from the toilet handle and clean the toilet bowl last. The IP said the housekeeping staff should be cleaning high-touch areas including handrails, door handles, bed remotes, television remotes, side tables and call lights. The IP said the housekeeping staff should use separate mop heads for each side of the residents' rooms.II. Urinary catheter failuresA. ObservationsOn 1/26/26 at 10:35 a.m. Resident #100 was sitting in his wheelchair. His catheter collection bag was sitting on the floor in a privacy bag.At 3:21 p.m. Resident #100 was lying in his bed. His catheter bag was attached to his bed, and the urinary catheter tubing was touching the ground.On 1/27/26 at 8:20 a.m. Resident #100 was lying in bed with his bed in the lowest position. Resident #100's catheter bag was attached to his bed, and the catheter bag was resting folded over on the floor.At 5:18 p.m. Resident #100 was lying in bed. His catheter bag was clipped to the foot of his bed, and the bag was resting on the floor.On 1/28/26 at 10:14 a.m. Resident #100 was sitting on the side of his bed with his catheter bag clipped to his bed and the bed in lowest position. Resident #100's catheter bag was slipping out of the bottom of the privacy bag with the bottom of the catheter bag folded over and resting on the floor. Resident #100's catheter tubing between the bag and the resident's leg was resting on the floor.At 11:02 a.m. HK #1 was mopping Resident #100's room. HK #1 donned gloves, put a mop head onto Resident #100's side of the room, pushed the mop through the room into the bathroom and began mopping the bathroom. HK #1 removed the mop head, grabbed a new mop head and began mopping Resident #100's side of the room. With the same gloved hands, HK #1 grabbed Resident #100's catheter tubing and lifted it off the floor, mopped underneath the area, and placed the tubing back onto the floor to continue mopping.On 1/29/26 at 12:19 p.m. Resident #100 was lying in bed. Resident #100's catheter bag was clipped to his trash can, with the bottom of the catheter bag folded over and touching the floor.At 1:08 p.m. Resident #100 was sitting up in bed eating his lunch. Resident #100's catheter bag was clipped to the trash can, and his catheter bag and tubing were touching the floor.B. Staff interviewsLicensed practical nurse (LPN) #4 was interviewed on 1/29/26 at 12:53 p.m. LPN #4 said the nursing staff provided catheter care each shift, and changed the catheter bags once per week. LPN #4 said the staff needed to wear a gown and gloves when handing the urinary catheter. LPN #4 said it was not okay for the urinary catheter tubing or bag to touch the floor, and the resident should have a basin to put the urinary catheter bag into, or clip the bag to their wheelchair or bed. LPN #4 said the catheter bag and tubing could not touch the floor as it was an infection control risk due to the catheter being a line that went into their body, and said the staff wanted to prevent infections as much as possible. LPN #4 said it was the resident's right to put the catheter bag wherever he chose to, but she would offer a basin for the catheter to rest in.LPN #4 was interviewed again on 1/29/26 at 1:10 p.m. LPN #4 said she spoke with the certified nurse aide (CNA) who was caring for Resident #100, and the CNA said the resident got up to go to the bathroom by himself a lot and would frequently move his catheter bag and clip it himself. LPN #4 said she still needed to provide education to the resident regarding where to clip his catheter and document the education in a progress note.The IP and a clinical resource were interviewed together on 1/29/26 at 2:31 p.m. The IP said urinary catheter bags should be hung below the level of the resident's bladder but should not be on the floor. The IP said the nursing staff sometimes put the catheter bags in basins on the floor as needed with a privacy bag, but said the catheter tubing and catheter bag itself should not be on the floor. The IP said nursing staff should educate residents who were alert and oriented on how placing their catheter bag on the floor was not sanitary and how it could lead to a urinary tract infection, and document their education in the resident's privacy notes. The clinical resource said the nursing staff should have also immediately sanitized the catheter tubing and bag after it had been resting on the floor.The IP said it was not okay for HK #1 to have grabbed Resident #100's urinary catheter tubing (see observations above), and said housekeeping staff would need to be educated on urinary catheter care as well.The nurse manager and director of nursing (DON) were interviewed together on 1/29/26 at 4:15 p.m. The DON and nurse manager said urinary catheters should not touch the ground, or be mopped under or around by the housekeeping staff. They both said they would be educating their staff on sanitary catheter practices.

Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in two of four medication carts and one of two medication storage rooms.Specifically, the facility failed to ensure residents' medications were labeled and dated appropriately with the resident's name and the date the medication was opened.Findings include:I. Facility policy and procedureThe Medication Access and Storage policy, revised October 2025, was provided by the nursing home administrator (NHA) on 2/2/26 at 6:35 p.m. It read in pertinent part, It is the policy of this facility to store all drugs and biologicals in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications.II. ObservationsOn 1/29/26 at 11:53 a.m. medication cart #1 on the fourth floor was observed with licensed practical nurse (LPN) #3. The following item was found:-There was one fluticasone propionate 50 micrograms (mcg) per actuation (mcg/act) nasal spray bottle stored in an appropriately labeled medication box; however, the individual medication bottle inside was not labelled with the resident's name or the date the medication was opened for Resident #47.On 1/29/26 at 12:17 p.m. the third floor medication room was observed with LPN #4. The following items were found:-There was one 2 milligram (mg) per 3 milliliter (ml) subcutaneous Ozempic injector stored in an appropriately labeled medication box; however, the individual medication pen-injector inside was not labelled with the resident's name or the date the medication was opened for Resident #92.-There was one 4 mg per 3 ml subcutaneous Ozempic injector stored in an appropriately labeled medication box; however, the individual medication pen-injector inside was not labelled with the resident's name or the date the medication was opened for Resident #35.On 1/29/26 at 12:28 p.m. medication cart #2 on the third floor was observed with LPN #4. The following item was found:-There was one LubriFresh P.M. ophthalmic ointment stored in an appropriately labeled medication box; however, the individual medication tube inside was not labelled with the resident's name or the date the medication was opened for Resident #95.III. Staff interviewsThe assistant director of nursing (ADON) was interviewed on 1/29/26 at 11:53 a.m. The ADON said she understood that medication bottles should be labelled inside their respective medication boxes. She said the medication inside the box should be labelled because if the box were to get damaged, the nursing staff would know who the medication was intended for.LPN #4 was interviewed on 1/29/26 at 12:28 p.m. LPN #4 said the medication bottles should be labelled inside their respective medication boxes to prevent confusion if the medication boxes were to be destroyed.

Based on observations, record review and interviews, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for one of three shower rooms, 12 of 22 sample resident room sinks and one (#2) of four residents reviewed for accident hazards out of 52 sample residents.Specifically, the facility failed to:-Ensure the water in facility shower rooms had safe bathing temperatures and staff had adequate monitoring equipment; and,-Ensure certified nurse aide (CNA) #5 transferred Resident #2 appropriately, which resulted in a fall for the resident. Findings include: I. Water temperature failures A. Facility policy and procedure The Water Temperatures policy and procedure, revised [DATE], was received from the nursing home administrator (NHA) on [DATE] at 6:35 p.m. It read in pertinent part, Tap water in the facility shall be kept within a temperature range to prevent scalding of residents. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120 degrees Fahrenheit (F). Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log. If at any time water temperatures feel excessive to the touch, staff will report this finding to their immediate supervisor. 2. Observations Water temperatures from random resident rooms and common areas were checked on [DATE] and found the following: At 10:05 a.m. the temperature of the hot water in room [ROOM NUMBER] was measured and found to be 133 degrees F. At 12:46 p.m. the temperature of the hot water in room [ROOM NUMBER] was measured and found to be 118.6 degrees F. At 12:54 p.m. the temperature of the hot water in room [ROOM NUMBER] was measured and found to be 125.2 degrees F. At 1:03 p.m. the temperature of the hot water in room [ROOM NUMBER] was measured and found to be 122.5 degrees F. At 1:20 p.m. the temperature of the hot water in room [ROOM NUMBER] was measured again and found to be 126.9 degrees F. At 1:23 p.m. the temperature of the hot water in room [ROOM NUMBER] was measured and found to be 122.4 degrees F. At 1:33 p.m. the temperature of the hot water in room [ROOM NUMBER] was measured and found to be 126.7 degrees F. At 1:37 p.m. the temperature of the hot water in room [ROOM NUMBER] was measured and found to be 121.1 degrees F. At 1:43 p.m. the temperature of the hot water in room [ROOM NUMBER] was measured and found to be 124.7 degrees F. 3. Facility's water temperature monitoring and documentation The facility's water temperature check log was provided by the NHA on [DATE]. The logs documented weekly monitoring of water temperatures in the three facility showers, three resident rooms, the kitchen and the laundry rooms. The log revealed the following: Water temperatures were measured on each floor of the building once per week from [DATE] through [DATE]. The facility water temperature in one of the resident rooms or shower rooms was measured to be below 100 degrees in three of the 11 instances recorded during this period. On [DATE] the water temperatures in the 2nd floor, 3rd floor, and 4th floor shower rooms were measured to be 114.5, 113.6 and 114.3 degrees F respectively. On [DATE] the water temperatures in the 2nd floor, 3rd floor, and 4th floor shower rooms were measured to be 115.3, 115.2 and 114.5 degrees F respectively. On [DATE] the water temperatures in the 2nd floor, 3rd floor, and 4th floor shower rooms were measured to be 116.5, 115.7 and 116.2 degrees F respectively. On [DATE] the water temperatures in the 2nd floor, 3rd floor, and 4th floor shower rooms were measured to be 116.5, 116.2 and 115.8 degrees F respectively. 4. Maintenance director interview and observations The maintenance director (MTD) was interviewed on [DATE] at 2:35 p.m. The MTD said the temperatures in his water maintenance logs typically ranged from 114 to 117 degrees F. The MTD said he checked each floor's water temperatures by measuring the temperatures in the shower rooms and one to two resident rooms per floor each week. The MTD said he also checked the water temperatures as needed if anyone reported any concerns. The MTD said he assessed the water temperature by letting the showers run for five minutes, and checked the temperature at first and after the five-minute mark. The MTD said he wanted the water temperatures to stay below the 120 degree F safe bathing threshold. The MTD said he checked the shower and room water temperatures with the same temperature probe each week. The MTD said the facility had recently had maintenance performed on its boiler due to issues with the facility's heat registers, but was not sure when the work was conducted. The MTD director was observed collecting the following water temperature measurements: On [DATE] at 2:43 p.m. the temperature of the shower room on the 400s hallway was measured at 116.6 degrees F. At 2:47 p.m. the hot water temperature in room [ROOM NUMBER] was measured at 118.4 degrees F. At 2:49 p.m. the hot water temperature in room [ROOM NUMBER] was measured at 126.8 degrees F. The MTD said the water was running hot and said he would address the issue right away. At 2:54 p.m. the hot water temperature in room [ROOM NUMBER] was measured at 123.8 degrees F. The MTD said the temperature of the water in the sink had jumped up really fast. At 3:02 p.m. the hot water temperature for the 300s floor shower room was measured at 116.6 degrees F. At 3:03 p.m. the hot water temperature in room [ROOM NUMBER] was measured at 122 degrees F. At 3:09 p.m. the hot water temperature in room [ROOM NUMBER] was measured at 123.8 degrees F. At 3:12 p.m. the hot water temperature in room [ROOM NUMBER] was measured at 114.8 degrees F. At 3:02 p.m. the hot water temperature for the 200s floor shower room was measured at 113 degrees F. At 3:20 p.m. the hot water temperature in room [ROOM NUMBER] was measured at 120.2 degrees F. At 3:24 p.m. the hot water temperature in room [ROOM NUMBER] was measured at 114.8 degrees F. At 3:27 p.m. the hot water temperature in room [ROOM NUMBER] was measured at 114.8 degrees F. 5. Staff interviews Certified nurse aide (CNA) #1 interviewed on [DATE] at 1:52 pm. CNA #1 said when assisting residents with bathing, he first tested the water temperature on his hand before the resident came into contact with the water. CNA #1 said he would then adjust the water and ask the resident if they felt comfortable with the temperature before proceeding. CNA #1 said if he could not adjust the temperature until it was comfortable, he would bathe the resident with wet wipes. CNA #1 said he would inform his supervisor and the maintenance staff immediately if there were any issues with the water temperatures. CNA #1 said he thought the maintenance staff checked the water temperature daily with a thermometer. CNA #2 was interviewed on [DATE] at 1:57 p.m. CNA #2 said when she was assisting residents with bathing, she checked the water temperature herself first and asked the resident to see if they were comfortable and if they were alert prior to bathing them. CNA #2 said if the resident was not alert or able to communicate, she would go slowly and relied on the resident's facial expressions and body language to determine if she needed to adjust the water temperature. CNA #2 said if she could not adjust the water to a comfortable temperature she would stop the shower and explain to the resident that they may need to perform a bed bath, then call maintenance and put in a work order to fix the bathing temperature issue. CNA #3 was interviewed on [DATE] at 2:50 p.m. CNA #3 said when assisting residents with bathing, she first checked the water temperature with the back of her hand, and asked the resident to touch the temperature to see if they were comfortable. CNA #3 said she sometimes checked the water temperature prior to bathing if a thermometer was available in the shower room. CNA #3 said she thought the maintenance staff checked the temperature in the shower rooms every once in a while. CNA #3 said she had not heard any concerns from residents regarding the bathing temperature being too hot or too cold. The NHA was interviewed on [DATE] at 3:45 p.m. The NHA said the MTD checked water temperatures weekly and the water temperatures he had measured were all below 120 degrees F. The NHA said she had received a grievance regarding cold showers, so she had also been checking the water temperatures in the shower rooms. The NHA said in that instance, the cold shower issue had not been that the water was too cold, but that the hot water was not staying consistent throughout the resident's showers. The NHA said she had a company come out to fix the issue shortly thereafter, and it had turned out to be an issue with the facility's water pump. The NHA said they had currently had some construction occurring in the same area as the facility's water pump and wondered if the construction workers may have bumped into or hit the water mixer and accidentally adjusted it. The NHA said the facility staff were going around to check the residents' water temperatures every fifteen minutes since the water temperature issues were identified and the water temperatures observed on [DATE] were out of their normal range. The NHA said she had never seen the water temperatures so high. The NHA said the facility staff were also interviewing any residents who had showers on [DATE] about their water temperatures. The NHA said if they had found higher water temperatures during their weekly audits it would have come up in the quality assurance process, but it had not been an issue in the quality assurance meetings she had been a part of. The NHA said she would not want anyone to burn themselves in the shower, and said the residents in the facility had not had any burns or skin issues related to hot water. The NHA said she did not think it was sufficient to check just one room on each floor, so going forward the MTD would check the water temperature for two rooms on each floor along with the shower rooms. The NHA said the nurses had an emergency kit with a thermometer in it but did not always have a thermometer available in the shower room to test the residents' bathing temperatures. The NHA said the CNAs always tested the water on their own hands and would have the resident test the water temperature to ensure it was comfortable for them prior to bathing. II. Fall management failures A. Facility policy and procedure The Fall Management System policy, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 6:35 p.m. It read in pertinent part, It is the policy of this facility to provide an environment that remains free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. B. Resident #2 1. Resident status Resident #2, age greater than 65, was admitted on [DATE] and expired on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included cauda equina syndrome (dysfunction of the collection of nerves at the end of the spinal cord), right sided hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke), colostomy and malignant neoplasm (cancer) of the bladder. The [DATE] minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was dependent on nursing staff for toileting, chair-to-bed transfers and she turned side to side in bed with staff assistance. 2. Record review A review of Resident #2's electronic medical record (EMR) revealed the resident sustained a witnessed fall in her room on [DATE] at approximately 10:00 a.m. The [DATE] incident report, provided by the director of nursing (DON) on [DATE] at 5:59 p.m., revealed a CNA reported during the morning transfer the resident's legs gave out and the resident began to slide down the edge of the bed. The CNA lowered Resident #2 down to the ground. According to the incident report, the physician, nurse manager and family were notified, and Resident #2 did not sustain injuries from the fall. -However, the incident report failed to indicate which CNA was involved in Resident #2's fall. Further review of Resident #2's EMR revealed the CNA who worked with the resident on [DATE] was CNA #5. Resident #2's comprehensive care plan, initiated on [DATE] and revised on [DATE], revealed the resident was at risk for falls and has had an actual fall related to impaired mobility, weakness, pain, cauda equina syndrome, asthma, history of cerebrovascular accident (CVA; stroke), sciatica (compression of the sciatic nerve), fibromyalgia (chronic pain disorder) and apraxia (difficulty producing speech). A pertinent intervention, initiated on [DATE], included staff education on the use of the gait belt for transfers and two-person assist due to the resident's severe weakness from cauda equina syndrome. Resident #2's EMR revealed the resident's fall risk assessment score on admission was low, with a score of five. After Resident #2 sustained the fall on [DATE], the fall risk assessment was repeated and determined an at risk score of 10. The [DATE] fall interdisciplinary team (IDT) progress note documented a new intervention to be implemented of two-person assistance for transfer with staff. -However, according to the fall care plan, the intervention for Resident #2 to become a two-person assist for transfers with staff was initiated on [DATE]. C. Staff interviews CNA #5 was interviewed on [DATE] at 2:33 p.m. CNA #5 said she was involved in Resident #2's assisted fall. She said she prepared to transfer Resident #2 from the bed to the wheelchair. She said the resident looked wobbly and weak, so she attempted to sit Resident #2 on the bed. CNA #5 said the resident was seated on the edge and had to be assisted to the ground. CNA #5 said Resident #2 was wearing non-slip socks and a gait belt when she attempted to independently transfer the resident from the bed to her chair. She said Resident #2 usually required one-person staff assistance to transfer. The DON was interviewed on [DATE] at 2:46 p.m. The DON said when a fall was sustained by a resident, the staff should try to determine the root cause of the fall with an IDT approach. She said the initial response should include making sure the resident was safe and could access their call light. The DON said the care plan should be updated when new interventions. She said after Resident #2's fall on [DATE] the fall care plan was revised with new interventions, including the two-person assist with transfers. The DON said she was unable to determine if a two-person transfer occurred at the time of the fall. The DON was interviewed again on [DATE] at 4:13 p.m. The DON said CNA #5 transferred Resident #2 independently on [DATE]. She said CNA #5 did not know Resident #2 became a two-person assist with transfers. She said the new intervention that was implemented after Resident #2's fall on [DATE] of the resident becoming a two person transfer was not transcribed onto the CNA tasks, which led to CNA #5's lack of knowledge of the resident's current transfer status.

Based on observations, record review and interviews, the facility failed to ensure the medication error rate was not greater than five percent (%).Specifically the facility's medication error rate was 7.69%, or two errors out of 26 opportunities for error. Findings include:I. Facility policy and procedureThe Medication Administration policy, revised October 2025, was provided by the nursing home administrator (NHA) on 2/2/26 at 6:35 p.m. It read in pertinent part, It is the policy of this facility that medications shall be administered as prescribed by the attending physician. Medications may not be set up in advance and must be administered within one hour before or after their prescribed time. Should a drug be withheld, refused or given other than at the scheduled time it should be appropriately documented on the medication administration record (MAR).II. Resident #86A. ObservationOn 1/28/26 at 9:34 a.m. licensed practical nurse (LPN) #2 prepared to administer medications to Resident #86. LPN #2 dispensed the resident's medications into a medication cup, including a pantoprazole sodium (medication used to treat excess acid in the stomach) delayed release 40 milligram (mg) oral tablet.LPN #2 administered the medications to Resident #86, including the 40 mg pantoprazole sodium tablet.-LPN #2 administered the incorrect dose of pantoprazole sodium to Resident #86 (see physician's order below).B. Record reviewReview of Resident #86's January 2026 computerized physician orders (CPO) revealed the following physician's order:Protonix (pantoprazole sodium) tablet delayed release 20 mg every day for heartburn.C. Staff interviewLPN #2 was interviewed on 1/28/26 at 10:49 a.m. LPN #2 said she would look at the resident's orders in the MAR while dispensing medications to make sure she followed the five rights of medication administration: right name, right time, right dosage, right route and accurate documentation. She said it was important to compare the medication order to the medication she was dispensing because the orders changed frequently, and the nursing staff would not know if the dose had changed.LPN #2 said pantoprazole sodium was indicated for heartburn and she did not realize that she administered the incorrect dose to Resident #86. She said if a resident received the incorrect dose of a medication, the resident could have side effects. LPN #2 said once someone notified her of her mistake, or she became aware of a mistake, she would call the physician to notify them of the error and complete a change of condition form as appropriate.III. Resident #118A. ObservationOn 1/29/26 at 8:17 a.m. registered nurse (RN) #2 prepared to administer medications to Resident #118, including Brimonidine tartrate ophthalmic solution (a medication used to treat glaucoma) 0.2 % eye drops.Resident #118 self-administered the Brimonidine eye drops with RN #2's supervision.Resident #118 self-administered two drops of the Brimonidine eye drops to the left eye independently.-RN #2 failed to instruct the resident to administer one drop to the left eye prior to Resident #118's self-administration of the Brimonidine eye drops (see physician's orders below).B. Record reviewReview of Resident #118's January 2026 CPO revealed the following physician's order:Brimonidine tartrate ophthalmic solution 0.2%, one drop to the left eye twice a day for ocular hypertension.-Review of Resident #118's electronic medical record (EMR) revealed a self-administration assessment had not been completed at the time of the observation.Cross reference F554: failure to an assessment was completed prior to the self-administration of medications. C. Staff interviewsRN #2 and the assistant director of nursing (ADON) were interviewed together on 1/29/26 at 12:11 p.m. RN #2 said she thought Resident #118's Brimonidine order was for two drops in the left eye because the resident had two different eye drop medications on the MAR. After she looked at the MAR, RN #2 said she was incorrect and the Brimonidine order was for one eye drop in the left eye.

