Every finding on record at Stonehenge of Springville

Based on observation, interview, and record review it was determined, for 2 of 24 sampled residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident that was dependent on staff and required maximum assistance for bed mobility and toilet use was left alone, rolled out of the bed, and received a laceration and bilateral femur fractures. In addition, staff were not educated on how to keep a resident safe from choking who had a risk versus benefit signed. Resident identifiers: 5 and 35. Findings included: 1. Resident 35 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease with late onset, lymphedema, morbid obesity, abnormalities of gait and mobility, chronic pain, and epilepsy. Resident 35's medical record was reviewed 3/4/25 through 3/5/25. Resident 35's physician progress note dated 1/18/25 revealed the following, patient with fall from bed, yesterday, during cares. subsequently sent to the ER [emergency room ] for evaluation where she was found to have bilateral femoral fractures . An incident report dated 1/12/25 documented, [Resident 35] was turned on her left side in bed for CNA [certified nursing assistant] to change her chuck, as the CNA was pulling on the chuck, her right leg moved forward towards the edge of the bed. CNA was able to go to the other side of the bed and hold her legs until assistance arrived to assist [resident 35] to the floor. She was placed in sling and lifted via hoyer lift back into bed. Only her legs were coming off the bed. Due to her weight it was safer for [resident 35] and staff to lower her to the floor and put her back in bed with the hoyer lift. My leg slipped. No injuries were documented on the incident report. On 1/13/25 a Skin/Wound note documented, . Pt [patient] had a recent fall out of bed and reported her left knee and bilateral ankles hurt. I asked pt if we could get x-rays of sites to r/o [rule out] any breaks. Pt stated she doesn't want any at this time. Pt stated she believes it is because she laid on that knee for awhile, but cannot think of anything specifically that could have caused the pain in her ankles other than just the fall. On 1/17/25 a nurses note revealed, At approximately 1005 [10:05 AM] patient was found on the floor in her room. She was found on the side of her bed, on her knees, holding onto the bedrail. Patient's left foot was bleeding. Staff assisted patient onto her back. RN [Registered Nurse] cleaned left foot and found a laceration next to her big toe. RN cleaned laceration and wrapped it with gauze and coban. Staff used hoyer lift to assist patient back into bed. Patient was c/o [complained of] pain in her legs/knees. RN called and notified MD [medical doctor]. MD recommended we send patient to hospital for X-rays and evaluation. RN called EMS [emergency medical services] to come transport patient. Patient was transported to [local hospital] at about 1100 [11:00 AM]. An incident report dated 1/17/25 documented, [Resident 35] was calling out for help, when aide entered the room she was on her knees at the side of the bed holding onto the and position bar. She had a bowel movement and urinated. Additional staff came in to assist her to the floor. She was laid down on the hoyer sling and assisted back into bed. On 1/17/25 at 7:40 PM a nurses note documented, Hospital called at 1715 [5:15 PM] and reported that [resident 35] was ready to return to the facility. They reported that the patient had 2 femur fractures and recommended the patient be admitted to hospice as she is a DNR [Do Not Resuscitate] and wishes to seek palliative care at this time . A quarterly Minimum Data Set (MDS) dated [DATE] documented that resident 35 had impairment to both sides of her lower extremity, which included hip, knee, ankle and foot. Resident 35 required maximum assistance and was dependent on staff for assistance, where staff did all of the effort or the assistance of two or more staff were required for the resident to complete the activity, in the areas of bed mobility, rolling from left to right, transfers, toilet use and personal hygiene. The MDS documented that resident 35 had a Brief Interview for Mental Status (BIMS) score of 12. A BIMS score of 8 to 12 would suggest moderate cognitive impairment. The CNA task list for the month of January 2025 was reviewed and documented the resident 35 required extensive assistance from staff and