Based on record review and interviews, the facility failed to provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being for two (#9 and #113) of seven residents reviewed for behavioral and emotional status out of 52 sample residents.Specifically, the facility failed to:-Identify and implement person-centered interventions after an assessed decline in mood and history of trauma for Resident #9; and,-Coordinate timely necessary behavioral, mental and emotional health care and services for Resident #113 after the resident expressed suicidal ideation. Findings include:I. Facility policy and procedureThe Behavioral Health Services policy and procedure, revised October 2025, was received from the nursing home administrator (NHA) on 2/2/26 at 6:35 p.m. It read in pertinent part, Trauma survivors will receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. The Social Service designee will also meet with resident and/or resident representative and attempt to identify possible psychosocial issues and needs that may be causing the behaviors or having an impact on resident's function, mood, and cognition. The plan of care will include non-pharmacological interventions and individualized, person-centered care approaches as well as trauma-informed approaches in accordance with resident's customary routines, with input from the resident and/or resident representative. Residents whose assessment did not reveal a diagnosis of mental or psychosocial adjustment difficulty, history of trauma, or post-traumatic stress disorder (PTSD) will have a plan of care developed to prevent a pattern of decreased social interaction and/or increased withdrawn, angry or depressive behaviors, unless the resident's clinical condition demonstrates that development of such pattern was unavoidable.II. Resident #9A. Resident statusResident #9, age less than 65, was admitted on [DATE]. According to the January 2026 computerized physician orders (CPO), diagnoses included type 2 diabetes, alcohol use with unspecified alcohol-induced disorder, unsteadiness on feet and need for assistance with personal care.The 11/9/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15.The PHQ-9 (patient health questionnaire for depression) assessment documented the resident had poor appetite or overeating in two to six days over the 14 day look-back period for the assessment. The assessment documented the resident had little interest or pleasure in doing things nearly every day of the 14 day look-back period for the assessment. The resident had a score of four out of 30 on the assessment, which indicated minimal depression.B. Record reviewThe cognition care plan, revised 11/5/25, revealed Resident #9 was at risk for impaired cognitive function or impaired thought processes due to his diabetes diagnosis, alcohol abuse and pain. Pertinent interventions included monitoring and documenting any changes in cognitive function and social services providing psychosocial support as needed.The language care plan, revised 11/5/25, revealed Resident #9 was at risk for a communication problem due to a language barrier as the resident spoke only Arabic. Pertinent interventions included providing a translator as necessary, using a translation tablet to communicate with the resident, and monitoring and recording any decline in cognitive status or mood.The psychosocial care plan, revised 11/14/25, revealed Resident #9 was at risk for psychosocial wellbeing problems due to his history of alcohol abuse and admission to the facility. Pertinent interventions included assisting, encouraging and supporting Resident #9 with setting realistic goals, allowing the resident time to answer questions and to verbalize his perceptions and fears, and removing the resident when conflict arose to a calm safe environment.The mood problem care plan, revised 11/5/25, revealed Resident #9 was at risk for a mood problem due to his history of alcohol abuse. Pertinent interventions included encouraging Resident #9 to express his feelings, monitoring and recording any mood patterns including signs/symptoms of depression, anxiety or sad mood, and monitoring and reporting to the physician any acute episodes of loss of pleasure or interest in activities, changes in appetite, and feelings of worthlessness or guilt.-Review of Resident #9's comprehensive care plan did not reveal any documentation of the resident's trauma history, nor any person-centered interventions related to his mood or behavior.A physician note, dated 11/3/25 at 3:00 p.m., revealed Resident #9 was to continue outpatient psychiatric therapy for his alcohol use disorder and depression. Resident #9 had a significant increase in alcohol use from February 2025 due to grief from the murder of his family in [NAME], and he was unable to mourn or process his grief effectively. Resident #9 had a history of refusal of psych meds and services, and the physician's plan included monitoring of the resident's mood and behavior and offering behavioral health services as needed.The 11/5/25 PHQ-9 documented the resident had poor appetite or overeating in two to six days, had little interest or pleasure in doing things nearly every day of the 14 day assessment period.The assessment documented the resident had minimal depression with a score of four out of 30.The 11/5/25 social services admission assessment documented Resident #9 did not have any psychosocial needs and did not have any history of trauma. The assessment documented the resident requested a translator when speaking with his physician as he primarily spoke Arabic. The assessment documented Resident #9 had mild cognitive impairment and had minimal depression.-However, according to the physician progress notes dated 11/3/25, the resident had a history of trauma related to the murder of his family in [NAME] and had significant alcohol use due to his grief.The 12/10/25 PHQ-9 revealed the resident had little interest or pleasure in doing things increased to nearly every day, felt tired or had little energy for half or more of the days, felt bad about himself nearly every day and felt he was moving or speaking slowly or was restless/fidgety on half or more days during the 14 day assessment period.Resident #9's depression score increased to 10 out of 30, which indicated he had moderate depression.A social services assessment, dated 12/12/25, revealed Resident #9 was reviewed by the social services team for his quarterly evaluation. The assessment documented Resident #9 did not have any psychosocial needs and did not have any history of trauma. The assessment documented the resident did not request a translator when speaking with his physician. The assessment documented Resident #9 was cognitively intact and had moderate depression.-However, Resident #9 had an increase in his assessed depression from mild to moderate and had a documented history of trauma. The resident's medical record did not reveal documentation that the facility had intervened when the resident's depression had worsened.C. Staff interviewsThe social services director (SSD) and social services assistant (SSA) were interviewed together on 1/29/26 at 10:07 a.m. The SSD said mood assessments were conducted when the resident was admitted , quarterly, if the resident had any change in condition or reported they were having a rough day, and at discharge. The SSD said they offered behavioral health services to residents when first admitted and documented whether the resident declined them. The SSD said if a resident's PHQ-9 depression assessment score declined, the social services staff would offer behavioral health services and psychosocial support to the residents, contact family for support and document the resident's response in the social services assessment.The SSA said Resident #9 did not leave his room very often. The SSA said Resident #9 was fairly neutral in mood, and was very nice and welcoming whenever she went into his room. The SSA said she had not seen any tearfulness or sadness from Resident #9 and said the resident had not complained to the social services team about anything. The SSA said Resident #9 did not have any history of trauma. The SSD said Resident #9 reported minimal depression during his initial assessment upon admission.The SSA said Resident #9 had moderate depression according to his mood assessment on 12/10/25. The SSA said she had not conducted the PHQ-9 with Resident #9 and was unsure what steps were taken when his score increased to indicate he went from mild to moderate depression on 12/10/25.Both the SSA and SSD said the residents' mood and behavior care plans had person-centered non-pharmacological interventions.The SSA said Resident #9's care plan included interventions such as encouraging the resident to express his feelings and to monitor and record his mood. The SSA said taking walks helped Resident #9 feel better, but otherwise the resident kept to himself and did not like to do much besides going on walks and being in his room.-However, Resident #9's care plan did not document any person-centered interventions related to his mood and behavior (see record review above). Certified nurse aide with medication authority (CNA-Med) #1 was interviewed on 1/29/26 at 10:59 a.m. CNA-Med #1 said Resident #9 stayed in his room most of the time, was a nice person but felt alone. CNA-Med #1 said she tried to get offer snacks and encouraged him to get out of his bed and talk to people. The director of nursing (DON) and assistant director of nursing (ADON) were interviewed together on 1/29/26 at 4:15 p.m. The DON said Resident #9 spoke a little bit of English but primarily spoke Arabic. She said a translation application on a tablet was used to communicate with Resident #9.The ADON said Resident #9 was not happy with being at the facility when he was first admitted , but became okay with being there over time. The ADON said they had to move the resident to the long-term care floor of the facility, which made Resident #9 a little sad. The ADON said she was not aware of any history of trauma for Resident #9. The DON said Resident #9 had a history of alcohol abuse and had a care plan for a mood problem related to his alcohol abuse. The ADON confirmed the physician's progress note discussed Resident #9's grief from the murder of his family in [NAME] and that he was unable to express his grief. The DON confirmed the information regarding the resident's trauma and grief was not included in the resident's comprehensive care plan. The DON said for residents with histories of trauma behavioral health services should be offered. The DON said she would create a trauma-informed care plan for Resident #9. The DON said if a resident was having mood issues the staff could also put the resident on behavior tracking even if they were not on any behavioral medications.III. Resident #113A. Resident statusResident #113, age greater than 68, was admitted on [DATE] and passed away on 11/9/25. According to the November 2025 CPO, diagnoses included speech and language deficits following cerebral infarction (stroke), muscle wasting, malignant neoplasm (cancer) of bone, and spinal stenosis (narrowing of spaces in the spine commonly causing pain, numbness, and weakness in the back, neck, legs, or arms).The 9/29/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15.The assessment indicated the resident had no behaviors. A PHQ-9 assessment was not conducted at the time.B. Record reviewThe cognitive function care plan, initiated 8/15/25, revealed Resident #113 was at risk for impaired cognitive function or impaired thought processes due to pain, medication side effects and history of stroke. Pertinent interventions included administering medications as ordered, monitoring and documenting any changes in cognitive function including memory and mental status, and social services providing psychosocial support as needed.The mood care plan, initiated 8/27/25, revealed Resident #113 had a potential for mood problems due to his admission to the facility and decline in his ability to perform tasks of daily living. Pertinent interventions included monitoring, documenting and reporting to the physician any mood patterns including signs or symptoms of depression, anxiety or sad mood and encouraging the resident to express his feelings.The depression care plan, initiated 8/19/25, revealed Resident #113 was at risk for depression due to a PHQ-9 score of 13 out of 30. Pertinent interventions included encouraging the resident to express his feelings and offering mental and behavioral health support as needed.The 8/18/25 PHQ-9 revealed Resident #113 had trouble falling or staying asleep, felt tired or had little energy and moved slowly or was fidgety/restless nearly every day and felt down, depressed or hopeless and felt bad about himself more than half of the days during the 14 day assessment period.The assessment documented the resident had a score of 13 out of 30, indicating moderate depression.The 9/30/25 quarterly PHQ-9 documented the resident's depression score increased to 14 out of 30.A social services assessment, dated 12/12/25, revealed Resident #113 was reviewed by the social services team for his quarterly evaluation. The assessment documented the resident did have psychosocial needs as he scored a 14 on his mood assessment, however the resident declined mental and behavioral health services.A progress note, dated 10/16/25 at 10:07 a.m., revealed Resident #113 had weight loss likely resulting from his cancer progression. The registered dietician and physician's assistant met with the resident to discuss his overall health decline and his not wanting to go to his oncology follow-up appointment. Resident #113 elected to pursue comfort care at the time without further oncology intervention.A physician progress note, dated 10/16/25 at 11:01 a.m., revealed the physician was informed by the DON that Resident #113 was refusing and canceling his upcoming oncology appointment. Resident #113 was more accepting of his progressive decline in health and the severity of his condition. The resident was aware of his poor prognosis due to his recent significant loss in function to his spine and both lower extremities, and continued to request to stop pursuing cancer treatment. Resident #113 was agreeable to a comfort care focus. A progress note, dated 10/23/25 at 11:41 a.m., revealed Resident #113 was at a high risk for skin breakdown due to his mobility issues and diagnosis of advancing cancer. Resident #113 would be transitioning to long-term care as he could no longer manage his self care. Resident #113 was considering palliative care as he was not ready to make the decision for hospice at the time.A progress note, dated 11/3/25 at 9:55 a.m., revealed the day prior (11/2/25) Resident #113 reportedly verbalized his wishes to end his life. On 11/3/25 when the nursing staff talked with Resident #113 about his statement the day prior, the resident said he realized his right arm was useless and knew his left arm would be the same soon and he would not be able to move. Resident #113 said he could not live like that and wished to die. When asked how he would accomplish that, Resident #113 said he would just lay in his bed and not eat. Resident #113 said he was comfortable and not in pain and wanted to be left alone. Resident #113 was given his call light but said he soon would not be able to use it.A social services progress note, dated 11/3/25 at 10:13 a.m., revealed a social services staff member spoke with Resident #113 about his suicidal ideation concerns. The social services staff asked Resident #113 who or what was helpful when he was feeling upset, to which the resident said speaking to his sister and having visits from her was helpful.A progress note, dated 11/3/25 at 10:20 a.m., documented Resident #113 said he was going to commit suicide by refusing all of his medications and food. Resident #113 was placed on 15 minute safety checks.-However, it was not documented whether Resident #113's physician was notified at the time.A physician note, dated 11/3/25 at 3:00 p.m., revealed the physician saw Resident #113 for a hospice discussion. Resident #113 reported increased weakness, and acknowledged that without treatment he would likely get worse. Resident #113 reported he was comfortable discussing options with hospice. The note documented the DON would send a hospice referral. The physician's assessment documented the resident did not have any current depressed mood, anxiety or agitation. -The physician note did not document any discussion or review of Resident #113's mention of suicidal ideation on 11/2/25.A physician note, dated 11/5/25 at 2:42 p.m., revealed the physician saw Resident #113 to follow-up on the resident's muscle spasticity and pain management. Resident #113 said his spasms were well controlled and did not feel the need to increase his medication dosage. The note documented the resident did not have any further questions or concerns. The note documented Resident #113's mood was stable and without agitation.-The physician note did not document any discussion or review of Resident #113's mention of suicidal ideation on 11/2/25.Progress notes, dated 11/3/25 at 9:31 p.m. through 11/7/25 at 8:11 a.m. revealed Resident #113 had multiple instances of refusing all medications aside from his as-needed doses of oxycodone (an opioid pain medication).A progress note, dated 11/8/25 at 6:21 p.m., revealed Resident #113 had only eaten his breakfast meal. Resident #113 had refused his lunch and his dinner but had drunk fluids at both mealtimes.A progress note, dated 11/9/25 at 6:36 a.m., revealed Resident #113 was found with no pulse and no respirations at 6:30 a.m. that morning (11/9/25). Resident #113 had complained of pain/discomfort at 2:00 a.m. that morning and had been medicated for his pain. Resident #113 complained of back pain again at 5:00 a.m. that morning, and the nurse on duty repositioned him and said he could receive another dose of pain medication at 6:00 a.m.Review of Resident #113's electronic medical record (EMR) did not reveal any social service follow-up notes, lethality assessments (see interview below), or documentation that behavioral health services were offered following Resident #113's mention of suicidal ideation on 11/2/25.An email from a hospice caseworker, dated 1/28/26 at 6:13 p.m., revealed the hospice company was contacted by the facility's resident services resource on 11/3/25 for Resident #113. The email documented the hospice caseworker received a call from the resident services resource on 11/3/25, who said Resident #113 was having a health decline and stated he was ready to die. On 11/5/25 the hospice service visited the facility and the hospice caseworker and resident services resource spoke with Resident #113 to discuss end of life support. When the hospice caseworker asked Resident #113 about his statements about dying, he denied feeling that way. Resident #113 said he was no longer having a health decline and said he was feeling fine and did not want to die. Resident #113 said he would call the hospice caseworker when he felt like he needed hospice services.C. Staff interviewsThe SSD, SSA and social services resource were interviewed together on 1/28/26 at 4:36 p.m. The SSD said when residents expressed suicidal ideation, the social services department conducted a lethality assessment for the resident, documented it in their EMR, and informed the resident's family and their physician. The SSD said the social services team would create a safety plan with the resident, assess them for mental health triggers, and offer the resident behavioral health services if it was not already in place. The SSD said the triggers, safety plan and offer of behavioral health services were all documented in the lethality assessment.The SSA said Resident #113 initially admitted to the facility for skilled therapy, but had cancer and passed away quickly from his condition. The SSA said Resident #113 was sad because of his disease process and losing his mobility.The SSD and the social services resource said Resident #113 was offered behavioral health services when he first admitted and several times throughout his stay at the facility during each social services assessment.-However, his last documented social services assessment was on 9/30/25 (see record review above).The SSD said after Resident #113 expressed suicidal ideation on 11/3/25, the SSA had spoken to the resident and initiated 15 minute safety checks. The SSA said she did not conducted a lethality screening following Resident #113's suicidal ideation. The SSA said she had notified the interdisciplinary team, the nurses on duty that day and Resident #113's provider following his statement regarding suicidal ideation. The SSA said she had also contacted Resident #113's sister as that was his support person.-However, review of Resident #113's EMR did not reveal any documentation that his sister or physician were contacted regarding his statements of suicidal ideation.The resident services resource was interviewed on 1/29/25 at 9:57 a.m. The resident services resource said she was working in the social services department at the time when Resident #113 was in the facility. The resident services resource said Resident #113's physician was consulted on 11/3/25 after the resident expressed suicidal ideation. The resident services resource said the provider must have been notified, as that would be the only reason the physician would have visited Resident #113 so frequently.-However, the physician documented the reason for visiting Resident #113 on 11/3/25 was to discuss hospice, and the reason for visiting the resident on 11/5/25 was to follow up on the resident's muscle spasticity. The physician's visits did not document any suicidal ideation (see record review above).The resident services resource said she thought the SSA based her course of action based on how Resident #113 was presenting to her at the time, and did not feel like a lethality assessment was needed. The resident services resource said behavioral health resources were offered to Resident #113 on 11/3/25.-However, review of Resident #113's EMR did not reveal any documentation that behavioral health services were offered after the resident expressed suicidal ideation.The resident services resource said Resident #113's health was declining significantly, and he had been making comments indicating he wanted to pass away, but said she did not view it as suicidal ideation.

Based on observations, record review and interviews, the facility failed to ensure the self-administration of medications was clinically appropriate for one (#118) of 10 residents out of 52 sample residents. Specifically, the facility failed to ensure an assessment was conducted to determine whether the self-administration of medications was clinically appropriate for Resident #118. Findings include:I. Resident #118A. Resident statusResident #118, age greater than 65, was admitted on [DATE]. According to the January 2026 computerized physician orders (CPO), diagnoses included third degree burn to the lower legs bilaterally (both legs) and anxiety disorder.The 1/27/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15.B. Resident observation and interviewOn 1/29/26 at 8:17 a.m. registered nurse (RN) #2 prepared to administer medications to Resident #118, including Brimonidine tartrate ophthalmic solution (a medication used to treat glaucoma) 0.2 % eye drops.Resident #118 said he was an adult and he could administer the eye drop to his left eye independently.Resident #118 self-administered the Brimonidine eye drops with RN #2's supervision.Resident #118 self-administered two drops of the Brimonidine eye drops to the left eye independently.C. Record reviewReview of Resident #118's January 2026 CPO revealed the following physician's order:Brimonidine tartrate ophthalmic solution 0.2%, one drop to the left eye twice a day for ocular hypertension.-Review of Resident #118's electronic medical record (EMR) did not reveal documentation to indicate that an assessment had been conducted to determine if Resident #118 was able to safely administer his own medications.Cross referenced F759: failure to ensure the medication error rate was less than 5%.D. Staff interviewRN #2 and the assistant director of nursing (ADON) were interviewed together on 1/29/26 at 12:11 p.m. RN #2 said she was not sure if Resident #118 had a self-administration assessment completed and began to look in the resident's EMR to see if it had been completed.The ADON said Resident #118 did not have a completed self-administration assessment, and only three to four residents in the whole building had a completed assessment. After searching in the resident's EMR, RN #2 agreed the assessment had not been completed. RN #2 said Resident #118 was non-compliant, often refused care and she had heard that if the resident did not like the way she did things then he might become aggressive.The ADON was interviewed again on 1/29/26 at 1:30 p.m. The ADON said she completed a self-administration assessment for Resident #118, contacted the provider to get the resident's eye drop orders to include the resident was able to independently administer medication under supervision and created a progress note which read in pertinent part, the resident was able to independently administer all eye drops under supervision, in accordance with provider instructions. She provided documentation of the changes made to the resident's EMR at that time.-However, the self-administration assessment was not completed until 1/29/26 (during the survey).

Based on observations and interviews, the facility failed to maintain a clean and sanitary homelike environment in one out of three units reviewed. Specifically, the facility failed to ensure the residents experienced a clean and sanitary homelike environment with living spaces free from odors, soiled and damaged floors and walls, chipped paint, clean living common area spaces and availability of clean linens. Findings include: I. Policy and procedures The Quality of Life Homelike Environment policy, revised December 2023, was received from the director of nursing (DON) on 5/16/24 at 6:57 p.m. It read in pertinent part, Staff shall provide person centered care that emphasizes the resident's comfort, independence and personal needs. The characteristics of the homelike environment are: -Clean, sanitary, orderly environment; -Comfortable yet adequate lighting; -Personalized furniture and room arrangements; and, -Clean, bed and bath linens. II. Observations During the survey, from 5/15/24 to 5/16/24, the second floor unit environment common areas were observed on several occasions. The following conditions were observed: -The hallway walls had a thick dried, blackish-brown substance along the bottom of the walls in the hallways. -The floor in the common area outside of the elevator was soiled with bread crumbs, a sticky white substance, and pieces of brown matter. -The dining room tables were soiled with a sticky dried clearish-yellow substance. -There were three large brown recliner chairs observed in the common area. The artificial leather upholstering was cracked and had peeled off on all of the chair's armrests making them impossible to clean and disinfect properly. The seat cushions and leg rests of the chairs had holes in them and the stuffing was coming out. Pieces of the chair remained from the chairs all over the floor. -The dining area just off the elevators had a strong smell of body odor. The floor was heavily soiled under each table with black stains and large areas of a dried clear substance. -The edges of the floor at the wall were heavily soiled with a heavy build-up of a black-colored substance that extended up onto the baseboards of the walls. -The walls in the common area were chipped and gouged across large surfaces and the pain was chipped off the walls. -The nurses' station counter was soiled with dried liquid spills and there was garbage and dried liquid spills on the floor around the nurses' cart. -The flooring tiles in the common area room's corners were chipped and broken with large missing pieces. The countertop used during dining service was soiled and had a large dried brown substance smeared on it. -The hallway walls behind the handrails were soiled as were the handrails which also had chipped paint. The second floor shower room was observed on 5/15/24 at 1:12 p.m., the room was not clean and had been vacant for an hour in the following condition: -The door to the shower room had been left tied open with a garbage bag; -There was standing water on the floor that had flowed out into the hallway just outside of the shower room; -One of the shower chairs' seats had brown matter on it and both shower chair legs had several areas that were covered with a dried brown substance; -There were four different hair brushes in the room containing a heavy amount of hair in the bristles of the brushes. None of the hair brushes were labeled with a resident name; -The floor of the shower room next to the drain had pieces of brown matter remaining from an earlier morning shower. -The floors in rooms #222, #221, #218 and #217 were heavily soiled and covered with a dried sticky substance. -The flooring at the corners of the rooms near the baseboards were heavily soiled with a black substance that extended up the baseboards. The walls were chipped, exposing the white plaster underneath. -The sheets on the resident beds in rooms #221 and #215 were soiled with brown stains and the room smelled of urine and strong body odor that could be smelled in the hallway several doors away. -The privacy curtains in rooms #202 and #204 were stained with dried food and brown, black, and yellow stains. -There were no washcloths or towels available to the residents in rooms #202, #204, #221, #217, #206, #215 and #216. One resident said he had to use paper towels because staff did not provide him with cloth towels and washcloths. -The walls in the residents' bathrooms in rooms #202, #205, #206, #217 #218, #221 and #222 contained a dried brown substance. The flooring in the bathrooms was heavily soiled with a black substance that extended up onto the baseboards and around the base of the toilet. The linoleum floor in the rooms was coming loose and had missing pieces of flooring. -room [ROOM NUMBER] had chipped walls and heavily gouged doors that exposed the material underneath the paint and stained the surface. The built-in dresser in the room had one drawer that was missing the veneer and its pull handle did not match the rest of the unit which stood out. The facing on the front of the sink was broken and a big piece was missing. III. Resident interviews Resident #12 was interviewed on 5/15/24 at 11:41 a.m. Resident #12 said there was no housekeeper working on the second floor that day. She said when the housekeepers took a day off there was no one to replace them to clean. Resident#12 said she usually had to ask the housekeeper to mop her floor two or three times because it rarely came clean with a one-time mopping. She said sometimes the floor was not mopped if she was not in the room to request it get mopped and there had been a recent occasion when the floor in the room was left dirty for several days. Resident #12 said her privacy curtain had not been taken down or washed in a long time and it was dingy and stained. Resident #12 pointed out a red stain on the privacy curtain and said it had been there for weeks. Resident #12 said she was concerned about the lack of cleanliness in her bathroom because it was heavily soiled and no matter how much the housekeeper cleaned it, it never came clean. Resident #12 said there was talk of renovations from the facility's management but she was not confident it would happen soon because the facility had been talking about completing renovations for several years. Resident #12 said the resident council had been complaining about poor housekeeping practices and a need to repaint and repair several damaged walls and floors throughout the facility. The resident council wanted the facility to put more effort into improving the facility environment. The resident said facility leadership had promised the resident council for the past year that they would renovate the facility but the only unit that was renovated was the short term rehabilitation unit. Resident #15 was interviewed on 5/15/24 at 11:50 a.m. Resident #15 said her room was not cleaned on a daily basis because the facility had trouble keeping staff. She said the most concerning thing was the dirty floor. She said the floor was left soiled for days sometimes when they didn't have a housekeeper or when the housekeeper was running behind. IV. Record review Resident council minutes, dated 5/7/24, read in pertinent part: Housekeeping: The second-floor housekeeper needs training. -Previous minutes were not available because the facility accidentally shredded the originals and did not have any other copies of the resident council minutes. V. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 5/16/24 at 12:30 p.m. CNA #1 said the shower floor was dried by propping the door open. CNA #1 said the shower room and the hair brushes were cleaned by the housekeepers. She said it was the housekeeper's responsibility to clean the shower room. (The housekeeper was not available to answer questions about the shower room.) Housekeeper (HSK) #1 was interviewed on 5/16/24 at 1:00 p.m. HSK #1 said she cleaned each of the residents' rooms in her assigned area every day. She said she started by cleaning the back of the room and moving forward to the front of the room. HSK #1 said she sprayed down and cleaned the resident's bedside table furniture and then cleaned the call light, the pull cord for the room light, the door handles and then moved to the bathroom to clean the sink and toilet. HSK #1 said then she swept and mopped the room. HSK #1 said it was hard to get the floors clean, especially at the edges of the room because the dirt did not come up with regular mopping. HSK#1 said she had a scraper to remove stuck on dirt but that did not work well to get the residents' room floors clean and she did not know what else to use to clean the floors and baseboards which were also heavily soiled. HSK #1 said the privacy curtains in the residents' rooms were supposed to be taken down every two to three days and sent to be washed. She said since it required a ladder to remove the curtains, the maintenance department had to help with the process. HSK #1 said she swept and mopped the floors in the common areas daily but they were heavily soiled and the areas did not come completely clean. The maintenance director (MTD) and the housekeeping supervisor (HSKS) were interviewed on 5/16/24 at 1:15 p.m. The MTD said he had identified the second floor maintenance and housekeeping issues and the facility had a plan to renovate the unit with paint and refreshed flooring. He said he observed the heavy dirt build up on the floors in residents' rooms and common areas and, because someone had rewaxed the floors without properly cleaning them, they were unable to remove the soiled buildup without stripping the floors first. The MTD said the facility hired a floor technician to strip and re-wax all of the flooring on the second and third floors but that process would take a couple of weeks to complete. The MTD said the residents' room walls were in the renovation plan due to a need to repair the chipped and scraped walls. The MTD said the privacy curtains were taken down and washed when the resident's room was deep cleaned (quarterly) with the deep clean. He said the leadership staff had talked about putting the privacy curtains on a more frequent cleaning schedule but that was not yet in place. The MTD said there was a schedule for daily cleaning in every resident room and a schedule for a deeper cleaning once a quarter. He said the second floor was the most problematic and hard to maintain. The MTD said there were several larger maintenance environment improvement projects occurring, such as window washing, and the facility planned to repaint all of the walls on the second floor. The HSKS said she recently took over the role as HSKS and she had recognized some housekeeping concerns. The HSKS said the residents' rooms were to be cleaned daily but they struggled to keep housekeeping staff so they were revising housekeeping services to ensure the resident areas were cleaned properly. The HSKS said housekeepers could remove dirty sheets if the resident was not in the room. She said maintenance of linens was the responsibility of the nursing staff. The MTD presented the facility's plan of improvement for facility cleanliness and said they had identified maintenance and housekeeping concerns and were currently working on improvements. The plan included creating an HSKS position because, per the MTD, he was unable to keep up with his identified concerns. The plan revealed that the facility had identified the following opportunities for an improved home-like environment and the facility had just started on the improvement. The plan documented: Action Plan Facility Cleanliness: Issues Identified: After receiving several complaints (from Google reviews, hospital case managers, families and residents) the facility completed a review of the complaints and identified the following issues: -Areas where dirt is in the corners and on the flooring where the wall meets the floor; -Flooring on the fourth floor in several rooms with scratches in the vinyl flooring; -Elevators are dirty and outdated; -Leaves and debris outside of the front door; -Radiators in the room with panels coming off; and, -Areas that paint needs to be retouched. The plan also identified a need for new roles for maintenance and staffers. -However, the facility improvement plan did not address all identified areas of concern observed during the survey from 5/15/24 to 5/16/24 (see observations and interviews above). 42193

Based on observations, record review and interviews, the facility failed to ensure one (#5) of two residents who required respiratory care received the care consistent with professional standards of practice out of 30 sample residents. Specifically, for Resident #5 the facility failed to: -Ensure a physician's order was in place for oxygen therapy; -Ensure a care plan was in place to include oxygen route, frequency, and liters required; and, -Accurately complete section O in the comprehensive minimum data set (MDS) assessment under respiratory treatments. Findings include: I. Facility policies and procedures The Oxygen Management policy, revised March 2019, was provided by the Director of Nursing (DON) on 11/13/23 at 1:31 p.m. The policy revealed in pertinent part: It is the policy of this facility that oxygen therapy is administered, as ordered by the physician or as an emergency measure until the order can be obtained. The purpose of the oxygen therapy is to provide sufficient oxygen to the bloodstream and tissues. Procedures for oxygen therapy to include: -Obtain appropriate physician's orders. -Identify residents. -Explain procedure. -Gather necessary equipment -Provide privacy for resident. -Wash hands properly. -Assemble the oxygen unit and flowmeter, making sure all connections are secure. -If using a reusable humidifier, fill the bottle to the correct level with distilled water and attach it to the oxygen unit. -Attach the oxygen delivery device to the oxygen unit. -Turn the unit on to the desired flow rate, and assess equipment for proper functioning: Airflow should be felt through the oxygen delivery device. Bubbles should be seen diffusing through the humidifier bottle. -If no evidence of oxygen flow, check connections and tubing for leaks. -Review the resident's care plan to evaluate for any special needs of the resident. II. Resident #5 status Resident #5, age above 65, was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO), fracture of unspecified parts of lumbosacral spine and pelvis, subsequent encounter for fracture with routine healing, nonrheumatic aortic (valve) stenosis, pulmonary hypertension, unspecified, pleural effusion, not elsewhere classified. The 10/25/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 14 out of 15. He had no behaviors and did not reject care. He required substantial/maximal assistance with personal hygiene and moderate assistance with mobility, however ambulation was not attempted due to medical condition or safety concerns. -The use of oxygen therapy was not coded on the MDS assessment under section O. III. Resident interview and record review A. Resident interview Resident #5 was interviewed on 11/7/23 at 1:00 p.m. He said he has been on oxygen since he was admitted and the tubing was changed weekly. B. Record review The medical record was reviewed on 11/7/23 and it revealed the resident did not have an order for the use of his oxygen. The care plan was reviewed on 11/7/23 and it revealed the use of oxygen therapy was not listed on the care plan as an active problem area. The care plan did not have goals and interventions listed for oxygen therapy. C. Observations Resident #5 was observed on 11/6/23, 11/7/23, and 11/8/23 from 9:00 a.m. to 5:00 p.m. His oxygen concentrator was set for 2 liters via a nasal cannula. IV. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 11/8/23 at 12:30 p.m. She said she would ask the nurse how many liters of oxygen a resident should be on. She said the nurse would look at the resident's order to clarify the liters to be used. Licensed practical nurse (LPN) #1 was interviewed on 11/8/23 at 12:35 p.m. She said she would look at the resident's order to see how many liters they should be using. She looked at Resident #5's medical record and said there was no physician's order for the use of his oxygen. She said there should have been a physician's order to include the liters, the route and the frequency. She said the oxygen should have been addressed in his care plan and the MDS assessment should have reflected the resident is on oxygen therapy. She said Resident #5 was on 2 liters since admission to the facility. The DON was interviewed on 11/13/23 at 9:36 p.m. She said all residents using oxygen should have an order including the liters, the route and the frequency. She said it should have been addressed in his care plan and should have been listed under section O in the MDS assessment. She said the care plan, MDS assessment and physician's order were updated after being identified during the survey process for the resident's oxygen therapy use. The DON said an oxygen inservice training was initiated on 11/8/23 that reviewed oxygen tubing storage, oxygen tubing infection control practices, oxygen tank positioning and physician orders related to oxygen therapy.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure oxygen was administered at the flow rate ordered by the physician to prevent potential complications for 1 (Resident #3) of 3 sampled residents reviewed for respiratory care. Findings included: Review of a facility policy titled, Oxygen Administration, revised November 2021, revealed, It is the policy of this facility that oxygen therapy is administered, as ordered by the physician or as an emergency measure until the order can be obtained. The policy also indicated, Reassess oxygen flowmeter for correct liter flow. Review of an Admission Record revealed Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set, dated dated dated [DATE], revealed Resident #3 had a Brief Interview for Mental Status score of 3, indicating the resident had severe cognitive impairment. According to the MDS, Resident #3 required extensive assistance of two or more people with bed mobility and transfer and received oxygen therapy while a resident. Review of an Order Summary Report revealed Resident #3 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 09/06/2022 at 10:18 AM revealed Resident #3 was receiving oxygen via a nasal cannula connected to an oxygen concentrator. The flow meter on the concentrator was set to deliver oxygen at four liters per minute, instead of one to three liters per minute as ordered by the physician. Observation on 09/07/2022 at 12:03 PM revealed Resident #3 was receiving oxygen at four liters per minute via nasal cannula. During an interview on 09/07/2022 at 12:04 PM, Registered Nurse (RN) #1 stated Resident #3's oxygen was ordered to be administered at three liters per minute. RN #1 observed Resident #3's oxygen concentrator and acknowledged the flow meter was set to four liters per minute. RN #1 reported the resident did not adjust the oxygen him/herself, and the staff were responsible for setting the oxygen flow rate correctly. During an interview on 09/08/2022 at 8:54 AM, Licensed Practical Nurse (LPN) Unit Manager #1 revealed oxygen should be administered as ordered by the physician, and if a resident needed the flow rate increased, the physician should be notified for an order change. LPN Unit Manager #1 acknowledged Resident #3's oxygen was ordered for administration at one to three liters per minute. During an interview on 09/08/2022 at 9:21 AM, the Director of Nursing (DON) indicated nursing staff should be checking every shift to ensure oxygen was being administered as ordered by the physician. The DON revealed it was expected for the staff to administer oxygen according to the orders. During an interview on 09/08/2022 at 4:45 PM, the Administrator revealed it was expected that physician orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure that before a resident was allowed to self-administer medications, the interdisciplinary team (IDT) assessed the resident's ability to safely and accurately do so for 1 (Resident #402) of 1 sampled resident reviewed for self-administration of medications. Findings included: Review of a facility policy titled, Self-Administration by Resident, dated November 2017, revealed, Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe, and the medications are appropriate and safe for self-administration. PROCEDURES: 1. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility, during the care planning process. 2. The interdisciplinary team determines the resident's ability to self-administer medications by means of a skill assessment conducted as part of the care plan process. Review of an Admission Record revealed the facility admitted Resident #402 on 08/30/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a 5-day Minimum Data Set, dated dated dated [DATE], revealed Resident #402 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Review of an Order Summary Report revealed Resident #402 had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] inhaler, two puffs every four hours, as needed for wheezing and shortness of breath. - [MEDICATION(S)] sodium gel 1% to be applied topically to both shoulders four times a day for pain. Observation on 09/06/2022 at 10:41 AM in Resident #402's room revealed a tube of [MEDICATION(S)] sodium topical gel (an anti-[CONDITION(S)]/pain relief medication) on the resident's over-the-bed table. The resident stated he/she applied the [MEDICATION(S)] sodium gel whenever he/she had arm or leg pain. Observation on 09/07/2022 at 12:08 PM in Resident #402's room revealed the tube of [MEDICATION(S)] sodium gel was on the resident's bedside table, along with an [MEDICATION(S)] (a medication used to open the airways) inhaler. Observation on 09/08/2022 at 8:29 AM in Resident #402's room revealed a tube of [MEDICATION(S)] ointment and an [MEDICATION(S)] inhaler on the resident's bedside table. Resident #402 was sitting on the side of the bed in the room. Observation on 09/08/2022 at 8:34 AM in Resident #402's room revealed the [MEDICATION(S)] ointment was on the resident's overbed table. Resident #402 stated he/she used the [MEDICATION(S)] for a sore on his/her foot and for a rash. Per Resident #402, a nurse had come into the room and removed a tube of [MEDICATION(S)] cream but left the [MEDICATION(S)]. Resident #402 stated he/she did not understand why the nurse did this, unless both creams were not supposed to be used at the same time. According to Resident #402, he/she used the [MEDICATION(S)] cream at night for left arm pain and used the [MEDICATION(S)] inhaler once a day. During an interview on 09/08/2022 at 8:38 AM, Registered Nurse (RN) #1 stated all medications were to be administered by a nurse unless the resident had been assessed, monitored for safety, and a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 09/08/2022, Licensed Practical Nurse (LPN) Unit Manager #1, revealed residents who wished to self-administer medications must be assessed for safety and a doctor's order should be obtained. LPN Unit Manager #1 indicated there were currently no residents in the facility who were assessed and care planned to self-administer medications. LPN Unit Manager #1 revealed Resident #402 should not have medications at his/her bedside due to a risk of receiving the wrong dose of medication if not assessed for safety. During an interview on 09/08/2022 at 9:28 AM, the Director of Nursing (DON) revealed a self-administration assessment, care plan, and a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON indicated Resident #402 should not have had medications in his/her room and stated the resident had not been assessed for this. The DON revealed there was an increased risk of medication side effects if Resident #402 was not accurately assessed for safety before being allowed to self-administer medication. The DON indicated in order for a resident to self-administer medications, it was expected that staff would accurately assess and that the interdisciplinary team would verify the resident could administer medications safely. During an interview on 09/08/2022 at 4:46 PM, the Administrator revealed he expected a resident to be evaluated and a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review and interviews the facility failed to ensure residents received care and services ordered by the physician for one (#2) of three residents reviewed for services. Specifically, the facility failed to ensure referrals were followed up and monitored to ensure Resident #2 received services for urology, gastrointestinal (GI) and a sleep study for a continuous positive airway pressure ([MEDICAL CONDITION]) related to sleep apnea. Findings include: I. Facility policy and procedure Review of the referral to outside agency policy, revised November 2017, provided by the director of nurses (DON) on 1/5/21 at 11:50 a.m. revealed The facility ensures that residents receive treatment and care from outside agencies, including specialized rehabilitation services where required, for routine or emergency care in order to meet their psychosocial, medical, nursing and/or concrete needs while safeguarding their protected health information .the business office is consulted to determine if Medicaid will pay for any outside services. II. Resident status Resident #2, age 74, was admitted on [DATE]. According to the January 2021 computerized physician orders [REDACTED]. -No bladder [DIAGNOSES REDACTED]. The 11/2/20 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 15 out of 15. Bladder and bowel were marked as always continent for urinary and bowel. [DIAGNOSES REDACTED]. Oxygen therapy was marked. III. Resident and family interview Resident #2 was interviewed on 1/4/21 at 9:17 a.m. She said she had been at the facility for over a year and had never received a [MEDICAL CONDITION]. She said she needed a sleep study for that but a sleep study had not been performed. She said she really needed the [MEDICAL CONDITION] machine. She said she had not gone to a urologist for a long time and thought she had a urinary tract infection [MEDICAL CONDITION]. She said it hurt when she urinated. [MEDICAL CONDITION] bad. She said she had been hurting for months. A family member for Resident #2 was interviewed on 1/4/21 at 4:48 p.m. She said this resident has had problems since May 2020. She said she was told they made a urologist appointment for the resident but it had not been done. She said she was worried for the health of Resident #2. IV. Record review Review of the physician/nurse practitioner (NP) progress notes revealed on 2/27/2020, .history of [MEDICAL CONDITION]-still smokes and spends a lot of time on portable oxygen (O2) .Medical history .chronic pain, restless leg syndrome, urinary incontinence, [MEDICAL CONDITIONS], Barretts esophagus, both rotator cuffs torn .Plan .obstructive sleep apnea (OSA): clinical notes: will check on arrangements for ([MEDICAL CONDITION]). Review of the physician/NP progress notes revealed on 3/20/2020, .Seeing patient today, she continues to complain of dysuria and mild urinary frequency burning .reports urinalysis was done at the pain clinic this week, however no results are available .Dysuria (painful or difficult urination): checking urinalysis, will start [MEDICATION NAME] 100 mg (milligram) three times daily x two days. Review of the progress note revealed on 6/1/2020, .voiced to the physician she had burning with urination, orders were given by MD to collect UA. Nurse obtained UA, urine was cloudy. Results came back positive UA. MD started Bactrim x 3 days . Review of the progress notes revealed on 6/4/2020, MD visit resident complained of abdominal pain. Order for abdominal x-ray received and ordered. Review of the progress note revealed on 6/30/2020, Called (facility name) to make three appointments for obstetricians (OB) women's clinic, gastrointestinal (GI) and sleep study. Faxed over the referral and orders to (facility name). Awaiting the results. I called them and they said this is the process to fax over orders and referral. Review of the January 2021 CPO revealed the resident had an order on 6/30/2020 for a GI consult and a sleep study for [MEDICAL CONDITION]. Review of the referrals sent to (facility name) on 6/30/2020 revealed a fax was sent for GI consult and a sleep study- [MEDICAL CONDITION]. Response from (facility name) on 7/30/2020 revealed Thank you for sending this referral. Unfortunately, we are unable to process this referral because we are not accepting external referral for sleep studies at this time. -No documented attempts were made to initiate a sleep study consult at a different facility location. Review of the physician/NP progress notes revealed on 7/16/2020, .Unable to care for herself secondary to medical issues seen acutely for complaints of dysuria- no fevers or chills .has history of [MEDICAL CONDITION] reflux disease (GERD) with Barrett's esophagus on [MEDICATION NAME]-denies any gastric complaints .Incontinence of urine: clinical notes: on Myrbetriq- recurrent urinary complaints- discussed need for appropriate perineal hygiene .Barrett's esophagus without [DIAGNOSES REDACTED]: clinical notes: on [MEDICATION NAME]- will arrange for GI for Barrett's esophagus. Review of the physician/NP progress notes revealed on 7/21/2020, .seeing patient today because of complaining of coughing all night long .she complains of dysuria which is a chronic complaint and has been treated in the past for urinary tract infections with antibiotics with no real relief. Serum white blood cell count normal each time a urinalysis is done. Denies fever, Complaints of dysuria . Review of the progress notes revealed on 7/28/2020, Referral sent to (facility name) again today for her three appointments. Will still need to await their call. Due to COVID (facility name) is behind. Review of the physician/NP progress notes revealed on 8/20/2020, .incontinence of urine: clinical notes: has had ongoing symptoms- on Myrbetriq- will arrange urology consult for evaluation. Cystoscopy. Review of the January 2021 CPO revealed the resident had an order on 8/27/2020 to schedule consultation with urology at (facility name) for complaint of chronic dysuria/pelvic pain. The end date was 8/28/2020 and was marked as completed. -The resident however was not seen by a urologist. Review of the physician/NP progress notes revealed on 9/30/2020, .seeing patient today to follow up on abdominal pain and recent x-ray done .Ultrasound completed as well for this and the conclusion is fatty liver .Patient continues to complain of generalized overall abdominal pain with worsening on the right lateral side and left lateral side .Ordered a computerized tomography (CT) of the abdomen and pelvis with contrast . Review of the physician/NP progress notes revealed on 10/1/2020, .Dysuria: clinical notes: persistent multiple urinary analysis (UA ' s) have shown no infection-will arrange for urology consult with probable cystoscopy .OSA: clinical notes: need to find results of sleep study or repeat. Then send to [MEDICAL CONDITION] for consult. Review of the January 2021 CPO revealed the resident had an order on 10/1/2020 for a sleep study for OSA. The end date was 11/28/2020 and marked as completed. -The resident however had not had a sleep study for OSA done yet. Review of the January 2021 CPO revealed the resident had an order on 10/1/2020 for urology consult for chronic dysuria. The end date was 11/28/2020 and was marked as completed. -The resident however had not had a urology consult for chronic dysuria. Review of the January 2021 CPO revealed the resident had an order on 10/1/2020 for a [MEDICAL CONDITION] consult after sleep study done with results. The end date was 12/31/2020 and marked as completed. -The resident however had not had a [MEDICAL CONDITION] consult. Review of the January 2021 CPO revealed the resident had an order on 10/2/2020 to schedule a GI consult at (different facility name) if they will see her- otherwise schedule at (facility name). No documented attempts were made to initiate a GI consult at a different facility. Review of the physician/NP progress notes revealed on 10/8/2020, .Dysuria: clinical notes: continues-repeated urinalysis indicates infection but no systemic symptoms- urology consult is pending .Barrett's esophagus without [DIAGNOSES REDACTED]: clinical notes: on [MEDICATION NAME]- GI consult pending . Review of the referrals sent to (facility name) on 10/12/2020 revealed a fax was sent for urology consult. Review of the progress notes revealed on 10/13/2020, Referral faxed again to (facility name) for urology consult. Review of the physician/NP progress notes revealed on 10/29/2020, .Urinary incontinence: clinical notes: urology consult still pending- consider discontinuing Myrbetriq- UA abnormal but no leucocytosis or fever. Review of the progress notes revealed on 11/23/2020, All referrals sent to (facility name) for appointments, they will review and due to COVID are behind. If resident becomes worse, send to the emergency room (ER) at (facility name) . Review of the referrals sent to (facility name) on 12/16/2020 revealed a fax was sent for urology, GI, pain and pelvic ultrasound. V. Record review during survey Review of the progress notes revealed on 1/5/21 at 9:46 a.m., Call placed to Dr (name) to request assistance with obtaining (resident) consults as several attempts have been made by the facility to obtain a consult. She was given the (facility name) phone number for the appointment referral line. Dr (name) agreed to call and assist with obtaining consult. Stated her dysuria is not urine related but is an issue with urethra and bladder and this is why the urology consult is requested. Thanked Dr (name) for assistance. Review of the progress notes revealed on 1/5/21 at 10:17 a.m., Spoke to (facility name) about referrals and why it was taking so long. This resident is on a waitlist for GI and was able to move her up for an appointment on 2/17/21 at 3 p.m. I was transferred to the urology clinic and spoke to the clinic who states that she is on a waitlist which usually takes three to four months. She is a priority two list due to not having elevated white blood cell (WBC). They transferred me to the nurse line and I left a message for (name) to call me back to see if she can help either push up the appointment or help me obtain and authorize .outside. Awaiting her phone call at present. Also notified Dr (name). Review of the progress notes revealed on 1/5/21 at 10:49 a.m., Dr (name) spoke to urology and they overbooked her for an appointment at (facility name) for 1/27/21 at 10:00 a.m . VI. Staff interviews The DON was interviewed on 1/4/21 at 11:40 a.m. She said she had sent referrals for services at (facility name) but they were backed up. She said she would get a message back from them, but nothing was done. She said the resident ' s only option was (facility name) for services. At 12:37 p.m., the DON said it took a long time to change the insurance option for a resident. She said the resident ' s current insurance option (facility name) was in place since the beginning of 2020. The DON said she was the one who made the resident ' s appointments and had left a message about two and a half weeks ago. She said Resident #2 told them she had a [MEDICAL CONDITION] at her previous facility. She said she called the previous facility and they denied that. She said Resident #2 did attend her OB appointment. The business office (BO) staff was interviewed on 1/5/21 at 8:56 a.m. He said (facility name) had been a challenge. He said if this facility was not providing services, the next step would have been to obtain an authorization. He said he was having difficulties with disenrolling residents from this provider. He said there was only one other resident with difficulties but that service issue was resolved after persistence. He said that he was unaware of any service issue with Resident #2 until 1/4/21. The DON was interviewed again on 1/5/21 at 9:37 a.m. She said she kept sending referrals for this resident. She said she was not aware of the resident ' s current concern regarding burning during urination. She said the other options they could have tried with Resident #2 included: 1) The primary care physician call (facility name) to assist in getting an appointment for the resident; 2) Apply for an authorization to Medicaid. She acknowledged that this had not been attempted for this resident. She said this process could take three to four months for approval; or 3) The resident could change her Medicaid plan which could take two to three hours on the phone. She acknowledged this had not been attempted with the resident. She said they would talk to the physician and would ask the resident if she wanted to have anything changed. The DON said no other residents had difficulties obtaining appointments. The DON acknowledged Resident #2 had not received a urology visit, GI visit or sleep study since she was admitted on [DATE]. The licensed practical nurse (LPN) was interviewed on 1/5/21 at 9:54 a.m. She said this resident had not mentioned to her anything about burning with urination. She said it had been a while since she was told anything by the resident. She said she would talk to the resident about her concerns. She said they had given her a lubricant a while back and the issue had improved. The LPN was interviewed again on 1/5/21 at 10:01 a.m. She said the resident told her it was burning from the outside of the area, during urination. She said she would call the doctor. She said they had been trying to get her to see a urologist, but it had not been done yet. She said no other residents were having difficulties. The DON was interviewed again on 1/5/21 at 10:37 a.m. She said she called (facility name) and was able to get a GI appointment for February. She said there was a wait list for urology. She said she asked them how to obtain an authorization and had the contact information. She said they would try and get her an authorization for another location. VII. Documents provided after survey Review of the (facility name) letter dated 1/6/21, revealed Per your request, I can confirm that (patient) was placed on the waitlist in the (facility name) urology department on 10/23/2020. She has a scheduled appointment 1/27/21 at 9:40 a.m. Review of the referral sent on 1/7/21 revealed a fax was sent to (facility name) for a sleep study.