had total dependence with bed mobility. A care plan Focus initiated on 6/11/24 and revised on 1/24/25, documented [Resident 35] has an Activities of Daily Living [ADL]/level of assistance required on admission and adaptive equipment used: 2 person supportive assist, Dependent, Wheelchair (manual or electric), Hoyer lift with transfer. With interventions initiated on 6/11/24 to include, provide any adaptive equipment to assist me obtaining my independence with ADLs: Trapeze, cane, slide board, walker, brace, bed rails, wheelchair, etc. Staff to assist with mobility and ADLs as needed. After the first fall a care plan revision was completed on 1/12/25 with the following intervention: 2 person assist with brief change. It should be noted according to the MDS dated [DATE], resident 35 was a 2 person assist. After the second fall another care plan revision was completed on 1/17/25 with the following intervention: Wider bariatric bed 54. The hospital notes dated 1/17/25 documented a CT (computed tomography) scan was completed and the results indicated, Acute comminuted and displaced fracture involving the distal femoral metadiaphysis. And acute periprosthetic fracture involving the right distal femur. On 3/5/25 at 11:07 AM, an interview was conducted with CNA 1. CNA 1 stated resident 35 was always good when she cared for her, but she could be forgetful at times. CNA 1 stated depending on the care resident 35 needed 1 to 2 people to assist her. CNA 1 stated she would use 2 people when resident 35 needed to use the bathroom. CNA 1 stated she hardly ever got up because it caused her a lot of pain, she was bed bound. CNA 1 stated resident 35 wanted to be left alone, lying on her side when she needed to have a bowel movement. On 3/6/25 at 3:41 PM, a telephone interview conducted with CNA 2. CNA 2 stated that he cared for resident 35 a few times. CNA 2 stated resident 35 was good to take care of but she needed full assist with brief changes and for bowel movements. CNA 2 stated that resident 35 wanted staff to step out of the room and then come back when she was finished with a bowel movement. CNA 2 stated resident 35 was cognitively aware but a little less with it at the end. CNA 2 stated that when resident 35 wanted us to help her with cares, staff moved the side tables out of the way, rolled resident 35 onto her left side, put a chux pad under her and then staff stepped out of the room because she liked her privacy. CNA 2 stated that resident 35 would then push her call light when she was done for us to come back into the room. CNA 2 stated that when he took care of her, she could stay on her left side and hold onto the repositioning bars. CNA 2 stated he did not think her bed had any lower side rails. CNA 2 was unsure if resident 35 was on an air mattress. CNA 2 stated that resident 35 could not move herself in bed and staff had to do everything for her. CNA 2 stated it would have been safer for the resident if we had stayed in the room with her but she requested that we leave. On 3/5/25 at 4:23 PM, an interview was conducted with the Certified Nursing Assistant Coordinator (CNAC). The CNAC stated that resident 35 was totally dependent on staff for cares and bed mobility. The CNAC stated it varied depending on who worked whether she was a 1 person or a 2 person assist. The CNAC stated that he was strong enough to assist her alone but some of the other female CNAs needed help. The CNAC stated he was assisting resident 35 when she fell out of bed the first time. The CNAC stated that resident 35 requested to lay her on her left side when she needed to have a bowel movement. The CNAC stated that he had laid her on there left side but she was already in the process of having her bowel movement on 1/12/25. The CNAC stated that he had to reposition the chux and as the new one was put under resident 35, her leg moved and it pulled her over. The CNAC stated that resident 35 held on to the bedrail and he was able to run around the bed while holding onto her legs. The CNAC stated when he got around the bed her legs were already touching the floor. The CNAC stated he then called for help on the radio and other staff were able to lower her down to the floor. The CNAC stated that resident 35 did say that her leg hurt, but it was the leg that she never moved. The CNAC stated that resident 35 had an air mattress. The CNAC stated that resident 35 had really, really