Based on observations, record review and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including COVID-19 novel Coronavirus in two of three resident neighborhoods. Specifically, the facility failed to: -Actively screen staff prior to the start of their shift for signs and symptoms of COVID-19; and, -Ensure residents were encouraged and assisted with hand hygiene prior to meals. Findings include: I. Actively screen staff prior to the start of their shift A. Professional reference The Centers for Disease Control (CDC) Coronavirus 2019 COVID-19,(6/25/2020) Preparing for COVID-19 in Nursing Homes retrieved 8/12/2020 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, documented in pertinent part,Screen all HCP (healthcare personnel) at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19. B. Facility policy and procedure The Tool Kit A, Section I, Center Preparedness: Infection Prevention Strategies and Guidance for COVID-19 policy, revised 8/5/2020, was received from the nursing home administrator (NHA) on 8/12/2020 at 1:35 p.m. The policy documented in pertinent part, An employee screening log will be used to document essential healthcare personnel, staff, agency, and facility-assigned (contracted) staff responses. The screening will include a temperature check (fever is considered >100ºF (Farenheit) and documentation of absence of cough, shortness of breath, chills, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose,nausea or vomiting, or diarrhea. This list does not include all possible symptoms. The facility must actively screen facility, agency staff and essential HCP (healthcare personnel) who have worked in or entered other facilities with suspected or confirmed COVID-19, and restrict them appropriately to reduce the spread of COVID-19 and/or respiratory illness. C. Record review The Employee and Essential Healthcare Personnel Screening logs were received for 8/8/2020 and 8/9/2020, from the director of nursing (DON) on 8/12/2020 at 10:30 a.m. The log failed to include staff COVID-19 screening prior to the the start of their shift for the following: -On 8/8/2020, there was no screening for, certified nurse aide (CNA) #3, CNA #4, CNA #6 or CNA #7. In addition, there was no screening for housekeeper (HK) #1 or cook (CK) #1. -On 8/9/2020, there was no screening for licensed practical nurse (LPN) #2 or LPN #3. In addition, there were no screenings for CNA #1, CNA #2, CNA #3, CNA #7, and CNA #9. There were no screening on the log for HK #2, HK #3 or dietary aide (DA) #1. D. Staff interviews The DON and staffing coordinator (SC) were interviewed together on 8/12/2020 at 10:25 a.m. The DON and SC reviewed the staff COVID-19 screening logs for 8/8/2020 and 8/9/2020. The SC confirmed the staff listed above were not on the screening log. The DON said the log was difficult to read, and many of the names were illegible. She said the infection preventionist (IP) reviewed the log daily, and on Mondays she reviewed the weekend screens. She said the manager on duty (MOD) over the weekend, had other responsibilities and therefore could not review the staff screenings on the weekend. The DON could not explain how the IP was verifying the screens if the names were illegible. She said she needed to add a line to the screening log for the staff to print their name, rather than just a signature. The DON said obviously our process is not working. The DON said all staff are screened at the front desk. The SC was interviewed again on 8/12/2020 at 11:06 a.m. She said the weekend staff positions were difficult to fill and sometimes she used agency staff to screen those coming in the facility at the front door. She said she called the staffing agency ahead of time after the screenings were not being completed (see above) and reviewed the process for screening staff and visitors at the front door with the agency staff. The dietary manager (DM) was interviewed on 8/12/2020 at 11:40 a.m. The DM said sometimes there was no one at the front desk and we checked our own temperatures. The DM said there was never anyone at the front desk when the CK #1 comes in at 5:00 a.m. She said CK#1 screened himself each day. The DM said frequently on the weekend there was no one at the front desk to complete staff screenings. She said it was hit and miss. The DM said if the staff were supposed to be screening themselves when no one was at the desk, then maybe they just did not do it (completed their own screening). The DON was interviewed again on 8/12/2020 at 3:52 p.m. She said Monday through Friday there is someone at the desk to screen visitors and staff from 6:30 a.m. to 5:00 p.m. She said if someone comes after those times, they ring the doorbell and the second floor nurse will come down to the front desk to screen them. She said on the weekend, there was someone at the desk from 6:30 a.m. to 6:00 p.m. She said if the cook was coming at 5:00 a.m., then there was no one to screen him. The DON said we will work on a new process. E. Facility follow-up On 8/12/2020 at 3:54 p.m., the DON provided an education inservice titled, Screening Process Prior to Starting Your Shift, dated 8/12/2020. The inservice documented in pertinent part, Enter the building through the front door only. Perform hand hygiene. Obtain and don a surgical mask. Perform temperature check and document. Answer questions asked by screener, be sure your name is legible and documented. It is mandatory that each person in the building be screened prior to your shift and documented. This list will be verified by the IP or MOD that all persons working have been screened. II. Ensure residents were encouraged and assisted with hand hygiene prior to meals A. Professional reference The CDC Interim Infection Prevention and Control (3/13/2020) Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes, retrieved 8/12/2020 from: https://www.cms.gov/files/document/qso-20-14-nh-revised.pdf, documented in pertinent part, Remind residents to practice social distancing and perform frequent hand hygiene. B. Facility policy and procedure The Tool Kit A, Section I, Center Preparedness:Infection Prevention Strategies and Guidance for COVID-19 policy, mentioned abovee, documented in pertinent part, Remind and/or assist residents with frequent hand hygiene and social distancing. C. Observations The lunch meal was observed on 8/11/2020 in the Rosewood and Columbine neighborhoods. The following was observed on the Rosewood neighborhood: At 12:24 p.m., CNA # 5 took a room tray to Resident #9 in the residents room. He placed the tray on a table in front of the resident. No hand hygiene was offered, or encouraged. At 12:25 p.m., LPN #1 took a room tray to Resident #10 in the residents room. She placed the tray on a table in front of the resident. No hand hygiene was offered, or encouraged. At 12:26 p.m., CNA # 5 and CNA #8 took two room trays to Resident #11 and Resident #12 in their room. They placed the trays on tables in front of the residents. No hand hygiene was offered or encouraged to either resident. At 12:27 p.m., the business office manager (BOM) took a room tray to Resident #13 in the residents room. He placed the tray on a table in front of the resident. No hand hygiene was offered, or encouraged. At the same time, CNA #8 delivered a room tray to Resident #14. She did not offer or encourage hand hygiene to Resident #14. At 12:28 p.m., the BOM took a room tray to Resident #15 in the residents room. He placed the tray on a table in front of the resident. No hand hygiene was offered or encouraged to the resident. At 12:29 p.m., CNA # 8 took a room tray to Resident #16 in the residents room. She placed the tray on a table in front of the resident. No hand hygiene was offered or encouraged to the resident. At 12:33 p.m., CNA # 8 took a room tray to Resident #17 in the residents room. She placed the tray on a table in front of the resident. No hand hygiene was offered or encouraged to the resident. At 12:34 p.m., the BOM took a room tray to Resident #18 in the residents room. He placed the tray on a table in front of the resident. No hand hygiene was offered or encouraged to the resident. At 12:34 p.m., CNA # 5 and LPN #1 took two room trays to Resident #19 and Resident #20 in their room. They placed the trays on tables in front of the residents. No hand hygiene was offered or encouraged to either resident. The following was observed on the Columbine neighborhood: At 12:01 p.m., the lunch trays were delivered to the third floor. Staff were observed delivering the room trays. CNA #10 was observed delivering lunch trays to several residents on the unit. He did not offer or encourage hand hygiene for Residents #5, #6, #7 or #8 prior to eating their lunch. CNA #11 was observed delivering lunch to several other residents in the same unit. He did not offer or encourage hand hygiene for Resident #2, #3 or #4 prior to eating their lunch. D. Staff interviews CNA #5 was interviewed on 8/12/2020 at 1:22 p.m. He said he offered the residents assistance to wash their hands after he takes them to the bathroom. CNA #12 was interviewed on 8/12/2020 at 1:25 p.m. She said she offered hand hygiene to the residents before meals, after they went to the bathroom and after they smoked. Registered nurse (RN) # on 8/12/2020 at 1:35 p.m. She said residents were offered hand hygiene after eating or touching an unclean surface. The DON was interviewed on 8/12/2020 at 3:52 p.m. She said the staff should have offered hand hygiene to the residents before meals, after smoking and after using the bathroom. She said she noticed the staff did not offer hand hygiene to the residents before lunch yesterday too. She said, I will work on that. III. Facility COVID-19 status The facility COVID-19 line listing was reviewed from March 2020 to 8/12/2020. The line listing documented the last resident to test positive was 4/28/2020. The last staff member tested positive on 7/24/2020. There were no known current positive residents or staff.

Based on observations, record review and interview, the facility failed to ensure a resident with a history of trauma and/or post-traumatic stress disorder, received appropriate treatment to attain the highest practicable mental and psychosocial well-being for one (#81) of six residents reviewed for accommodations out of 33 sample residents. The facility was aware the resident requested female caregivers but failed to routinely schedule female staff to assist Resident #81 with her activities of daily living (ADLs), resulting in the feelings lack of self worth. The resident had a past trauma that left the resident paralyzed and fearful of male caregivers. The resident required extensive assistance of two or more female staff for bed mobility and transferring. The facility was also aware that the resident's need for female staff was frequently not honored, causing the resident anxiety and stress. The facility's failure to accommodate the resident's needs and preferences resulted in extended waits to go to bed, which induced the resident's feelings of stress, anxiety, tearfulness and lack of self worth. The facility was aware of the resident's past trauma, but considered the preferences of staff unit placement over the needs and preferences of the resident. Cross reference to F725, sufficient nursing staff Findings include: I. Facility policy and procedure The Resident Rights policy and procedure, dated February 2017, was provided by the business office manager on 2/27/20 at 2:04 p.m. The policy read in pertinent part: The facility protects and promotes the rights of each resident. The resident has the right to a dignified existence, self-determination, and communication with access to persons and services inside and outside of the facility. The facility staff will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes the maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.The facility provides equal access to quality care regardless of diagnosis, severity of condition, or payment source. II. Resident #81 status Resident #81, under age 60, was admitted on [DATE], with an initial admission date of [DATE]. According to the February 2020 computerized physician orders [REDACTED]. According to the 1/10/20 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS), score of 15 out 15. She required extensive assistance of two or more staff with ADLs for bed mobility, and transfering. She required extensive assistance of one for toileting, dressing, and personal hygiene. III. Resident interview Resident #81 was interviewed on 2/24/20 at 8:56 a.m. She said she was not comfortable with male certified nurse aides (CNAs), providing care to her because of a past trauma with a man, resulting in paralysis. She said the facility was aware that she wanted only female CNAs. Resident #81 said there were usually not enough female aides on her unit to assist her to bed. She said her unit was often staffed with male CNAs and she had to wait for a CNA from another unit to assist her to bed, resulting in long waits to go to bed. She said the lack of female aides available for her care caused her anxiety and frustration. She said she often had to worry that she would have increased pain the following morning because she had to sit in her chair for long periods at a time and not be able to lie down at her preferred bed time. She said she preferred to lie down between 9:00 p.m. and 9:45 p.m. Resident #81 was interviewed on 2/25/20 at 10:33 a.m., during a resident group interview. She said on the night of 2/25/20, she had to wait until 11:00 p.m. for a female CNA to leave their assigned unit and assist her. She said she required a lot of assistance to go to bed, and was not able to lie down until 11:45 p.m. She said she felt it was unfair to her she could not go to bed near her preferred bedtime, because not enough female CNAs were staffed on her unit constantly at night. Resident #81 said the facility knew why she could not have male CNAs. She said the lack of female CNAs scheduled on her unit made her feel that her needs did not matter, causing her to cry out in frustration. The resident was interviewed on 2/27/20 at 1:39 p.m. She said the female nurse would help her sometimes in the morning to get out of bed, but seldom would female nurses help her lie down at night. IV. Record review The social service note on 9/16/19 read Resident #81 discussed with social services that she was in a domestic violence situation that led to her paralysis. The care plan for behavior, revised on 10/22/18, read the resident could become demanding with her cares, had a [DIAGNOSES REDACTED]. Interventions included to allow choices and modify environment, situations, and/or treatment to minimize episodes. According to the behavior care plan, the resident needed to accept staffing limitations, and her preferences were identified as a behavior. The care plan further read: This resident chooses only those who she wants within the building to care for her and to turn her. She will not take an alternative solution and she has none (solutions) herself, just does what she wants. I explained that I (unidentified writer) have to staff with those we have to help her. The resident's care plan did not include her preference for female CNAs or how to accommodate those needs. The February 2010 staffing schedule was provided by the staffing scheduler (SCH) on 2/25/20 at 2:19 p.m. The February staffing schedule revealed the 2:30 p.m. to 10:30 p.m. shift on the unit where Resident #81 lived was frequently staffed with male CNAs. According to the schedule, either two male CNAs were assigned to the unit or two male CNAs and one female CNA. The schedule and the SCH indicated the female CNA scheduled was on restricted light duty. The following dates were without a scheduled female CNA able to assist Resident #81 to bed: -2/5/20 -2/10/20 -2/11/20 -2/14/20 -2/17/20 -2/18/20 -2/19/20 -2/24/20 -2/25/20 According to the 2/19/20 schedule, the facility had an opportunity to staff three CNAs in addition to the light duty female CNA. However, the three CNAs were all male. D. Staff interviews The social service director (SSD) was interviewed on 2/27/20 at 8:39 a.m. He said he was new to the facility and still learning the needs of each resident. He said care plans should reflect individual resident needs, be dynamic (ever changing), and person-centered. The SSD reviewed the behavior care plan documented in the medical record of Resident #81. He said the care plan was demeaning towards her and her needs. He said staff needed to treat everyone as an individual, listen and respond to the resident's needs. The resident should not feel that her needs were less than, or be told that this was just how things were going to be, without consideration or accommodation. The SSD said staff should be sensitive to resident needs, especially when the resident had needs related to past trauma. He said staff should honor her wishes, and think outside the box to meet her needs. He said she should have female staff assistance without undue stress or waiting. He said staffing should be adjusted on her unit to meet her needs and preferences. He said he would meet with the resident and advocate for her request. The SSD said the facility needed to improve their practice of handling resident needs related to past trauma. The director of nursing (DON) was interviewed on 2/27/20 at 10:42 a.m. The DON said she was aware of the past trauma of Resident #81, and knew she was not comfortable with men providing care. She said the unit was staffed with one female CNA and a female nurse. The nurse should assist if needed. She said the female CNA assigned should not be a CNA on restricted or light duty. The DON said they had limited female staff available to work on the unit of Resident #81, but the SCH made provisions for another female CNA to leave her assigned unit to attend to Resident #81. She said the provision should not interfere with the time the resident was able to get ready and go to bed. The DON said she would have to move staff from their preferred units to accommodate Resident #81. The DON said moving staff could cause problems and frustrations with the staff. The DON said she instructed the SCH to accommodate by having a female CNA provide resident cares on her preferred assigned unit and also assist Resident #81 who lived on a different unit. The DON said a resident should not have to wait over a half an hour to receive assistance. The DON said Resident #81 had told her that she had to wait over a half hour for staff to assist her to bed which caused her to hurt the following day. The DON said the resident was often anxious about who was going to care for her at night. The DON said her anxiety resulted in the resident exhibiting behaviors such as repeated calls to the SCH and attempting to modify the staffing schedule. The SCH was interviewed on 2/27/20 at 11:41 a.m. with the human resource corporate consultant (CSC). The SCH said she was aware of the past trauma and preferences of Resident #81. She said the resident should always have two female staff available to provide care, one of which should not be a light duty CNA. She said the female light duty CNA identified on the staff schedule could not push, pull, turn or lift the resident due to her restrictions. The SCH said Resident #81 was difficult to assist because of her extensive care needs. The SCH said female staff had complained that she was too hard and turning her hurt their back. The SCH said the resident and the staff would benefit from having the assistance of three female staff to assist the resident to bed. The SCH said she did not have the staff on the unit to have a consistent supply of two to three CNAs to be staffed on the resident's unit. She said she tried to accommodate the needs of Resident #81, by asking a CNA from another unit to assist the resident when she needed to go to bed. The SCH said Resident #81 would frequently call her to ask who was scheduled to assist her at night. The SCH said the resident was directed to contact the DON and/or reach out to the charge nurse for staffing concerns related to who was scheduled to work on her unit. The SCH agreed that lack of female CNAs on the unit caused the resident anxiety. She said the male aides on the unit of Resident #81 were scheduled on that unit because that unit was part of their set assignment. The SCH said the unit was often staffed with more male staff than female staff to allow consistent staff schedules and staff unit preferences to reduce staff stress. She said she usually had more female CNAs available but currently two were out on medical leave. The SCH also said she had several open positions and recently lost some staff related to poor attendance. She said she recently added a female CNA to the unit from a staffing agency. The SCH said the staffing challenges and sometimes residents, including Resident #81, caused residents to have to wait for care because staff were handling other residents' needs. The human resource corporate consultant (CSC) said the facility staff challenges should not cause a resident undue stress or make her have to wait for care. He said the facility needed to provide care that best suited the resident. He said staff needed to accomodate the needs of all residents. The CSC said the staffing schedule should have been modified to ensure Resident #81 had female staff available on a consistent basis. The SCH said resident needs should be the facility's number one priority and residents should not have to feel stressed related to staffing challenges. A licensed practical nurse (LPN) who provided care for Resident #81 was interviewed on 2/27/20 at 1:35 p.m. She said she was aware of the resident's preference for female staff. She did she helped get Resident #81 up in the morning when she was available but did not work on the evening shift to help the resident go to bed. She said the resident had expressed to her that she had to wait awhile for staff to assist her to bed at night. She said the resident expressed pain and frustration in the morning when her time preferences to lie down in the 9:00 p.m. hour and get up out of bed at or shortly after 7:00 a.m. were not met. She said Resident #81 frequently complained of pain at a level of seven out of 10 (severe pain) in the morning. The SSD and the SCH were interviewed again on 2/27/20 at 1:45 p.m. The SCH said she and the SSD met with the resident and determined that a lot of the resident's stress was related to the fear of the unknown in regards to who was going to provide her care. The SCH said she had met with staff and adjusted the schedule to ensure the resident had more female staff scheduled on her unit seven days a week to limit the resident's anxiety and provide consistent female staff to help her needs without undue waiting and frustration. She said a staff schedule identifying who was scheduled to work with Resident #81 each day would be provided to the resident in her room. The SSD said he would also provide any needed supportive assistance and frequent visits with her, to make sure she felt her needs were met. He said he would continue to assist her and staff to work towards a solution. He said the facility needed to improve communication with her so she felt safe, comfortable and heard. The nursing home administrator (NHA) was interviewed on 2/27/2020 at 2:15 p.m. The NHA said he was aware Resident #81 preferred only female staff. The NHA said she only wanted the people she wanted. He said he was working on other solutions. He said he was not aware of her associated signs of distress or related behaviors. He said the resident did not self seclude, hide in her room, or avoid participating in community activities. The NHA said he spoke with Resident #81 daily and felt she tried to control things that no one could control. The NHA said he tried to meet her needs as best as he could.