large legs and that they had just pulled her over. The CNAC stated after the incident he informed the staff on duty that day to always go in with 2 people as a safety precaution. The CNAC stated when resident 35 was rolled onto her side then the staff would leave the room because the resident asked them to. On 3/10/25 at 10:00 AM, a conference call was conducted with Administrator (ADM), Director of Nursing (DON), and Regional Nurse Consultant (RNC). The Administrator went over the time line of the 2 falls resident 35 had experienced on 1/12/25 and 1/17/25. The ADM stated resident 35 wanted to be left alone in the room when she needed to have bowel movement because she was a very private person. The ADM stated staff respected her wishes and that was the way it had been done for as long as he could remember. The ADM stated after the first assist to the floor on 1/12/25 an intervention was put into place for the resident to be a 2 person assist when positioning her. The ADM stated the intervention worked because on 1/14/25 resident 35 was repositioned and did not fall out of bed when she was left alone. The ADM stated resident 35 was cognitively intact. The ADM stated that keeping a resident safe looked like the outcome on 1/14/25 where she did not have a fall when left alone. The DON stated she was able to verbalize she was safe. The DON stated she was stressed out and anxious so she was unable to state what happened on 1/17/25. The ADM stated that she would not allow staff to stay in the room with her when she was having a bowel movement, so she was left alone. The RNC stated that all falls were investigated because a new intervention needed to be put into place, hopefully they were safe and staff monitored residents after the fall. The RNC stated within the investigation, if there was a concern, then would be report to the State Survey Agency. The RNC stated it was reported to Red CAP but they did not feel like it was an issue so it was not reported to the state. The ADM stated there was no cause for concern because they knew exactly what had happened. The RNC stated they made sure to put interventions in place to keep the residents safe. The RNC stated an investigation was completed for interventions to be put into place, not because abuse or neglect was suspected. The ADM stated he did interview staff after the fall because it was not necessary they knew exactly what happened. The ADM stated the CNA's involved were interviewed on 3/6/25. It should be noted the CNA interviews were conducted after the survey team had discussed the concerns with the administration. On 3/10/25 at 11:00 AM, an interview was conducted with CNA 6. CNA 6 stated resident 35 had declined physically and mentally prior to the falls. CNA 6 stated resident 35 was always a 2 person assist, one CNA to stand on each side of the bed to keep her safe. CNA 6 stated it was hard for resident 35 to move herself, she would use her upper arms to try to help but it was not much help. CNA 6 stated resident 35 liked to lie on her left side to have a bowel movement. CNA 6 stated the residents bed was a bariatric air mattress and was placed in the center of the room and not against a wall. CNA 6 stated the CNAs would position her close to the right side of the bed on her side, give her the call light and leave the room so she had privacy. CNA 6 stated on the day of the second fall, CNA 6 and CNA 4 positioned resident 35 on her side as she liked, gave her the call light and the resident stated, I will hit the light when I'm ready and don't go too far. CNA 6 stated that was what resident 35 always said then we left the room. CNA 6 stated they went down the hall a little bit, into another resident's room to assist them. CNA 6 stated they had been in the room about 5 minutes and another aide came in to get the Hoyer lift and informed then that resident 35 had fallen out of bed. CNA 6 stated when they returned to resident 35's room, she had fallen out of bed on the left side and was in a kneeling position. CNA 6 stated the quarter side rail was bent and the resident was hanging on to it. CNA 6 stated it would have been safer for the resident if the staff stayed in the room, but the resident refused because she was a very private person. On 3/10/25 at 12:00 PM, an interview was conducted with CNA 4. CNA 4 stated resident 35 was bedbound and was particular with the cares she received. CNA 4 stated before the resident's first fall she was a 1 person assist but after the fall she was a 2 person assist. CNA 4 stated resident 35 was quite large and would try to help with repositioning with her upper arms but she could not move her legs so the CNAs had to reposition them. CNA 4 stated on the day of the fall, herself and CNA 6 positioned resident 35 on her left side, gave her the call light and left the room with her lying in bed on her left side as she preferred. CNA 4 stated they went down the hallway, into another residents room when they heard her yelling. CNA 4 stated they entered resident 35's room and she was holding onto the side rail and she had fallen out of bed. It should be noted that resident 35 was a 2 person assist and had a fall out of bed on 1/12/25 with only 1 staff in the room. Resident 35 continued to be left alone after being repositioned on her side and fell out of bed again 5 days later resulting in bilateral femur fractures. Neither of the falls were reported to the State Survey Agency at the time of occurrence or after the falls and there was no investigation. 30563 2. Resident 5 was admitted to the facility on [DATE] with diagnoses which included dementia, major depressive disorder, severe intellectual disabilities, dysphagia, and schizoaffective disorder. On 3/3/25 at 12:19 PM, an observation was made of the lunch meal. Resident 5 was observed to be sitting at a table by himself drinking milk and coughing after each sip. Resident 5 was observed to eat with no coughing. Resident 5 began drinking a thin beverage and was coughing as he drank it. Staff were observed to assist other residents in the dining room. At 12:27 PM, resident 5 took another drink of lemonade and coughed again. Resident 5 was observed to cough louder and Registered Nurse (RN) 2 looked at him and then looked away. The Regional Nurse Consultant (RNC) and Certified Nursing Assistant (CNA) 1 were observed in the dining room. On 3/4/25 at 12:10 PM, an observation was made of resident 5 eating lunch. Resident 5 was observed to be sitting at a table by himself drinking quick sips from a mug. Resident 5 was observed to have a soft wet cough. Resident 5 was observed to pick up a glass with milk and coughed after every drink he took. Resident 5 was observed to drink a yellow beverage and had a soft wet cough. Resident 5's liquids and food were observed to be falling out of his mouth. The Restorative Nursing Aide (RNA) was observed to be feeding another resident across the dining room. CNA 1 was observed to assist another resident and reminded resident 5 to slow down when he took his last bite before leaving the dining room. Resident 5's medical record was reviewed 3/3/25 through 3/5/25. A quarterly MDS dated [DATE] revealed resident 5 had short-term and long-term memory problems. Resident 5 had moderate impaired cognitive skills for daily decision making. Resident 5 had loss of liquids/solids from mouth when eating or drinking, holding food in mouth/cheeks or residual food in mouth after meals, coughing or choking during meals or when swallowing medications and complained of difficulty or pain when swallowing. A physician's order dated 1/17/24 revealed regular, diet easy to chew textures, thin/regular liquids consistency. A form titled Risk vs. Benefit with no date revealed the risks for having regular texture and thin liquids was aspiration and the benefits was a prolonged life. The form further revealed I further hold [name of facility], its owners, and staff blameless of any injury or illness that may be incurred as a result of not following these recommendations. Resident 5's name was on the form and two nurses' signatures, another witness and the nurse manager's signatures. An email dated 7/15/24 at 3:10 PM from the Resident Advocate (RA) to resident 5's Power of Attorney (POA) revealed the RA was reaching out because the facility needed an updated risk versus benefit for resident 5 to have regular texture rather than thickened. The email revealed He has been doing great with the regular liquids. The POA responded on 7/15/24 Yes, please proceed. A care plan dated 8/14/19 and updated on 2/25/25 revealed Nutrition and Dietary I am at risk for nutrition and/or hydration risk as evidenced by: Chewing problems. R v B [risk verses benefit] to receive thin fluids despite recommendation for thickened fluids and easy to chew diet texture. Resident requests his