Based on observations, record review and interviews, the facility failed to ensure pain management services for one (#31) of four residents reviewed out of 33 sample residents. The facility failed to prevent increased pain during range of motion (ROM) services by therapy for Resident #31 who had a fractured left clavicle. The facility was aware the resident had a history of [REDACTED]. However, the facility failed to assess, document, report to the physician and respond to the resident's pain. The nursing staff failed to communicate with therapy and implement a plan to premedicate the resident for pain in preparation for therapy sessions. The occupational and physical therapists performed range of motion and weight-bearing exercises although the resident had a fractured clavicle and verbalized pain during therapy sessions. The resident's pain during therapy sessions was not communicated by therapy to nursing staff or the physician. The facility further failed to develop a comprehensive, person-centered pain management care plan for Resident #31. As a result, the resident stated during interview that she could feel and hear her bones grinding during therapy sessions, and she experienced increased, severe pain, which she described as excruciating, tormenting and horrible. Cross-reference to F684, highest practicable quality of care: the facility failed to ensure a timely orthopedic consultation was provided as ordered by the physician, ensure a physician order [REDACTED].#31's sling and performing range of motion (ROM) and resistance (weight) exercises to the resident's affected left upper extremity (LUE), and ensure the resident's fractured clavicle and related pain management issues were included in the resident's care plan. Findings include: I. Facility policy and procedure The nursing home administrator (NHA) provided a copy of the facility's pain policy on 2/26/2020 at 11:13 a.m. The policy, last revised in July 2017, documented in pertinent part: The facility recognizes the inter-relationship between uncontrolled pain and the decline in functional abilities, leading to an impaired quality of life. The facility will evaluate and identify residents experiencing pain; evaluate the existing pain and the cause(s); determine the type and severity of the pain; and develop a care plan for pain management consistent with the comprehensive care plan and resident's goal and preferences. The care plan is implemented and evaluated for its effectiveness. Acute pain, also known as warning pain, is a discomfort or signal that alerts you something is wrong in your body. Pain results from any condition that stimulates the body's sensors, such as infections, injuries, hemorrhages, tumors, and metabolic and endocrine problems. Acute pain usually abates as the underlying problem is treated. Early management of acute pain may hasten the recovery of the causative problem and reduce the length of treatment. II. Resident #31's status Resident #31, less than [AGE] years old, was readmitted on [DATE]. According to the February 2020 computerized physician orders [REDACTED]. The fractured clavicle was not included in the list of [DIAGNOSES REDACTED]. The 11/26/19 minimum data set (MDS) assessment coded the resident as cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had sustained a fracture resulting from falls in the past six months prior to this assessment. No pain experience was recorded. The resident received an opioid for seven days prior to this assessment. The resident did not reject evaluation or care. The resident required one person physical assistance with transfer, walking, locomotion, dressing and personal hygiene. III. Resident status on admission The comment portion of the referral note by the referring physician, dated 11/16/19 at 7:43 a.m., reported Resident #31 failed at home. She's had 5 falls with the last fall being last evening. She now has a clavicle fracture. Her family member cannot care for her as she is unable to assist with any of her daily needs. IV. Resident observation and interview Resident #31 was observed on 2/24/2020 at 9:45 a.m. while she sat in her bed. The resident had a red/pinkish protrusion around her left clavicle (collar) bone. This protrusion was not observed on the resident's right collar bone. The resident was not wearing a sling. Resident #31 was interviewed on 2/24/2020 at 9:56 a.m. The resident was grimacing and almost tearful throughout the interview. The resident stated she discharged home in November of 2019 and had a fall at home which resulted in her fractured left clavicle. The resident stated, I got readmitted back at the facility . I have been in constant pain since re-admitting to the facility. She expressed that her most excruciating pain was during range of motion exercises with occupational and physical therapy (OT and PT). Specifically, the resident stated she could feel her bones grinding against each other (referring to her fractured clavicle) and it caused a sensation she described as tormenting and horrible. She added that her pain experience was different every day. V. Record review A. History and physical A review of the admitting physician history and physical completed with Resident #31 on 11/19/19 revealed the resident was admitted to a hospital and was diagnosed with [REDACTED]. B. Medication administration records A review of the resident's October 2019 (pre-clavicle fracture) through February 2019 (post clavicle fracture) medication administration records (MARs) revealed a [MEDICATION NAME] was the only additional pain medication Resident #31 received after she sustained the fracture to her left clavicle Specifically, the MARs (before and after the clavicle fracture) revealed the resident continued to be on the same pain medication which included: -Aspirin tablet 81 mg, give 1 tablet by mouth in the evening for supplement; -[MEDICATION NAME] Sodium tablet Delayed Release 75 mg, give 1 tablet by mouth two times a day for inflammation; -[MEDICATION NAME]-[MEDICATION NAME] tablet 10-325 mg, give 1 tablet by mouth three times a day for pain; -[MEDICATION NAME] tablet 325 mg, give 2 tablets by mouth every six hours as needed for pain; and -Observation: Pain - Observe every shift. If pain present, complete pain flow sheet and treat trying non-pharmacological interventions prior to medicating if appropriate. Document in the progress notes every shift per protocol. [MEDICATION NAME] Patch 4%, apply to left shoulder topically one time a day for pain, added to the resident's pain management regimen on 11/19/19 at 2:01 p.m., and discontinued on 2/19/2020 at 1:36 p.m. The MAR indicated [REDACTED]. C. Pain assessment The resident's pain assessment, dated 11/22/19, on admission, reported that Resident #31 had in the last five days been on a scheduled pain management regimen, received as-needed (PRN) pain medications, and also received non-medication interventions for pain. The assessment also documented that Resident #31 reported she had frequent pain or hurting during the last 5 days prior to the assessment. Her pain was located in her left fractured clavicle and she described the pain as sharp. It also documented that Resident #31 had a history of [REDACTED]. The resident rated her pain at a five on a scale of zero through 10. Resting and medication were what relieved her pain. The assessment only listed [MEDICATION NAME] 10-325mg three times a day as the medication the resident's pain was being managed with. There was no documentation of an assessment to determine the effectiveness of the [MEDICATION NAME] with reference to addressing the resident's pain with her fractured clavicle. There was no documentation of the resident's acceptable level of pain. There was no documentation of whether or not the resident's pain interfered with her daily activities or her sleep. The pain scale documentation of the resident's verbalized pain rating did not reflect her expressed pain concern during the survey. D. Failure to schedule orthopedic consultation and evaluate sling use A review of the resident's medical record revealed [REDACTED]. There was no evidence or observation (see above) of the facility providing a sling to support the resident's affected left arm/clavicle. Likewise, there was no order to initiate or discontinue a sling to the resident's affected arm. E. Therapy notes Review of the resident's physical and occupational therapy (PT and OT) notes revealed the precautions/ contraindications portion of the exercise sessions documented: status [REDACTED]. 1. OT notes The OT progress note dated 2/13/2020 documented that Resident #31 participated in a graded therapeutic exercise to increase strength, endurance and ROM to LUE for functional performance of ADLs. During the session, Resident #31 performed resistance exercise with a theraband to the LUE (there was no order for the resident to partake in such exercise). The pain at rest and pain with movement recorded for this session was zero and four consecutively out of 10. Complexities/barriers impacting the session were identified as history of left clavicle fracture, unhealed properly. The document also revealed Resident #31 reported that her LUE remaining still was what helped with her pain. According to the OT progress note dated 2/20/2020, Resident #31 participated in a guided therapeutic exercise to increase strength, endurance and ROM to bilateral upper extremities (BUE) for performance of activities of daily living (ADLs). During the session, Resident #31 performed BUE bicep curls, chest presses, internal/ external rotations and overhead presses using three-pound weights for LUE and five-pound weights for RUE (there was no order for the resident to partake in such exercise).The pain at rest and pain with movement recorded for this session was zero and four consecutively out of 10. The document also revealed that Resident #31 reported that her LUE remaining still was what helped with her pain. The progress note further documented that the resident participated in facilitation of crossing midline and weight shifting with BUE activity. Complexities/barriers impacting the sessions were identified as resident complaint of left shoulder pain. 2. PT notes The PT treatment encounter note dated 2/5/2020 documented Resident #31's pain at rest was zero out of 10, The frequency was intermittent; the location was her left shoulder. She also reported neck pain and described the pain as aching to sharp. The pain with movement was rated at five out of 10. The frequency of the resident's pain with movement was described as hourly and the location was the resident's shoulder with active range of motion (AROM) like gleno-humeral flexion, abduction or extention beyond comfortable range identified as the cause of pain. The resident also reported neck pain, which was reported as usually worse in the morning. The PT treatment encounter note documented a pattern of pain description similar as that reported for the following days: -2/12/2020 resident reported pain at rest and with movement as 3/10 and 7/10 consecutively -2/17/2020 resident reported pain at rest and with movement as 0/10 and 5/10 consecutively; -2/18/2020 resident reported pain at rest and with movement as 3/10 and 7/10 consecutively -2/19/2020 resident reported pain at rest and with movement as 3/10 and 6/10 consecutively; -2/21/2020 resident reported pain at rest and with movement as 2/10 and 5/10 consecutively -2/24/2020 resident reported pain at rest and with movement as 3/10 and 6/10 consecutively F. Shift by shift nursing pain assessments Documented pain levels on the medication administration records (MARs) were significantly below documented pain levels by therapy, and in many cases indicated zero pain. There was no evidence the resident was pre-medicated for pain prior to the physical or occupational therapy sessions. Therapy notes did not specify the time frame that they worked with the resident or that they requested pain medication prior to therapy. The resident was still receiving therapy services during the survey, mostly for lower extremity exercises and balancing. There was no documentation in therapy or nursing notes that the resident's physician was notified of her pain during therapy sessions. G. Care plans The resident's pain risk care plan, initiated on 3/31/16 and last revised on 4/19/18 during her prior admission to the facility, documented the resident was at risk for pain due to [DIAGNOSES REDACTED]. The resident's pain was not care planned when she was readmitted to the facility on [DATE] after she suffered a fractured clavicle. The readmitting [DIAGNOSES REDACTED]. The care plan also did not document treatment for [REDACTED]. VI. Staff interviews Certified nurse aide (CNA) #10 was interviewed on 2/26/2020 at 2:05 p.m. He said he was familiar with the resident. He said Resident #31 was independent with most of her care but that pain affected her independence with activities of daily living (ADLs) sometimes. CNA #10 said when the resident was in a lot of pain from her chronic pain and the pain from her fractured clavicle she could not sleep well sometimes. The CNA said he recalled calling the nurse one day not long ago when Resident #31 was moaning and making sounds and appeared to be in a lot of pain. CNA #10 said, I walked to the nurses' station to get the nurse on duty to address the resident's pain. Registered nurse (RN) #2 was interviewed on 2/26/2020 at 3:30 p.m. She said when a resident was in pain, she would have the resident rate her pain and medicate accordingly. She said nurses did not have access to the computer program the therapists used in documenting their treatment of [REDACTED]. She reviewed Resident #31's Medication Administration Record [REDACTED]. The hospital discharging physician was interviewed on 2/26/2020 at 10:23 a.m. via telephone. The physician stated it was important to provide timely follow-up consultation with orthopedics as the resident needed to be evaluated by an expert (referring to the orthopedic surgeon) who then made the decision to address the next line of treatment of [REDACTED]. The OT and PT were interviewed on 2/27/2020 at 9:37 a.m. The OT said she had done some therapeutic exercises to Resident #31's left upper extremity (referring to the ROM and resistance exercise). She reviewed the resident's medical record and agreed that there was no order from the physician to do so. The OT verified that it was important to obtain a physician order [REDACTED].#31's use of the sling because the sling helped hold the resident's fractured clavicle in place and required the orthopedic surgeon's review to determine whether or not it was safe to discontinue the resident's use of the sling. The OT acknowledged that she instructed the resident to discontinue her use of the sling without having an order to do so. She also verified she did not document that decision and her rationale for doing so. The PT verified that though Resident #31 had an order for [REDACTED]. He verified that not having an order for [REDACTED]. The PT however verified that there was no follow-up x-ray on file since Resident #31's re-admission in November 2019. He stated it was important to have an x-ray to guarantee that the bone had healed. The PT agreed that pain could result from moving a body part with a fractured bone. The DON was interviewed on 2/25/2020 at 10:28 a.m. She said when a resident was in pain, the information was communicated to the nurse who documented the location of the pain, the intensity and the frequency of the pain and would medicate or provide non-pharmacological intervention as necessary. The DON stated resident pain management was discussed at weekly interdisciplinary team (IDT) meetings and changes to the pain management regimen were made as necessary, and the initial interventions remained if it was determined that they had proven effective. The DON said the PT and OT were not included in the IDT team who reviewed Resident #31's pain management regimen. She denied being aware that the resident complained of pain during therapy sessions. The DON said it was important for the therapy and nursing department to communicate information pertinent to the resident's care in order to improve the quality of care the resident received from the facility. She concluded the interview stating she would initiate an all inclusive IDT, to ensure all departments responsible for the resident's health care management were included.