meals no longer be served on a divided plate. Guardians aware and in agreement. Unavoidable weight loss per hospice physician. Interventions were initiated on 8/14/19 which included encourage to drink fluids of choice, ensure that beverages offered comply with diet, observe for signs and symptoms of dehydration, provide supplements as ordered, and provide diet as ordered. Skilled nursing evaluations dated 11/16/24 and 11/15/24 revealed the same information. Nutrition: Taking nutrition and hydration orally. No complaints of thirst. No signs / symptoms of a swallowing disorder. Mucous membranes moist. Requires assistance with meals (feed / set up) as needed. Difficulty chewing noted. Complaints of thirst: No. Coughing or choking during meals or when swallowing. Loss of liquids / solids from mouth when eating or drinking. A nursing progress note dated 12/24/24 at 12:02 PM revealed, Patient was given a cupcake today during a Christmas activity. Patient began to choke on the cupcake. He got up and went to his room, CNA followed. Patient was struggling to breath. CNA performed the Heimlich maneuver, patient began coughing up and vomiting saliva. Patient began breathing normal, and wanted to lie down in bed. PA [Physician's Assistant] ., assessed lung sounds. Lung sounds are congested at this time. Patient breathing normal. Vital signs all within normal ranges for patient's baseline. Family notified of incident. A nutrition note dated 1/23/25 revealed Difficulty chewing noted. Difficulty swallowing at times. Complaints of thirst: No. Coughing or choking during meals or when swallowing. On 2/17/25 at 10:40 AM an MDS note revealed, MDS Interview with patient, supplemented by answers from CNA [CNA coordinator] for questions that could not be answered by the resident due to his preference of being nonverbal. Loss of liquids/solids from mouth while eating: yes Holding food in mouth/cheeks, residuals: yes Coughing/choking during meals or medications: yes Complaints of difficulty/pain when swallowing: yes Diet consumed daily while a resident at [name of facility]: regular diet, easy to chew texture, thin/regular liquids consistency. Resident has a known chewing/swallowing problem and POA has been given information regarding the risks vs benefits of thin fluids when thick fluids recommended and diet texture recommendations. POA has requested we provide resident with thin liquids and easy to chew texture for diet per patient preferences. Patient is monitored by staff while eating meals in the dining room. A form titled Dietary Profile dated 2/18/25 revealed, [Resident 5] continues to drink and eat foods that he chokes on. He has signed a risk vs benefit to have regular texture and regular thickness. [Resident 5] eats all his meals on a divided plate. He continues to eat all his meals in the dining room. Will continue to monitor. On 3/4/25 at 12:39 PM, an interview was conducted with CNA 1 who stated resident 5 should have thickened liquids, but had a risk versus benefit signed. CNA 1 stated resident 5 coughed a lot and staff watched him when he was eating. CNA 1 stated resident 5 was non-verbal, but occasionally he was able to shake his head yes and no. CNA 1 stated resident 5's sister was his POA. CNA 1 stated staff were to observe resident 5 while eating but had no other instructions on how to keep him safe when drinking thin liquids. On 3/4/25 at 12:49 PM, an interview was conducted with the Director of Therapy (DOT). The DOT stated resident 5 was not receiving Speech Language Pathology (SLP) services. The DOT stated resident 5 ignored his diet order. The DOT stated SLP was initially contacted for resident 5's swallowing but then a risk vs. benefit was signed. The DOT stated resident 5 signed his risk vs benefit but did not have then mental capacity to benefit from SLP services. The DOT stated staff could direct resident 5 while he was eating but he continued to eat what he wanted. The DOT stated education for staff to keep resident 5 safe would come from the nursing department and not from therapy. The DOT stated SLP had not provided education to staff regarding keeping resident 5 safe with thin liquids. On 3/4/25 at 12:58 PM, an interview was conducted with the RNA. The RNA stated SLP usually evaluated residents with swallowing problems. The RNA stated resident 5 had a hard time swallowing and had a risk vs. benefit signed, so he could eat anything. The RNA stated she had a history of working with residents that had swallowing issues so she would expect staff to watch resident 5 when he was eating and watch for excess phlegm. The RNA stated resident 5 needed to be reminded to swallow correctly and tuck his chin when he swallowed. The RNA stated staff needed to make sure his mouth was clear before taking the next bite. On 3/4/25 at 1:05 PM, the CNA Coordinator was interviewed. The CNA Coordinator stated he provided education to CNA's about resident's diets and encouraged residents to follow their diets for their health. The CNA coordinator stated if a resident refused to follow their diet order a risk vs benefit was signed. The CNA coordinator stated if a resident had a risk vs benefit, the CNA's were required to keep an eye on the resident more frequently and make sure they were ok when eating and they were not choking. The CNA coordinator stated he was at the facility when resident 5 was choking on 12/24/25. The CNA coordinator stated the Activities Director was handing out cupcakes and they had little plastic light bulb rings on them. The CNA coordinator stated the Activities Director did not think to remove the ring before giving the cupcake to the residents. The CNA coordinator stated resident 5 was a fast eater and put the cupcake in his mouth. The CNA coordinator stated a staff member radioed everyone to the dining room and resident 5 was choking but kind of breathing. The CNA coordinator stated resident 5 left the dining room and went to his room. The CNA coordinator stated he tried the Heimlich maneuver and then resident 5 pushed him away, bent over and pulled a ring out of his mouth. The CNA coordinator stated after the incident the Activities Director was educated to remove plastic items from food. The CNA coordinator stated he also provided a meeting with nurses and CNA's that was like a refresher. The CNA coordinator stated he talked about residents that were at risk for aspiration or choking and who had a risk vs benefit. The CNA coordinator stated with a risk vs benefit staff needed to watch residents and ensure there was nothing on the food that was not edible. The CNA coordinator stated he did not have documentation of the refresher education. On 3/5/25 at 12:33 PM, an interview was conducted with CNA 3. CNA 3 stated resident 5 choked a lot and he had a signed risk vs benefit. CNA 3 stated staff needed to watch resident 5 when he ate so he did not choke. CNA 3 stated resident 5 ate snacks like chips and Cheetos in his room and she made sure she did not have crumbs in his bed when he was done. CNA 3 stated resident 5 ate his meals in the dining room. CNA 3 stated she was not aware of interventions to keep resident 5 safe when he was eating and drinking. On 3/5/25 at 12:38 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated if a resident did not want to follow the physician ordered diet, then a risk vs benefit form was signed by POA. RN 1 stated especially if it was a change in texture or liquids. RN 1 stated the POA needed to be made aware of the risk for aspiration. RN 1 stated resident 5 had a risk vs benefit for his diet texture. RN 1 stated resident 5 was allowed to have regular thin liquids and all of the CNA's knew. RN 1 stated resident 5 fed himself so staff did not need to be with him when he ate. RN 1 stated resident 5 was supervised in the dining room when he ate but was unsupervised when eating snacks and beverages in his room. RN 1 stated there was no education provided by SLP on the ways to keep resident 5 as safe as possible. On 3/5/25 at 3:18 PM, an interview was conducted with the DON. The DON stated a risk vs benefit should be done with the resident and management, if a resident refused the physician ordered diet. The DON stated resident's had the right to refuse diet modifications. The DON stated it should be documented why the treatment was recommended for the resident. The DON stated there was education provided that the resident who chose not to follow and the resident was able to sign the form. The DON stated if a resident was not cognitively able, then management reached out to POA or state guardian for the risk vs benefit. The DON stated resident 5 was not cognitively able to sign a risk vs benefit. The DON stated resident 5's family was contacted via email July 2024. The DON stated staff needed to monitor resident 5 and watch him during meals. The DON