Based on observation, record review and interviews, the facility failed to ensure residents received adequate supervision and assistance to prevent accidents for one (#198) of three residents reviewed out of 33 sample residents. The facility failed to assess Resident #198 thoroughly for risk of falls, and implement immediate and effective interventions to prevent Resident #198 from falling. As a result, the resident fell twice. The second fall, out of a raised bed, caused a head injury which resulted in death. Findings include: I. Facility policy and procedure The Fall Management policy was received from the director of nursing (DON) on [DATE] at 3:00 p.m. The policy documented in pertinent part: When a resident is found on the floor, the facility is obligated to investigate to determine how the resident got there and put into place an intervention to minimize it from recurring. -Upon admission, the admitting nurse will complete the Fall Risk User Defined Assessment (UDA), the nursing care plan, address risk factors related to the resident in the plan of care and implement appropriate interventions. -Residents will be assessed quarterly, annually and with significant change using the fall risk UDA. The care plan is updated as appropriate. -When a fall occurs the nurse will discuss recommended interventions to reduce the potential for additional falls with the resident and the resident's representative and document in the care plan and progress notes. -The interdisciplinary team (IDT) reviews all resident falls within 24 to 72 hours at the IDT meeting to evaluate circumstances and probable cause. -The IDT will complete the Interdisciplinary Post Fall Review UDA. -The IDT will discuss recommended significant changes to the Care Plan to minimize repeat falls. -The care plan will be reviewed and/or revised as indicated. -Residents with potential head injury, neurological checks are completed and documented per instructions. -Residents who have experienced actual falls will be reviewed each week at the At Risk meeting. -The At Risk committee will review residents with falls for documentation, compliance, and interventions on a weekly basis. II. Resident status Resident #198, age 70, was admitted to the facility on [DATE]. According to the [DATE] computerized physician orders [REDACTED]. The [DATE] minimum data set (MDS) assessment documented the resident had short term memory loss, moderately impaired cognitive skills for daily decisions, disorganized thinking and inattention. He required limited one person assistance with bed mobility, and supervision for transfers, dressing, eating, toileting, and personal hygiene. He was at risk for falls. The assessment documented he had no falls since admission. However, this was not accurate, as the resident had fallen on [DATE] (see below). He was occasionally incontinent of bowel and bladder, and used a walker for mobility. His balance was unsteady. He was on oxygen. III. Family interview Resident #198's family was interviewed on [DATE] at 3:28 p.m. The family member said Resident #198 had fallen at the facility from a raised bed, hit his head, and passed away at the hospital. She said the resident was at risk for falling and the facility should have known he was at risk. The family member said the resident had suffered a stroke in the past and had memory loss. She said she did not believe the resident was capable of raising the bed using the bed control by himself. She said she had received a copy of the coroner's report that documented the resident had died from [MEDICATION NAME] force trauma to the head due to an accident at the nursing home. IV. Record review The resident's electronic medical record included documents from the prior nursing facility the resident came from. The records, dated [DATE] from the previous facility, documented the resident was deconditioned and weak. He needed to be reminded to call for assistance when going to the bathroom due to falls and weakness. A. Fall without injury [DATE] The progress notes in the resident's medical record were reviewed. On [DATE] at 11:25 p.m. the licensed practical nurse (LPN) documented that around 10:15 p.m., the resident was found on the floor in a sitting position, close to the bathroom door. The registered nurse (RN) supervisor was notified and performed a head to toe assessment; there was no noted injury. On [DATE] at 10:34 p.m. the SBAR (situation, background, assessment and recommendation) assessment completed by the LPN documented, Resident looks good with no injury at this time. Resident is combative, independent, does self care. On [DATE] at 12:22 a.m. the RN documented further, Resident was found sitting on the floor with his back resting on his wheelchair, both legs stretched out in front of him. He stated that he tripped over his nasal cannula (oxygen) line while walking to the bathroom by himself. Physical assessment from head to toe completed with no visible injury nor bruises at this time of assessment. Active range of motion (ROM) to both upper and lower extremities completed by this nurse. Resident is verbally responsive to nurse, assisted to standing position and he walked over to his bed without any assistance, at the presence of nurses and staff. Neuro check started, physician and family were notified by the nurse. Denies any pain. The neurological check assessments dated [DATE] at 10:15 p.m. were reviewed. The neurological checks were incomplete (cross reference F684 quality of care). The documentation revealed the following: -On [DATE] at 10:15 a.m. through [DATE] at 4:45 a.m. there was no assessment documented of the resident's eye response; -[DATE] at 2:45 a.m., the resident's vital signs (blood pressure, temperature, respirations, and pulse) were not checked because he was sleeping; -[DATE] 7:45 p.m., the neurological checks did not include vital signs, pupil reaction or eye signs, or motor response; -[DATE] at 11:45 p.m., the neurological checks did not include the eye, motor or verbal response; and -[DATE] at 3:45 a.m., the neurological checks did not include the level of consciousness, pupil or eye signs, eye, motor or verbal response. There were no neurological checks for: -[DATE] from 3:00 p.m. to 10:00 p.m.; -[DATE] 10:00 p.m. to 6:00 a.m. (except for eye, motor and verbal response); -[DATE] 6:00 a.m. to 2:00 p.m.; -[DATE] 2:00 p.m. to 10:00 p.m.; and -[DATE] 10:00 p.m. to 6:00 a.m. The neurological checks documented multiple low blood pressures. On [DATE] at 10:15 p.m., at the time of the fall, the resident's blood pressure was ,[DATE]. On [DATE] at 1:45 a.m., the blood pressure was ,[DATE]; and at 3:45 a.m. the blood pressure was ,[DATE]. The nurses' progress notes were reviewed. There was no documentation that addressed the resident's low blood pressure, or concerns for falls (cross-reference F684). There was no documentation from the nurse regarding interventions put in place to prevent further falls related to the resident taking himself to the bathroom and tripping over his oxygen tubing. There was no documentation or post fall review from the IDT regarding the fall on [DATE]. There was no documentation from the At Risk committee meeting regarding the fall [DATE]. There was no fall risk assessment completed on admission or after the fall on [DATE]. The physical therapy (PT) notes dated [DATE] were reviewed. The PT notes documented the resident was a fall risk, oxygen dependent, frail, and had weakness and decreased endurance. His safety awareness was impaired. The notes documented the resident had not fallen in the past year. However, he had fallen two days before, on [DATE]. The PT notes documented the resident fatigued easily during gait and a four wheeled walker was requested. This was not included in his care plan. He was discharged [DATE] due to refusing physical therapy, there were no recommendations. The occupational therapy (OT) notes dated [DATE] were reviewed. The OT notes documented the resident was a fall risk due to decreased strength, endurance, coordination, functional balance and safety. The notes documented the resident's upper and lower extremity strength was impaired. The resident was discharged from OT on [DATE] and recommendations were that the resident required supervision for safety. The physician's note dated [DATE] documented there have been no falls. However, the resident had fallen eight days before on [DATE]. The facility failed to ensure the provider was aware of the resident's fall. The physician's note dated [DATE] documented due to the resident's significant dementia and concern for falls, his blood pressure medication would be decreased and he would continue to be monitored closely. However, the facility failed to implement and document any fall interventions related to resident's known low blood pressure and risk of falls. B. Fall from bed with head injury [DATE] On [DATE] at 4:51 a.m., an SBAR note documented the resident had an unwitnessed fall and sustained injury. The document revealed resident was found on the floor by his bedside. Sustained a deep cut and bump to the left side of his face. RN supervisor was notified, she came and assessed, resident is alert and oriented times two, able to follow commands. Wound was treated, the resident continues to bleed from wound sites, RN supervisor encouraged to send the resident to the emergency room for further evaluation. On [DATE] at 7:21 a.m. a nurse's note documented, At about 4:20 a.m., certified nurse aide (CNA) reports to this nurse that she found the resident on the floor. This writer went and checked. Upon arrival, the resident was lying on the floor by his bedside, noted he had raised the bed to the highest height which may have caused the fall. Alert and able to follow commands, was asked how he fell and if he hit his head, the resident stated yes, I hit my head, get me up from the floor please. Observed bleeding on the left side of his face, and pool of blood on the floor. RN supervisor was quickly notified, she came and assessed. Noted bump, deep cut with bleeding to left side of face, closer to eyelid area. Ice pack was placed at the bump area and gauze placed over the bleeding site, unable to stop bleeding. RN supervisor encouraged to call 911 and send the resident out for further evaluation. On [DATE] at 5:06 a.m. The RN documented, This nurse called at 4:20 a.m. to assess the resident due to fall. Resident's head was in a pool of blood. Resident agitated and confused, unable to answer what happened. Unable to stop bleeding after some time, an order was received to send the resident to the emergency room . A resident Fall Risk assessment was completed on [DATE] at 4:51 a.m. after the second fall. The fall risk assessment documented the resident's risks included: he was ambulatory and incontinent, he had poor vision with or without glasses and his balance was a problem while standing and walking. He had decreased muscular coordination and a change in gait pattern when walking through a doorway. He required the use of assistive devices. He was on one to two medications that affected his risk, and had predisposing diseases that put him at risk. He scored a 10. The fall risk instructions documented that a score of 10 or greater the resident would be considered a high fall risk. A prevention protocol should be initiated immediately and documented on the care plan. The resident's [DATE] Medication Administration Record [REDACTED]. He was not on any other anticoagulants. In addition, the resident was on at least four medications that could have contributed to his fall risk: [MEDICATION NAME] and Atorvastatin. The resident's care plan, initiated [DATE] and revised on [DATE], was reviewed. The care plan documented the resident was at risk for falls related to muscle weakness and fluctuations in muscle strength and endurance and difficulty walking. Interventions included: -Anticipate and meet the resident's needs, be sure the resident's call light is within reach, the resident needs prompt response to all requests for assistance; -Ensure the resident is wearing appropriate footwear when ambulating or mobilizing in a wheelchair; -Follow facility fall protocol; -Physical therapy to evaluate and treat. The care plan did not include any kind of toileting program after the fall on [DATE], for the staff to assist the resident to the bathroom. The care plan did not address the resident's use of a walker, or unsteady balance. The care plan did not address the resident's poor vision or confusion. The care plan did not address the resident's low blood pressure and potential for dizziness. The care plan did not address the oxygen tubing the resident had tripped on going to the bathroom on [DATE], when he fell . The care plan was not revised after the resident's fall on [DATE]. On [DATE], the medical director documented the resident had a history of [REDACTED]. He has dementia and although he has had a history of [REDACTED]. However, the resident fell [DATE]. The medical director further documented, He was on anticoagulants and developed a subarachnoid hemorrhage and subsequently succumbed. He further documented the physician at the hospital stated the fall may have had nothing to do with his ultimate death. The hospital records were reviewed. The hospital records documented the resident presented on [DATE] with a 1.5 centimeter laceration to the left eye and subarachnoid hemorrhage. He was status [REDACTED]. His prognosis was poor, with multiple comorbidities, and now with subarachnoid hemorrhage that would likely progress to [DIAGNOSES REDACTED]. The death certificate from the coroner was reviewed on [DATE]. The death certificate documented the immediate cause of death was [MEDICATION NAME] force trauma head injuries with complications, approximately two weeks prior. Significant conditions contributing to the death but not resulting in the underlying cause, were [MEDICAL CONDITION], chronic obstructive [MEDICAL CONDITION], diabetes mellitus, hypertension, cardiovascular disease, [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. The death certificate documented the resident was witnessed to roll out of bed and strike his head on the bed during the fall. He was pronounced dead on [DATE] at 5:02 p.m. The facility reported the [MEDICAL CONDITION] on [DATE] to the state health department. The investigation by the facility documented the resident was alert when he left the facility and had no change in level of consciousness. His bed was in the high position and it was unclear if the resident thought the bed control was a call light. It was unknown why the bed was up or what happened. V. Staff interviews LPN #2 was interviewed on [DATE] at 10:32 a.m. by phone. She said she was the nurse on duty the evening Resident #198 fell on [DATE]. She said the resident had raised his bed to the highest position earlier in the shift and the staff lowered it. LPN #2 said she did not put the resident on frequent checks after the first incident of raising his bed to the highest level, despite knowing he was a fall risk. She did not recall what time the bed was raised earlier in the shift. She said later that night the CNA found him on the floor bleeding on the left side of his head and lying on the right side of his bed. The bed was at the highest position. She did not recall what he was wearing on his feet. She said she did not recall where his call light was. She said the resident was at high risk for falling because his gait and balance were unsteady and he had weakness in his knees due to wounds. RN #3 was interviewed on [DATE] at 11:51 a.m. She said she was the RN supervisor on duty [DATE] when resident #198 fell out of bed. She said he was on the floor bleeding from the left side of his head, he was confused and refused to allow the staff to take vital signs. She applied pressure to the laceration but was unable to stop the bleeding and sent him to the hospital. She said his bed was in the high position. She did not know how high it was. She did not know where his call light was. She did not know if he was a fall risk. She had not met him before that night. LPN #1 was interviewed on [DATE] at 8:07 a.m. She said the resident was quiet and confused. She said he would get out of bed by himself and sit in a chair. She said he used a walker for mobility but his balance was not good. She said he did not require assistance ambulating, but she said he was at risk for falling due to his poor balance and his use of oxygen. The director of nursing (DON) was interviewed on [DATE] at 9:19 a.m. She said a fall risk assessment should have been done for Resident #198 on admission and after the fall on [DATE] to prevent further falls. She said she did not know why they were not done. The DON said she did not interview any of the staff after the fall on [DATE], and was not aware that he had raised the bed up in the high position earlier in the shift prior to his fall that night. She said she did not have an investigation.There was no investigation regarding who (resident or staff ) raised the bed, whether the resident could use his call light, was the call light in reach, was the call light on when he fell , when the resident was last checked, how often had he been checked. The DON said the staff should have put him on frequent checks after the first time the bed was found raised earlier that evening. She said they had forms they could use at the desk to do this. She could not say how frequently the staff should have checked him after the first raising of the bed, but said he should have been on frequent checks to keep him safe. The DON said it was not in the resident's character to raise the bed himself. She said the medical record did not indicate if his call light was in reach or where it was. She could not answer why there was no IDT note after the first fall, no new interventions, or updates to the care plan. She said, I don't see that we did anything after his first fall on [DATE]; we did not update the care plan. The DON said the staff were now required to call her with each fall and she walked them through each step. She said the nurse should do an SBAR after the fall, the IDT should meet and document a note, the care plan should be updated, and there should be a fall risk assessment done. Neurological checks if required and an internal risk form should be completed. She said she started this new process of calling her with each fall in [DATE]. The nursing home administrator (NHA) was interviewed on [DATE] at 3:14 p.m. He said the DON had spoken to the hospital neurosurgeon who said maybe the resident had a stroke and then fell out of the bed. The NHA said he did not report the incident to the state until four days after it occured because he could not get any information from the hospital. The NHA said his investigation did not include any interviews with staff except the LPN assigned that night. He had not reviewed any hospital records and was not aware of the cause of the resident's death.