stated staff monitored for aspiration. The DON stated resident 5 loved food and coffee. The DON stated staff sometimes needed to tell him to slow down when eating. The DON stated on 12/24/24, there was a Christmas party and a cupcake with a plastic ring was given to resident 5. The DON stated she received a call from the CNA who was watching the activity and resident 5 started coughing really hard, jumped up and took off to his room. The DON stated she and the Physician's Assistant went to resident 5's room. The DON stated resident 5 was breathing the whole time. The DON stated the Heimlich maneuver was done and resident 5 pushed away from the CNA, then bent over and pulled the ring out of his mouth. The DON stated the Physician Assistant assessed resident 5 and there were no concerns. The DON stated education provided to Activities Director to make sure if residents were not cognitively aware to remove plastic objects or anything that could cause them to choke. The DON stated no education provided to other staff. The DON stated SLP has not been involved in resident 5's care.

Based on observation, interview, and record review, for 1 of 24 sampled residents, the facility did not develop and implement a comprehensive person-centered care plan consistent with the resident's rights that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, a resident who had multiple falls had repeated interventions implemented after falls and staff were not aware of the interventions that were on the care plan. Resident identifier: 29. Findings include: On 3/3/25 at 10:30 AM, an observation was made of resident 29 in his room. Resident 29 was observed to be in bed with his bed in a low position and the call light within reach. There was a call don't fall sign on his wall. Resident 29's medical record was reviewed 3/3/25 through 3/5/25. Resident 29 was admitted to the facility on [DATE] with diagnoses which included hemiplegia affecting right dominant side, epilepsy, major depressive disorder, dementia, and personal history of traumatic brain injury. A Quarterly Minimum Data Set (MDS) assessment, dated 12/4/24, indicated a Brief Interview for Mental Status (BIMS) score of 3. A BIMS score between 0-7 indicated severe cognitive impairment. It further indicated resident 29 required supervision or touching assistance to stand from a sitting position, substantial/maximal assistance to walk 10 feet, and used a manual wheelchair. A physician's order, dated 7/29/24, indicated, Keep resident in shorts if possible, to prevent him from tripping over long pants. The Care Plan dated 12/18/24 and resided on 2/28/25 indicated, RISK FOR FALLS I am at risk for falls r/t [related to] Gait and balance problems, Hx [history] of falls, Psychotropic drug use, R [right] hemiplegia 5/27/23:Un-witnessed Fall 6/9/23:Un-witnessed Fall 6/10/23:Witnessed Fall 6/16/23:Witnessed Fall 10/8/23:unwitnessed fall 10/19/23:Un-witnessed fall 10/31/23:unwitnessed fall 11/1/23:Un-witnessed fall 12/8/23:unwitnessed fall 1.12.24:unwitnessed fall 2.29.24Fall during staff assist 3/31/24:Witnessed Fall 4/1/24:Unwitnessed Fall 4/4/24:Witnessed Fall 4/5/24:Unwitnessed Fall 4/08/24:unwitnessed fall 4/23/24:witnessed fall 4/28/24:Witnessed fall 5/4/24:Witnessed fall 5/7/24:Unwitnessed fall 5/22/24:Unwitnessed fall 5/25/24:WF 7/12/24:WF 7/29/24:Unwitnessed fall 8.16.24:Unwitnessed fall 8/23/24:Staff Assisted Fall 9/4/24:WF 9/8/24:Unwitnessed fall 10/1/24:WF [witnessed fall] 11/19/24: WF 12/8/24:WF 12/17/24 WF 01/02/25: unwitnessed fall 02/09 02/21/25:WF 02/27/25- UNWITNESSED FALL. The goal revised on 10/7/24 was I will be free from falls during my stay. Interventions included: a. 1/12/24 Clothing inventory review to discard, replace, or hem pants that are too long. Date Initiated: 01/15/2024 b. 5/22/24: Personalize wheelchair with brightly colored tape to encourage resident use. c. 5/27/23 Unwitnessed Fall: Ankle brace fitted to patient to prevent rolling ankle when ambulating Date Initiated: 05/29/2023 d. 6/9/23: New task for CNA's [Certified Nursing Assistant] to ensure resident is wearing Right ankle brace during waking hours e. 7/29/24: Dress patient in shorts to eliminate trip hazard of pajama pants that may be too long. f. 10/31/23: encourage wearing ankle brace during ambulation On 3/5/25 at 10:42 AM, an interview was conducted with Certified Nursing Assistant (CNA) 5. CNA 5 stated resident 29 fell a lot and