Based on observations, record review and interviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for five (#31, #198, #73, #58 and #54) of nine out of 33 sample residents. Specifically, the facility failed to ensure: -A timely orthopedic consultation was provided as ordered by the physician to follow up on Resident #31's admitting [DIAGNOSES REDACTED]. -A physician order was sought and obtained prior to removing Resident #31's sling and performing range of motion (ROM) and resistance (weight) exercises to the affected left upper extremity (LUE); -The admitting [DIAGNOSES REDACTED].#31's care plan. These failures resulted in Resident #31 experiencing increased, severe pain and potentially delayed healing of a fractured clavicle. The facility further failed to ensure: -Neurological assessments were completed per instructions, and abnormal vital signs assessments were reported and followed up on, for Resident #198; -Medications were available for administration for Resident #73; -Neurological assessments was initiated immediately after an unwitnessed fall for Resident #58; -Resident #54's vital signs were taken prior to the administration of a hypertensive medication to ensure the resident was within the physician-ordered parameters. Findings include: I. Failure to ensure proper care for Resident #31's fractured clavicle Cross-reference F697 pain management: the facility failed to prevent increased pain during range of motion (ROM) services by therapy which resulted in the resident experiencing severe pain. A. Resident #31's status Resident #31, less than [AGE] years old, was readmitted on [DATE]. According to the February 2020 computerized physician orders (CPO), [DIAGNOSES REDACTED]. The resident [DIAGNOSES REDACTED]. The 11/26/19 minimum data set (MDS) assessment coded the resident as cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had sustained a fracture resulting from falls in the past six months prior to this assessment. No pain experience was recorded. The resident received an opioid for seven days prior to this assessment. The resident did not reject evaluation or care. The resident required one person physical assistance with transfer, walking, locomotion, dressing and personal hygiene. B. Resident status on admission A review of the referral comment portion of the referral note by the referring physician, dated 11/16/19 at 7:43 a.m., reported Resident #31 failed at home. She's had 5 falls with the last fall being last evening. She now has a clavicle fracture. Her family member cannot care for her as she is unable to assist with any of her daily needs. C. Observation Resident #31 was observed on 2/24/2020 at 9:45 a.m. while the resident sat in her bed. The resident had a red/pinkish protrusion around her left clavicle (collar) bone. This protrusion was not observed on the resident's right collar bone. The resident was not wearing a sling. D. Resident interview Resident #31 was interviewed on 2/24/2020 at 9:56 a.m. The resident stated she discharged home in November of 2019 and had a fall at home which resulted in her fractured left clavicle. Specifically, the resident stated, I blacked out and fell in November of 2019 and fractured my collar bone in the process. My family member took me to the emergency room (ER) and I was under observation for three days. An X-ray of the left collar bone was conducted which indicated a fracture. The ER doctor recommended that I follow-up with an orthopedic surgeon. Furthermore, the resident stated, I got readmitted back at the facility, and there has been no ortho follow-up. I have been in constant pain since re-admitting to the facility. She expressed that her most excruciating pain was during range of motion exercises with occupational and physical therapy (OT and PT). Specifically, the resident stated she could feel her bones grinding against each other (referring to her fractured clavicle) and it caused a sensation she described as tormenting and horrible. The resident stated, I have not been spoken to about my orthopedic consultation or appointment since I readmitted . In fact, I had to look for a business card of a spine surgeon I have used in the past and provided the same to the DON about three days ago in an attempt to speedily ensure that a consultation with the orthopedic surgeon was made as it does not seem the facility was doing anything to make that happen. The resident reported that she had been wearing a sling to her affected arm since her clavicle fracture, but she was instructed by the occupational therapist (OT) to discontinue the use of the sling because her fracture should have healed. She said she did not feel her fracture had healed because it was still painful. E. Record review 1. History and physical - lack of follow-up on recommendations A review of the admitting physician history and physical completed with Resident #31 on 11/19/19 revealed the resident was admitted to a hospital and was diagnosed with [REDACTED]. A review of the resident's medical record revealed [REDACTED]. There was no documentation or care planning for providing a sling to support the resident's affected left arm/clavicle. There was no physician order to initiate or discontinue a sling to the resident's affected arm. 2. Therapy notes Review of PT and OT notes revealed the therapists were aware of the resident's fractured clavicle. The precautions/contraindications portion of the exercise sessions with Resident #31 documented: status [REDACTED]. a. OT notes The OT progress note dated 2/13/2020 documented that Resident #31 participated in a graded therapeutic exercise to increase strength, endurance and ROM to LUE for functional performance of ADLs. During the session, Resident #31 performed resistance exercise with a theraband to the LUE (there was no order for the resident to partake in such exercise). The pain at rest and pain with movement recorded for this session was zero and four consecutively out of 10. Complexities/barriers impacting the session were identified as history of left clavicle fracture, unhealed properly. The document also revealed Resident #31 reported that her LUE remaining still was what helped with her pain. According to the OT progress note dated 2/20/2020, Resident #31 participated in a guided therapeutic exercise to increase strength, endurance and ROM to bilateral upper extremities (BUE) for performance of activities of daily living (ADLs). During the session, Resident #31 performed BUE bicep curls, chest presses, internal/ external rotations and overhead presses using three-pound weights for LUE and five-pound weights for RUE (there was no order for the resident to partake in such exercise).The pain at rest and pain with movement recorded for this session was zero and four consecutively out of 10. The document also revealed that Resident #31 reported that her LUE remaining still was what helped with her pain. The progress note further documented that the resident participated in facilitation of crossing midline and weight shifting with BUE activity. Complexities/barriers impacting the sessions were identified as resident complaint of left shoulder pain. b. PT notes The PT treatment encounter note dated 2/24/2020 documented Resident #31's pain at rest was three out of 10, The frequency was intermittent; the location was her left shoulder. She also reported neck pain and described the pain as aching to sharp. The pain with movement was rated at six out of 10. The frequency of the resident's pain with movement was described as hourly and the location was the resident's shoulder with active range of motion (AROM) like gleno-humeral flexion, abduction or extention beyond comfortable range identified as the cause of pain. The resident also reported neck pain, which was reported as usually worse in the morning. The PT treatment encounter notes documented a pattern of pain descriptions on the following dates: -2/5/2020 resident reported pain at rest and with movement as 0/10 and 5/10 consecutively; -2/12/2020 resident reported pain at rest and with movement as 3/10 and 7/10 consecutively; -2/17/2020 resident reported pain at rest and with movement as 0/10 and 5/10 consecutively; -2/18/2020 resident reported pain at rest and with movement as 3/10 and 7/10 consecutively; -2/19/2020 resident reported pain at rest and with movement as 3/10 and 6/10 consecutively; -2/21/2020 resident reported pain at rest and with movement as 2/10 and 5/10 consecutively. Documented pain levels on the medication administration records (MARs) were significantly below documented pain levels by therapy. There was no evidence if the resident was pre-medicated for pain prior to the physical or occupational therapy sessions. Therapy notes did not specify the time frame that they worked with the resident. 3. Care plans The resident's pain care plan, initiated on 3/31/16 and last revised on 4/19/18, during her prior admission to the facility, documented the resident was at risk for pain due to [DIAGNOSES REDACTED]. The resident's pain was not care planned when she was readmitted to the facility on [DATE] after she suffered a fractured clavicle. The readmitting [DIAGNOSES REDACTED]. The care plan also did not document treatment for [REDACTED]. F. Staff interviews Registered nurse (RN) #2 was interviewed on 2/26/2020 at 3:30 p.m. She said when a resident was admitted to the facility, the admitting nurse was responsible for inputting the necessary referral information such as recommended consults, hospital diagnoses, physician ordered medications and so on. RN #2 said it was important that each resident's admitting [DIAGNOSES REDACTED]. She reviewed Resident #31's care plan and verified that the resident's admitting [DIAGNOSES REDACTED]. The discharging physician was interviewed on 2/26/2020 at 10:23 a.m. via telephone. The physician stated it was important to timely follow-up consultation with orthopedics as the resident needed to be evaluated by an expert (orthopedic surgeon) who then made the decision to address the next line of treatment of [REDACTED]. The OT and PT were interviewed on 2/27/2020 at 9:37 a.m. The OT stated before she treated a resident, she would like to have a clarified physician order which detailed the location, type and frequency of therapeutic exercises the physician wanted with the resident. The OT also said she had done some therapeutic exercises to Resident #31's LUE (referring to the ROM and resistance exercise). She reviewed the resident's medical record and agreed that there was no order from the physician to do so. The OT verified that it was important to obtain a physician order prior to discontinuing Resident #31's use of the sling because the sling helped hold the resident's fractured clavicle in place and required the orthopedic surgeon's review to determine whether or not it was safe to discontinue the resident's use of the sling. The OT acknowledged that she instructed the resident to discontinue her use of the sling without having an order to do so. She also verified she did not document that decision and her rationale for doing so. The PT verified that though Resident #31 had an order for [REDACTED]. He verified that not having an order for [REDACTED]. The PT however verified that there was no follow-up x-ray on file since Resident #31's re-admission in November 2019. He stated it was important to have an x-ray to guarantee that the bone had healed. The PT agreed that pain could result from moving a body part with a fractured bone. The DON was interviewed on 2/25/2020 at 10:28 a.m. The DON said the resident declined an appointment to see an orthopedic surgeon on two occasions due to the resident needing time to get over her husband's passing which occurred sometimes around mid January of 2020. The DON reviewed the resident's medical record and verified there was no documentation of Resident #31's declining an appointment. The DON further stated, I guess we wanted to give her time to get over the situation with her husband. The DON however acknowledged there had been enough time to schedule an ortho appointment between 11/19/19 and 2/25/2020. The DON also reviewed the resident's physician orders and verified that there was no order to perform PT and OT services to the resident's LUE. The DON further verified that no follow-up x-ray was done since Resident #31 was readmitted . In addition, the DON agreed it was important for nursing and rehab staff to coordinate care to better address Resident #31's pain. Specifically, the DON said, I believe we would have done a better job if nurses and rehab staff had clear communication which addressed the resident's care (pain treatment related to fracture). She added that it was important for rehab staff to schedule their treatment session with consideration of the timeline of Resident #31 pain medication to help minimize her exacerbated pain experience during therapy sessions. The DON also said it was important to keep the sling on the resident pending her appointment with the orthopedic surgeon as it was relevant to at least keep the fractured bone in apposition (properly aligned). She concluded the interview by stating interdisciplinary team had to meet to address the care provided to Resident #31 and make amends going forward. G. Facility follow-up The DON input a late entry note in Resident #31's progress notes, dated 2/25/2020 at 11:58 a.m., which documented: Appointment made 1/17/20 at ortho one and due to husband just passing away last week re scheduled for 2/4 and resident did not want to go to this place but will look for her past orthopedic. On 2/21 the resident brought the card to my office and I explained to her that the offices were closed and I would call on Monday morning to obtain. The DON and the assistant director of nursing (ADON) were interviewed on 2/26/2020 at 11:53 a.m. The ADON stated she would want to see the resident's left clavicle fracture listed as part of her [DIAGNOSES REDACTED]. She said, It was important to do so in order to ensure there was no lag in the resident's care, particularly since it has to do with addressing her pain. She reviewed the resident's medical record and verified that the fractured clavicle was not listed as part of the resident's medical [DIAGNOSES REDACTED]. The DON provided an updated medical [DIAGNOSES REDACTED].#31's fractured left clavicle as part of her medical [DIAGNOSES REDACTED]. II. Failure to complete neurological assessments and follow up on abnormal vital signs assessments for Resident #198 A. Facility policy and procedure The Fall Management policy was received from the director of nursing (DON) on 2/26/2020 at 3:00 p.m. The policy documented in pertinent part, In the event a resident has a fall and it has been determined they hit their head or it cannot be determined if they hit their head, neurological checks are completed and documented per instructions. B. Resident #198 status Resident #198, age 70, was admitted to the facility on [DATE]. According to the December 2019 computerized physician orders (CPO), [DIAGNOSES REDACTED]. The 10/24/19 minimum data set (MDS) assessment documented the resident had short term memory loss, moderately impaired cognitive skills for daily decisions, disorganized thinking and inattention. He required limited one assist with bed mobility, supervision for transfers, dressing, eating, toileting, and personal hygiene. The assessment documented he had no falls since admission. However, the resident had fallen on 10/20/19. He was occasionally incontinent of bowel and bladder, and used a walker for mobility. His balance was unsteady. C. Record review The progress notes were reviewed. On 10/20/19 at 11:25 p.m. the licensed practical nurse (LPN) documented that around 10:15 p.m., the resident was found on the floor in a sitting position, close to the bathroom door. The registered nurse (RN) supervisor was notified and performed a head to toe assessment. There was no noted injury. On 10/21/19 at 12:22 a.m. the RN documented further, Resident was found sitting on the floor with his back resting on his wheelchair, both legs stretched out in front of him. He stated that he tripped over his nasal cannula (oxygen) line while walking to the bathroom by himself. Physical assessment from head to toe completed with no visible injury nor bruises at this time of assessment. Active range of motion (ROM) to both upper and lower extremities completed by this nurse. Resident is verbally responsive to nurse, assisted to standing position and he walked over to his bed without any assistance, at the presence of nurses and staff. Neuro checks started, physician and family were notified by the nurse. Denies any pain. The neurological check assessments dated 10/20/19 at 10:15 p.m. were reviewed. The instructions at the top of the form documented to complete the neurological assessment every 30 minutes times four, then every one hour times four, then every four hours for 24 hours, then every eight hours for the remaining 72 hours. The neurological assessment included checking the vital signs (blood pressure, temperature, respirations, and pulse), level of consciousness, pupil reaction and eye signs, eye, motor and verbal response. The neurological checks were incomplete. The documentation revealed the following: -On 10/20/19 at 10:15 a.m. through 10/21/19 at 4:45 a.m. there was no assessment documented of the residents eye response; -10/21/19 at 2:45 a.m., the resident's vital signs were not checked because he was sleeping; -10/21/19 7:45 p.m., the neurological checks did not include vital signs, pupil reaction or eye signs, or motor response; -10/21/19 at 11:45 p.m., the neurological checks did not include the eye, motor or verbal response; and -10/22/19 at 3:45 a.m., the neurological checks did not include the level of consciousness, pupil or eye signs, eye, motor or verbal response. There were no neurological checks for: -10/22/19 from 3:00 p.m. to 10:00 p.m.; -10/22/19 10:00 p.m. to 6:00 a.m. (except for eye, motor and verbal response); -10/23/19 6:00 a.m. to 2:00 p.m.; -10/23/19 2:00 p.m. to 10:00 p.m.; and -10/23/19 10:00 p.m. to 6:00 a.m. The neurological checks documented multiple low blood pressures. On 10/20/19 at 10:15 at the time of the fall, the resident's blood pressure was 85/51 (older adult normal range 120/80). On 10/21/19 at 1:45 a.m., the blood pressure was 76/43, and at 3:45 a.m. the blood pressure was 69/39. The nurses' progress notes were reviewed. There was no documentation that addressed the resident's low blood pressure. D. Staff interviews The DON was interviewed on 2/27/29 at 9:17 a.m. She reviewed the neurological checks initiated 10/20/19. She said they were not done correctly. She said the neuro checks should have been done even if the resident was sleeping. The DON said the staff should have awakened the resident to complete the assessment and ensure there were no changes to his neurological status. She said it looked as if the resident's blood pressure and pulse were running low and there should have been follow up, including notifying the physician. She said the nurses didn't complete this at all, they did not do a good job. She said, They didn't even do anything from 10/22/19 to 10/23/19. The DON said she did not like the current form they used for neurological checks because it only checked the status every 30 minutes in the beginning. She said she would be ordering a new form. III. Failure to ensure medications were available for administration for Resident #73 A. Facility policy and procedure The Medication Administration policy, revised June 2008, was received from the DON on 2/26/2020 at 3:15 p.m. The policy documented in pertinent part, Resident medications are administered in an accurate, safe, timely and sanitary manner. Begin new medication orders timely. Begin routine orders on the same day ordered. B. Resident #73 status Resident #73, age 86, was admitted on [DATE] and readmitted on [DATE]. According to the February 2020 computerized physician orders (CPO), [DIAGNOSES REDACTED]. The 1/9/2020 MDS assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required extensive assistance with bed mobility, transfers, dressing, personal hygiene, toileting and bathing. She had frequent complaints of pain. C. Resident interview Resident #73 was interviewed on 2/24/2020 at 3:52 p.m. She said the nurses frequently did not have her medications and she had to go without them. She said she had missed her eye drops for [MEDICATION NAME] degeneration many times because they ran out of them. She said she had not received her eye vitamins and blood pressure medications several times. Resident #73 said they had even run out of insulin and her [MEDICATION NAME] pain medication. She could not recall the dates she missed medications but said it had happened multiple times in the last year. D. Record review The nurse progress notes, medication administration records (MARs), and controlled drug count sheets were reviewed and documented the following: -The resident had orders for [MEDICATION NAME] 2 mg (milligrams) every eight hours for pain. The controlled drug sheets for January 2020 and MARs were reviewed. The MAR indicated [REDACTED]. On 1/22/19, the 6:00 a.m. dose of [MEDICATION NAME] was not signed off the controlled drug sheet. In addition, the controlled drug count sheet for the [MEDICATION NAME] doses administered from 11/28/19 through 12/8/19 was requested three times from the DON, and not received. -On 2/25/2020 at 10:23 a.m, the nurse progress notes documented, [MEDICATION NAME] solution 0.5% eye drops for [DIAGNOSES REDACTED], was not given because the nurse was waiting for pharmacy to deliver. -On 2/20/2020 at 10:20 a.m, the nurse progress notes documented, Dorzolamide HCL solution 2% eye drops, for [DIAGNOSES REDACTED], was not given because the nurse was waiting for pharmacy to deliver. -On 1/29/2020 11:04 a.m., the nurse progress notes documented, Ocular vitamins, eye health supplement, was not given because the nurse was waiting for supply. -On 1/28/2020 10:21 a.m., the nurse progress notes documented, Ocular vitamins, eye health supplement, was not given because the nurse was waiting for supply. -On 1/27/2020 10:52 a.m., the nurse progress notes documented, Ocular vitamins, eye health supplement, was not given because the nurse was waiting for supply. -On 1/23/2020, 12/26/19, 12/16/19, 12/9/19, 12/8/19, 12/2/19, the nurse progress notes documented, Icy Hot Patch to the left knee at bedtime for knee pain was not administered because it was on order. -On 11/26/19, 11/25/19, 11/22/19 to 11/20/19, the nurse progress notes documented, [MEDICATION NAME] vitamins for supplemental eye health were not given because the nurse was waiting for supply. -On 10/11/19 at 10:19 p.m., the nurse progress notes documented, [MEDICATION NAME]15 units subcutaneously at bedtime for diabetes. Notify physician if the fasting blood sugar is less than 70 or greater than 400. The insulin was not given because the medication was not available, called the pharmacy to order, will be coming after midnight. There was no blood glucose level documented. There was no follow up documentation that the resident received the insulin that night. -On 10/5/19 through 6/21/19 there were more than 10 nurse progress notes documenting that the resident's [MEDICATION NAME] Solution 22.3-6.8mg/ml (milligrams per milliliter) eye drops, for [DIAGNOSES REDACTED], were not given because it was not available. -On 4/14/19 at 10:37 a.m., the nurse progress notes documented, [MEDICATION NAME]10 units subcutaneous in the morning was not given because the nurse was waiting for the pharmacy to deliver the medication STAT. The blood glucose level was 203. The nurse notified the physician and received orders to check a fasting blood glucose level before dinner and call the physician if the results were over 250 mg/dL (milligrams per decilitre). E. Staff interviews Registered nurse (RN) 31 was interviewed on 2/25/2020 at 10;31 a.m. She said sometimes medications were unavailable. She said medications could be reordered through the computer or by pulling the label on the medication card and faxing it to the pharmacy. She said if medications were not available in her cart, she would check the facility backup supply and call the pharmacy. She did not indicate the physician would be notified. Licensed practical nurse (LPN) #1 was interviewed on 2/26/2020 at 11:32 a.m. She said if she did not have a medication available she would notify the physician and call the pharmacy to get the medication. She said she would also try to get it out of the facility backup supply. She could not answer if medications were frequently unavailable. The DON was interviewed on 2/26/2020 at 11:32 a.m. She said the nurse should notify the physician when medications were not available, call the pharmacy, and attempt to get it from the facility's backup supply. She said she would investigate the omitted medications noted. The DON was interviewed again on 2/27/2020 at 9:29 a.m. She said the resident's [MEDICATION NAME] and Dorzolamide HCl eye drops had not been delivered from the pharmacy because it had been ordered too soon and could not be sent sooner than 30 days from the last supply. She said the nurses could have filled out a form for the facility to cover the cost of ordering the medication early, but they had not done that. The DON said she could not figure out what happened with the missed [MEDICATION NAME]doses, but he would be educating the nurses to notify the physician and the DON in this situation. The DON further said there was no reason for the resident to have missed the eye vitamins because the facility had them in house stock. She said Icy Hot was not part of the facility formulary and therefore they did not carry the medication in their house stock. She said she had called the physician today to get the order changed to Biofreeze. The DON said she was still looking for the controlled drug sheet for Diluadid doses 11/28/19 through 12/8/19. She said she was the nurse on duty 1/22/2020 and the resident refused the medication. She said she did not document it properly. The DON said she was still investigating the missed dose from 1/17/2020. IV. Failure to start neurological assessments timely after an unwitnessed fall for Resident #58 A. Resident status Resident #58, age 66, was admitted on [DATE]. According to the February 2020 CPO, [DIAGNOSES REDACTED]. The 12/21/19 MDS assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The resident did not exhibit any behaviors. The resident required extensive staff assistance for bed mobility, dressing, eating, toileting and personal hygiene. B. Record review The care plan for falls, revised on 4/5/19, revealed the resident was at high risk for falls related to muscle weakness and a history of falls. Some of the interventions revealed to anticipate the resident's needs. Place the resident's call light within reach and encourage the resident to use the call light for assistance as needed. Provide prompt response to the resident's use of the call light for assistance. The fall risk assessment, performed on 12/7/19 at 7:43 p.m., revealed the resident had a score of 12 or high risk. The situation, background, assessment, recommendations (SBAR) summary dated 12/29/19 at 7:33 a.m., by a licensed practical nurse (LPN) revealed the resident was assessed by a registered nurse (RN). The resident walked from her bed into the bathroom and fell . The resident's wheelchair was by the closet door in her room. The resident's bed was in the lowest position and the call light was within reach. The fall was unwitnessed and no injuries were observed. The fall risk assessment, performed on 12/29/19 at 6:41 p.m., revealed the resident had a score of 17 or high risk. The interdisciplinary (IDT) post fall review, dated 12/29/2020 at 6:43 p.m., revealed the resident had an unwitnessed fall with no injuries on this date at 7:30 a.m. The location of the fall was in the resident's bathroom. The resident performed an unassisted transfer from her bed. The resident had an unsteady gait, cognitive deficits and a history of falls. The resident wore socks at the time of the fall. The resident was encouraged to use the call light for assistance. The Neurological Record (NR) revealed the facility started the neurological assessments for the fall on 12/29/19 at 3:30 p.m. The fall occurred at 7:33 a.m. There was an eight hour delay in starting the assessments for this unwitnessed fall. The facility nursing staff did not follow the frequency listed on the NR. A nurse note dated 12/30/19 at 3:40 a.m. by an RN revealed the resident fell while coming out of the bathroom. The resident had no complaints of pain and there were no post fall injuries observed. Neurological assessments were at the resident's baseline. A nurse note dated 12/31/19 at 12:40 p.m. by an RN revealed the resident continued to be monitored for a previous fall. The resident was stable and was at her baseline for the day. C. Staff inter

Based on observations, record review and staff interviews, the facility failed to ensure food items were stored and served under sanitary conditions for one of one serving areas. Specifically, the facility failed to ensure: -Opened food items were labelled and dated; -Dented canned food items were not put in the rotation, ready to be used and served; and -Cooking utensils were stored appropriately. Findings include: I. Facility policy and procedure The Receiving policy, revised in September of 2017, was provided by the certified dietary manager (CDM) on 2/27/2020 at 1:30 p.m. The policy read in part, Safe food handling procedures for time and temperature control will be practiced in the transportation, delivery and subsequent storage of all food items. II. Opened and unlabelled food items A. Observation During the initial tour of the kitchen on 2/24/2020 at 8:36 a.m. opened food items which had no labels/dates were observed. The food materials included: -Two packs of plain bagels; -Three packs of Sara(NAME)whole grain bagels; -Two containers of Wholesome Farm liquid whole eggs with citric acid; -A bowl of lettuce and tomatoes in the refrigerator; -Two packs of corn tortillas; -One box of Sysco classic complete mashed potatoes; -One pack of egg noodles; -Two packs of durum wheat semolina pasta; -Two containers of Sysco Imperial brown gravy mix; and -Two containers of Sysco Imperial country style gravy B. Interview The CDM was interviewed on 2/27/2020 at 8:52 a.m. The CDM said it was important to label/date stamp opened food items to track how long they had been opened and also to know if they were usable. She said the best practice was to toss unlabelled/ dated food items. The CDM tossed the aforementioned food items. She stated she would educate dietary staff on the need to date stamp open food items going forward. III. Dented food cans A. Observation During the initial tour of the kitchen on 2/24/2020 at 8:36 a.m., canned foods which were dented around the seams were observed on the shelf and ready to be served. The canned food items included: -one can of applesauce; -one can of sliced pears; and -one can of mandarin oranges. B. Interview The CDM was interviewed on 2/27/2020 at 8:52 a.m.The CDM verified that the facility cared for vulnerable individuals and that it was essential to ensure foods served to such a population were free from contaminants. Specifically, the CDM verified that the three identified cans were dented enough to have raised a red flag for dietary staff not to have shelved them ready to serve. In addition, the CDM stated the risk associated with canned food dented around the seam was that the dents could result in pinhole-size openings and that the mixture of air and moisture from the food within the can had the potential to spur bacteria growth hence contaminating the food. She reported that the standard was to store dented cans separately and request credit for them from the suppliers. The CDM concluded the interview stating she would provide education to dietary staff going forward. IV. Failure to ensure utensils were stored in sanitary manner A. Observation During observations of the afternoon meal on 2/26/2020 beginning at 12:00 p.m., the pizza cutter, measuring spoons, spatulas, tongs and whisks were observed in the kitchen cabinets. The cabinets which housed the aforementioned items had a mixture of oily and black dustlike particles at the bottom which were consistent with long standing dirt. There were also tiny particles which the CDM described as crumbs. The cabinets had no mats in them, thus the cooking utensils were sitting directly on the dirty surfaces as described above. The CDM examined the cabinets using her finger to gather the particles and agreed that they were indeed dirty. B. Interview The CDM was interviewed on 2/26/2020 at 8:52 a.m. The CDM stated resident safety is a top priority and that proper cleaning and sanitizing was how the goal of keeping residents safe could be met. The CDM said what she thought was wrong with the cabinets was that dietary staff were just wiping the cabinets without putting the drawers through the dishwasher. She added that she believed the crumbs observed in the cabinets were from the cabinet drawers being left ajar and the piles of crumbs kept making their way into the cabinets. She concluded that education would be provided to dietary staff on the need to clean and sanitize the kitchen more effectively. V. Follow-up The CDM provided copies of in-service attendance records for the topics: -Dented cans; -Food storage and labelling; and -Cleaning and sanitizing. The in-service attendance reported a start date of 2/27/2020. The document further reported an identified solution which read: Dented cans cannot be stored on the can rack and cannot be used in food preparation. All canned goods will be appropriately inspected for dents, rust or bulges. Damaged cans will be segregated and clearly identified for return to vendor or disposal, as appropriate. The document further read: All food preparation areas, food services areas and dining areas will be maintained in a clean and sanitary condition. The in-services document itemized the procedures through which kitchen sanitation was to be achieved and it read as follows: The dining services director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls ceilings, lighting and ventilation; -The dining services director will ensure that all employees are knowledgeable in the proper procedures for cleaning and sanitizing of all food service equipment and surfaces; -All food contact surfaces will be cleaned and sanitized after each use; -The dining services director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas and surfaces; and -All dining areas will be cleaned and sanitized after each use. The CDM was interviewed on 2/27/2020 at 1:16 p.m. The CDM verified that the facility conducted the above mentioned in-service because they were informed during survey of the above observations.

Based on record review and interviews, the facility failed to provide sufficient nursing staff to ensure the residents received the care and services they required to achieve their highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed to ensure enough staff were available to adequately care for the residents, as residents felt and expressed their activities of daily living (ADLs) of toileting assistance, transferring, showers, and overall call light response, were not met and addressed in a timely manner. Cross-reference: F604 restraints, F677 ADLs, F684 quality of care, F689 falls/accidents, F697 pain management, F698 [MEDICAL TREATMENT] services, F742 psychosocial well-being, and F758 unnecessary medications. Findings include: I. Resident interviews Residents, who per facility assessment were cognitively independent and interviewable, made the following comments about nursing staffing. Resident #81 was interviewed on 2/24/20 at 8:58 a.m. She said call light response time needed much improvement. Resident #81 said there was not enough staff to help everyone in a timely manner. She said she sometimes had to wait over an hour in the morning and 45 minutes to two hours to lie down at night. She said staff either ignored her or just did not have the staff available to assist her. She said she required two female staff to assist her with ADL care. Resident #73 was interviewed on 2/24/20 at 10:09 a.m. She said she preferred to get up at 7:00 a.m., but that did not always happen. She said recently she woke up at 7:20 a.m. and turned on her call light. According to the resident, no one answered the call light. She said she waited 15 minutes then decided to get herself out of bed. The CNA then came into her room, turned off the call light, and left. The resident said she had to take herself to the nurses' station to ask for help. She had to cover herself with a gown that had a broken snap, her hair was clumped together, she had shoes on with no socks, and needed a new brief. She said the CNA approached her and told her that he could not assist because he needed to feed another resident and did not have the time to help her. Resident #73 expressed her frustration and said she wanted to leave the facility. Resident #10 was interviewed on 2/24/20 at 11:42 a.m. He said he recently had his catheter bag overflow and leak on his clothes and his bedding in the middle of the night. He said he called for help but no one came. He said he had to clean himself up the best he could. Resident #51 was interviewed on 2/24/20 at 1:35 p.m. She said there was not enough staff to help on the 2:30 p.m. to 10:30 p.m. evening shift or sometimes on the overnight shift. She said they usually had only two CNAs working. She said call lights routinely took a 15 to 30 minute response with three CNAs. She said when there were only two CNAs available, the call light response time jumped up to 45 minutes. Resident #51 said the CNAs just could not handle everyone's needs without long waits. She said she had experienced weekend nights where she waited all night for assistance, and no one came. Resident #44 was interviewed on 2/24/20 at 2:49 p.m. He said call light response time had been a big concern for him. He said he was able to provide most of his own care but at night he would have a lot of pain and needed more assistance. He said it would take 30 to 45 minutes for someone to check on him after he pushed the call light. Resident #44 said there were sometimes only one to two CNAs at night. He said he felt that the staff did the best they could to assist everyone but they just needed more help, and the nurse did not usually answer the call lights. II. Group interview A group interview was held on 2/25/20 at 10:00 a.m. with five alert and oriented residents selected by the facility for participation. The residents represented all three units. The residents said they felt the CNAs worked hard but were short handed, resulting in long waits for care and services. They said they had not had consistent staff coverage. They said they were also aware that some staff were let go and some staff quit. One resident said she had to go to bed sometimes 45 minutes to two hours past her preferred bedtime because she had to wait for CNA availability. One resident said they need to hire more staff to meet everyone's needs. He said he was independent but other residents needed a lot of help. The group said they addressed their concerns in resident council but had not seen much change. One resident said she had to wait a long time for even simple requests such as getting ice. She said the staff was just too busy, CNAs tried to meet everyone's needs but they just did not have enough help. One resident said he had to wait for 45 minutes in pain at night because no one answered his call light, so he took himself to the nurses' station to request pain medication. Another resident said dinners were sometimes late because there was not enough staff to help. According to the group, they felt their biggest concern was that the facility needed to ensure there was enough staff to be able to answer call lights to check to see if there were serious problems with the residents, even if the staff could not meet all their needs right away. III. Record review A. Resident council meeting minutes The resident council minutes for January 2020 and February 2020 were reviewed. According to the January minutes, residents felt there was a shortage of CNAs available related to staff turnover and staff on vacation. According to the February minutes, residents felt they were short a CNA over weekends between 6:30 p.m. and 9:00 p.m. The residents also identified a shortage of nursing staff on the 3rd floor unit between 7:30 a.m. and 8:00 a.m. Specific details of dates were not provided. B. Staffing schedules The February 2020 staff schedule was reviewed. The schedule revealed the following: The weekend schedule for the 6:30 p.m. to 6:30 a.m. shift on 2/1/20 for the second floor unit indicated only two CNAs worked between 6:30 p.m. and 10:30 p.m. The 6:30 a.m. to 2:30 p.m. shift for the second floor unit had only two CNAs on 2/2/20, 2/5/20, 2/3/20, 2/4/20 , 2/9/20, 2/11/20, and 2/27/20. The 2:30 a.m. to 10:30 p.m. shift for the second floor unit had only two CNAs on 2/9/20, 2/10/20, 2/11/20, and 2/22/20. The 6:30 a.m. to 2:30 p.m. shift for the second floor unit indicated the third CNA scheduled was in training and shadowed the second CNA on the unit on 2/10/20 and 2/11/20. The 2:30 p.m. to 10:30 p.m. shift for the second floor unit, indicated a third CNA was on restricted light duty from 2:30 p.m. to 6:30 p.m. on 2/13/20, 2/14/20, 2/17/20, 2/18/20, 2/20/20, 2/21/20, 2/24/20. The 6:30 p.m. to 6:30 a.m. schedule for the second floor unit for 2/15/20 and 2/16/20, revealed the unit had only two CNAs from 6:30 p.m. to 10:30 p.m The weekend 6:30 a.m. to 6:30 p.m. shift for the second floor unit on 2/15/20 had only two CNAs scheduled. According to a note on the schedule, no coverage was found. The third CNA on the third floor unit had to rotate between the two floors. The 6:30 a.m. to 2:30 p.m. shift on 2/19/20, for the second floor unit, had only one CNA scheduled on the unit between 6:30 a.m. and 8:30 a.m. The weekend 6:30 a.m. to 6:30 p.m. shift for the second floor unit on 2/23/20 had only two CNAs scheduled. According to a note on the schedule, no coverage was found. The 6:30 a.m. to 2:30 p.m. shift for the second floor on 2/24/20, indicated only two CNA's were scheduled between 12:00 p.m. and 2:30 p.m The 6:30 a.m. to 2:30 p.m. shift for the third floor unit had only two CNA's on 2/1/20 and 2/11/20. The weekend schedule for the 6:30 p.m. to 6:30 a.m. shift on 2/1/20 for the third floor unit indicated only one CNA worked between 6:30 p.m. and 10:00 p.m. The 6:30 p.m. to 6:30 a.m. schedule for the third floor unit for 2/16/20 revealed the unit had only two CNAs from 6:30 p.m. to 10:30 p.m. The 2:30 p.m. to 10:30 p.m. shift for the third floor unit had only two CNAs on 2/18/20 and 2/20/20. The 6:30 a.m. to 2:30 p.m. shift on 2/19/20, for the second floor unit and third floor unit, indicated only two CNAs worked on the second floor. The third CNA on the third floor worked on the second floor between 8:30 a.m. and 11 a.m., leaving the third floor with only two CNAs. The 6:30 a.m. to 2:30 p.m. shift for the third floor on 2/24/20, indicated only two CNAs were scheduled from 6:30 a.m. to 9:45 a.m. The 2:30 p.m. to 10:30 p.m. shift for the third floor on 2/24/20, indicated only two CNA's worked between 6:30 p.m. and 10:30 p.m. C. Resident census and conditions The census and conditions of residents form, provided by the facility on 2/24/20, revealed 97 residents resided in the facility. Care needs of the residents were documented as follows: -14 residents were dependent on staff for bathing and 80 residents needed the assistance of one or two staff to bath; -Five residents were dependent on staff for dressing and 91 residents needed the assistance of one or two staff to dress; -Eight residents were dependent on staff for transferring and 81 residents needed to the assistance of one or two staff to transfer; -Six residents were dependent on staff for toileting and 84 residents needed the assistance of one or two staff to use the toilet; - Four residents were dependent on staff for eating and 69 residents needed the assistance of one or two staff to eat; -22 residents were frequently or occasionally incontinent of bladder; -20 residents were frequently or occasionally incontinent of bowel; -Five residents were bedfast all or most of the time; -39 resident were in their wheelchairs all or most of the time; -19 residents had a [DIAGNOSES REDACTED].>-Four residents had current pressure injuries and 53 residents received preventative skin care; -Two residents recieved [MEDICAL TREATMENT] services; -Three residents received intravenous therapy, nutritions, and/or blood transfusion -23 residents recieved respiratory care; -Nine residents had contractures; -Three residents received [MEDICAL CONDITION] care; -Nine resident has a indwelling or external catheter; -Three residents received ostomy care; -Five residents received suctioning; -Six residents were tube fed; -11 residents received therapy services; -Nine residents received antibiotic therapy; -11 residents had behavioral healthcare needs; -44 residents were on psychoactive medication; and -74 residents were on a pain management program. D. Facility assessment The facility assessment was provided on 2/25/20 by the facility. The facility assessment indicated the facility had 3 units. The assessment revealed: -44 or more residents lived on the second floor unit; -46 or more residents lived on the third floor unit; and, -16 or more residents lived on the fourth floor unit. According to the facility assessment, staffing was determined by census and acuity. According to the assessment, the facility should adapt staffing levels based on resident needs and preferences, including activity of daily living assistance, (ADLs). The assessment indicated staff shortages should be replaced quickly, with the assistance of PRN (as needed) staff, the scheduler, the health information manager (HIM), and certified nursing aides (CNA's). IV. Staff interviews Licensed practical nurse (LPN) #4 was interviewed on 2/24/20 at 8:59 a.m. She revealed the third floor unit had 41 residents and needed to have three CNAs to provide care on the 6:30 a.m. to 2:30 p.m. shift. She said they currently had only two CNAs working on the morning shift of 2/24/20. LPN #1 was interviewed on 2/25/20 at 2:53 p.m. She said Resident #10 requested to have a shower on the evening of 2/24/20. She said she told him that they only had CNAs working and could not fit him in. She said there were just not enough CNAs sometimes. The scheduler (SCH) was interviewed on 2/26/20 at approximately 10:00 a.m., with the director of nursing. According to the SCH, the second and third floor unit required two nurses, three CNAs for the day and evening shift, and one nurse and two CNAs overnight. According to the DON, she recently increased staffing from one to two nurses and one CNA for the day and evening shift. The SCH said the facility currently used an agency CNA to help fill in the holes when possible. She said they had some CNAs on leave. She said she had had to place a CNA on the second floor who was on restricted light duty. The SCH said the light duty CNA could not turn, push, pull or transfer residents, and was limited to nail care and taking meal orders and vitals. The light duty CNA had been in place of a third CNA on the unit but could not do most of the ADL needs that CNAs without restrictions could do. The SCH said she tried to replace the holes in the schedule. She said, when possible, she used an agency CNA when she could not find anyone else to work the needed shifts. The DON was interviewed on 2/27/19 at 10:42 a.m. She said she wished she could hire five more staff. She said she had several open positions and had staff turnover related to poor attendance. CNA #6 was interviewed on 2/27/20 at 2:25 p.m. He said he had experienced coverage shortages recently but as a seasoned CNA, he could handle the extra workload. He said it seemed difficult for the new staff to keep up with the heavier resident load. CNA #2 was interviewed on 2/27/20 at 2:31 p.m. She said she has been a CNA for [AGE] years. She said she had had to work short for several weeks. She said it was related to a high staff turnover. She said it was too difficult for only two CNAs to have to tend to the high acuity needs of 45 residents. CNA #11 was interviewed on 2/27/20 at 5:15 p.m. He said staff shortages were frequent and put too much burden on the staff who worked to provide care for the residents. The SCH was interviewed again on 2/27/20 at 11:41 a.m. with the human resource corporate consultant (CSC). She said she tried to accommodate the needs of residents but staffing coverage had been a challenge. The SCH said a light duty CNA should not count as a third CNA on the second floor. She said she was aware that she needed more staff. The SCH said she recently lost three staff members, had two CNAs out on medical leave, and had open positions on every shift. She said she had three open positions on the day shift, two open positions on the evening shift, and two open overnight positions. The CSC said the facility was always trying to improve its staffing coverage but struggled to get qualified staff to apply. He said they encouraged the use of agency staff, and with help from the corporation, were looking into the possibility of increasing the wage scale to meet the current market value of the positions. He said all efforts were being made to recruit staff. He said increasing staff would reduce the stress of the staff, and better meet the needs of the residents.

Based on observations, record review and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure the following areas were free from multiple environmental concerns observed during repeated tours of the facility: -13 of 66 resident rooms/bathrooms; -Three of nine hallways; -One of four dining rooms; -One of one activity room; -One of three common areas; and -One of three nurses' stations. Findings include: I. Facility policies and procedures The Physical Plant Interior Maintenance policy, revised March 2008, was provided by the nursing home administrator (NHA) on 2/27/2020 at 11:30 a.m. The policy revealed all interior areas of the building were inspected within a one-month period to ensure proper condition and function. Interior maintenance of the physical plant was an essential function of the preventive maintenance program to assure employee and resident safety. -Daily inspect all halls and exits for obstructions. -Check cove base for cleanliness and tightness. Replace or re-glue loose areas of the cove base. Report cleaning issues to housekeeping for additional cleanliness. -Check all areas of ceramic/vinyl flooring for repairs and cleanliness. Repair/report all damaged areas. Report cleaning issues to housekeeping for additional cleanliness. The Common (Public) Areas Cleaning policy, revised April 2005, was provided by the NHA on 2/27/2020 at 11:30 a.m. The policy revealed day rooms and lounges were cleaned daily to provide clean, odor-free and neat appearing public areas. -Check walls and spot wash as necessary. -Dry mop, then wet mop hard surface floors daily with a disinfectant solution. Move furniture to clean underneath, per schedule. II. Observations Two environmental tours of the facility were conducted on 2/25/2020 at 1:05 p.m., and on 2/26/20 at 9:00 a.m. Observations revealed: room [ROOM NUMBER]: dirty (covered or marked with an unclean substance) room cove base, chipped paint on one red accent wall, dirty room corners, missing piece of laminate on the dresser, one missing towel holder, one broken towel holder, loose laminate under the sink, chipped paint on the closet doors, chipped paint on the door frame, multiple dirty floor tiles, dirty closet floor. room [ROOM NUMBER] bathroom: chipped paint on the door frame, chipped paint on the door, dirty caulk around the toilet base, two unfinished sheetrock patches on one wall, dirty linoleum floor, dirty room corners, dirty bathtub, dirty caulk at the bathtub base, three small holes in one wall, mismatched paint on one wall, chipped paint on the metal heater cover. room [ROOM NUMBER]: black marks on the wall by the window, dirty room cove base, dirty room corners, dirty plastic window heater cover, two missing floor tiles under the sink, one missing towel bar, several adhesive remnants on the sink countertop surface, chipped paint on the closet doors, chipped paint on the entrance door frame, dirty wall under the sink, sheetrock damage on two walls, chipped paint on one entrance wall nightlight cover, four cracked floor tiles, missing wood strip on one dresser drawer. room [ROOM NUMBER] bathroom: dirty linoleum floor, dirty room corners, dirty caulk around the toilet base, chipped paint on the metal heater cover, dirty bathtub, dirty caulk at the bathtub base, chipped paint on the wall behind the toilet, chipped paint on the door, chipped paint on the door frame. room [ROOM NUMBER]: sheetrock damage around the hand soap dispenser, dirty room cove base, dirty room corners, four cracked floor tiles, two unfinished sheetrock patches, chipped paint on the closet doors, dirty room floor tiles, chipped paint on the entrance door, chipped paint on the door frame. room [ROOM NUMBER] bathroom: dirty bathtub, dirty caulk at the bathtub base, dirty linoleum floor, dirty room corners, dirty caulk around the toilet base, chipped paint on the door, chipped paint on the door frame, chipped paint on the metal heater cover, loose metal heater cover, dirty cove base, dirty room corners. room [ROOM NUMBER]: dirty room cove base, dirty room corners, chipped paint on the closet doors, dirty closet floor, missing cove base, dirty laminate under the sink, missing wood on one drawer at the sink. room [ROOM NUMBER] bathroom: dirty tub, dirty caulk at the bathtub base, dirty floor, chipped paint on the door, chipped paint on the door frame, dirty room corners, one water damage ceiling tile, dirty brown stain around the toilet base. room [ROOM NUMBER]: missing cove base, dirty cove base, dirty room corners, multiple dirty floor tiles, loose metal baseboard wall heater, chipped paint on the entrance door frame, one broken entrance floor tile. room [ROOM NUMBER] bathroom: dirty bathtub, dirty caulk at the bathtub base, yellow caulk around the toilet base, dirty metal heater cover, dirty linoleum floor, dirty room corners, chipped paint on the wall behind the toilet, chipped paint on the door frame. room [ROOM NUMBER]: dirty room cover base, dirty room corners, chipped paint on the closet doors, chipped paint on the entrance door, chipped paint on the door frame, chipped paint on the ceiling above the window, chipped wood on the corner of the sink counter, one hole in the wall behind the headboard of bed one, water damage on the ceiling above the window. room [ROOM NUMBER] bathroom: dirty bathtub, dirty caulk at the bathtub base, dirty linoleum floor, dirty room corners, chipped paint on the door, chipped paint on the door frame, chipped paint on the metal heater cover, two dirty walls. room [ROOM NUMBER]: dirty cove base, dirty room corners, dirty plastic on the window heater cover, multiple dirty floor tiles, brown water stain on the ceiling above the window, bubbled paint on two walls by the window, multiple chipped paint areas on one wall, chipped paint on the door frame, dirty entrance floor tiles, black marks on the door, chipped paint on the closet doors, chipped ceiling paint in the middle of the room, long unused coaxial television cable along one wall. room [ROOM NUMBER] bathroom: dirty bathtub, dirty caulk at the bathtub base, dirty floor, yellowed caulk around the toilet base, chipped paint on the door, chipped paint on the door frame, chipped paint on the metal heater cover, chipped paint on the wall above the heater. room [ROOM NUMBER]: dirty room cover base, dirty room corners, loose laminate on the sink counter, loose wood on the sink counter, chipped paint on the closet doors, dirty clothes closet floor, chipped paint on the door, chipped paint on the door frame, multiple dirty floor tiles, sheetrock damage around the hand soap dispenser, lint in the front plastic cover of the window heater. room [ROOM NUMBER] bathroom: dirty bathtub, dirty caulk at the bathtub base, chipped paint on the wall around the bathtub water faucets, chipped paint on the wall behind the toilet, chipped paint on the metal heater cover, chipped paint on the door, chipped paint on the door frame, loose cove base, dirty room cove base, dirty room corners. room [ROOM NUMBER]: one hole in one closet door, dirty room cove base, dirty room corners, chipped paint on the door, chipped paint on the door frame, multiple dirty floor tiles, chipped paint on the red accent wall, dirty entrance floor tiles. room [ROOM NUMBER] bathroom: dirty bathtub, dirty caulk at the bathtub base, loose metal heater cover, dirty floor corners, dirty caulk around the toilet base, chipped paint on the door, chipped paint on the door frame. room [ROOM NUMBER]: dirty room cover base, dirty room corners, loose laminate at the sink countertop, chipped laminate at the sink countertop, sheetrock damage around the hand soap dispenser, chipped paint on one wall behind the headboard, chipped paint on the door fame, black marks on the entrance door. room [ROOM NUMBER] bathroom: dirty bathtub, dirty caulk at the bathtub base, dirty linoleum floor, dirty caulk around the toilet base, loose metal heater cover, chipped paint on door, chipped paint on the door frame. room [ROOM NUMBER]: dirty cove base, dirty room corners, multiple dirty floor tiles, chipped paint on the wall by the window, missing room cove base, five pieces of loose/missing laminate on the dresser, missing laminate on the edge of the dresser. room [ROOM NUMBER] bathroom: one large hole in the wall, chipped paint on the metal heater cover, loose metal heater cover, chipped paint on the door, chipped paint on the door frame, loose caulk around the toilet base, loose caulk at the sink, chipped paint on one wall, two bathroom lights containing electrical outlets without evidence of a connection to a ground fault circuit interrupter. room [ROOM NUMBER]: dirty room cove base, dirty room corners, loose wall heater cover, multiple dirty floor tiles, one missing floor tile, four missing sections of laminate on the dresser, one torn/loose window screen, chipped paint on the closet doors, chipped paint on the door frame, black mark on the door, missing cove base by the closet doors, dirty personal floor fan, large roll of wall insulation lying on the ledge outside the room window. room [ROOM NUMBER] bathroom: yellowed linoleum floor, chipped paint on the metal heater cover, chipped paint on the door, chipped paint on the door frame, yellowed caulk around the toilet base, cracked caulk at the sink, two bathroom lights containing electrical outlets without evidence of a connection to a ground fault circuit interrupter. room [ROOM NUMBER]: dirty room cove base, dirty room corners, missing cove base, multiple dirty floor tiles, loose laminate on the dresser, two missing dresser door handles, two holes in the wall at the window, dirty plastic heater cover at the window, chipped paint on the door, chipped paint on the door frame, chipped paint on the closet doors, chipped paint on one wall. room [ROOM NUMBER] bathroom: dirty floor, missing caulk around the toilet base, chipped paint on the door, chipped paint on the door frame, chipped paint on one wall, chipped paint on the toilet riser, chipped paint around the hand soap dispenser, seven small holes in one wall, dirty entrance transition area, two bathroom lights containing electrical outlets without evidence of a connection to a ground fault circuit interrupter. Hallway for resident rooms 301 to 308: eight metal handrails (boxed shaped with a top, bottom, and two sides) with chipped paint on all rails, multiple areas of dirty cove base, multiple dirty floor tiles, dirty transition area at entrance to hall, dirty corners behind fire doors. Hallway for rooms 309 to 316: eight metal handrails with chipped paint on all rails, multiple areas of dirty cove base, multiple dirty floor tiles, dirty hall corners, sheetrock damage on the wall to the left of the hand sanitizer adjacent to the elevator, mismatched paint on the wall around the computer kiosk, multiple black marks on the restroom door and door frame. Hallway for rooms 317 to 323: eight metal handrails with chipped paint on all rails, multiple areas of dirty cove base, multiple dirty floor tiles, dirty hallway corners, eight broken floor tiles, black marks on the elevator door frame, multiple areas of chipped paint on the walls, chipped paint on the spa room door and door frame. Third floor dining room: chipped paint on three walls, large area of unfinished sheetrock damage over one one window, loose/sagging paint from water damage on one wall in the corner, dirty cover base throughout the room, dirty room corners, two broken five wheeled chairs, chipped paint on three room wall metal heater covers, missing room cover base, one loose metal wall heater cover, multiple black marks on one wall, multiple dirty floor tiles. Activity room: dirty cove base, dirty cover base on the pole in the middle of the room, dirty room corners, dirty floor tiles at entrance to the room, dirty floor tiles adjacent to the cover base throughout the room, one dirty electrical outlet, missing laminate edge of the sink counter, dirty cove base under the sink cabinets, chipped paint on the stove, dirty stove base, dirty floor around the stove/refrigerator, chipped paint on two wall metal heater covers, chipped paint on one room corner edge, two loose floor tiles near the windows, missing cove base at the ramp by the sliding doors, chipped paint over the sliding doors near the ceiling, two sliding plastic folding doors to the activity office off the track. Third floor common area adjacent to the nurses' station: multiple areas of chipped paint on three walls, dirty area cove base, dirty room corners, multiple dirty floor tiles, one broken floor tile, chipped paint on two fire door frames, chipped paint on two sets of fire doors, sheetrock damage on the wall beside the elevator, black marks on the elevator door frame, one section of a metal handrail with chipped paint on all rails. Third floor nurses' station: multiple areas of chipped paint all along the wall surface of the desk, multiple areas of chipped laminate along the top portion of the desk, dirty cove base at the bottom of the desk, chipped paint on the eye wash station door, dirty plastic laminate on the eye wash station door, dirty floors tiles at the entrance of the eye wash station room, dirty floor tiles at the entrance to the medication storage room room, dirty cove base adjacent to the eye wash station and the medication storage room entrance doors, dirty cove base in the nurse station area, missing cove base in the nurse station area, dirty floor in the nurse station area, unfinished wall patch behind the metal record rack, four protruding screw heads on one wall, four unused anchors on one wall. III. Resident council minutes The resident council minutes dated 1/4/2020 and 2/7/2020 revealed that residents had expressed concerns with the cleanliness in the facility and in their rooms. IV. Resident group interview A resident group interview was conducted on 2/25/2020 at 10:15 a.m. According to residents #27, #81 and #95 the second floor did not receive housekeeping services on Sundays and Mondays. The residents said their rooms received inadequate cleaning procedures such as wiping down items, scrubbing and mopping. V. Staff interviews An additional environmental tour of the facility was conducted with the NHA, maintenance director (MD), housekeeper (HSK) #1 and HSK #2. The above mentioned concerns were observed and documented by the NHA and the MD. The NHA said the facility staff filled out work orders in maintenance logs that were located at each of the three nurses' stations. He said the work orders were reviewed daily. He said maintenance concerns could also be brought to the attention of the MD by phone calls, phone texts, and grievance forms. He said daily rounds were conducted in the facility and the facility used the Technology-Enhanced Learning in Science (TELS) computerized system for routine maintenance update reminders. He said the TELS system was reviewed daily. HSK #2 said each resident room/bathroom was cleaned daily and deep cleaned each month. He said a deep clean involved removing all of the furniture and resident property from the room. The room was cleaned and the floor was stripped/waxed. He said the common areas were cleaned daily. The NHA said he was unsure if he had work orders for the aforementioned observations.