needed a lot of reminders to use his wheelchair. CNA 5 did not know if resident 29 had interventions about having to wear certain pants or shorts and stated he did not wear a brace on his ankle. On 3/5/25 at 11:12 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated resident 29 was a bit confused and struggled to remember to call for help before getting up. LPN 1 stated that resident 29 was a high risk for falling due to his unsteady gait. LPN 1 stated he tended to walk out of his room without his wheelchair to ask if he could be shaved tomorrow. LPN 1 was not sure if he had certain interventions concerning his pants or shorts. On 3/5/25 at 11:33 AM, an interview was conducted with CNA 3. CNA 3 stated resident 29 would get up on his own without his wheelchair and go to the bathroom. CNA 3 stated that he can stand up, but he should not be walking on his own. CNA 3 stated he continuously asked about shaving even when he was shaved the same day. CNA 3 stated she did not know why there was orange tape on the wheelchair and was not sure if he had certain interventions concerning his pants or shorts but that she did have to help him put his clothes on every day. CNA 3 stated he did not wear an ankle brace. On 3/5/25 at 11:57 AM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 29 had a brain injury that caused him to fixate on things and he wanted to shave every day and he felt like he needed to tell somebody. The DON stated that had caused a lot of falls because he would stick his head out of his room or walk to the nurse's station to let staff know that he needed to shave even if he had already shaved that day. The DON stated he cannot walk due to an unsteady gait and he could not remember to use his call light. The DON stated his wheelchair was wrapped with bright orange tape on the arms to draw his attention to the wheelchair and that he would occasionally get in his wheelchair. The DON stated that he had not worn an ankle brace since she had worked at the facility. The DON stated they had a lot of staff turnover, and the nurses were expected to read what was on the resident's care plan. The DON stated after each fall she ensured the nurse put the date of the fall on the care plan but the nurses were also expected to update the care plan with an intervention.

Based on interview, observation, and record review it was determined, for 1 of 24 sampled residents, that the facility did not ensure residents who displayed or was diagnosed with mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. Specifically, a resident diagnosed with depression and anxiety who verbalized she wanted to die and was ready to die, refused medications, displayed crying episodes, and threatened another resident with physical harm was not offered or provided behavioral health services. Resident identifier: 28. Findings include: On 3/3/25 at 10:41 AM, an interview and observation was conducted with resident 28. Resident 28 was in her bed with her eyes closed. Resident 28 opened her eyes, she answered interview questions with one to two word answers. Resident 28 was withdrawn and displayed a flat affect throughout the interaction. On 3/3/25 at 11:11 AM, an observation was made of resident 28 in the dining room playing bingo. Resident 28 was observed to maintain a flat affect and had minimal interaction with other residents or staff. On 3/4/25 at 12:09 PM, an observation was made of resident 28 in the dining room eating lunch. Resident 28 was sitting next to two other residents, she did not interact with other residents or staff and stared blankly in the room with a flat affect while she ate lunch. A resident spoke to resident 28 and she looked at him and gave no verbal response, she had an annoyed facial expression. At 12:18 PM, resident 28 started coughing on her food, staff asked her if she was okay, and she nodded yes. At 12:24 PM, resident 28 had finished eating and was staring around the room with a flat affect. At 12:28 PM, a staff member took resident 28 to her room via wheelchair. Resident 28's medical record was reviewed 3/3/25 through 3/5/25. Resident 28 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included intraductal carcinoma in situ of right breast, dysphagia, type 2 diabetes mellitus with diabetic neuropathy, aphasia, cerebral infarction, depression, acute kidney failure, and generalized anxiety disorder. A Preadmission Screening Resident Review (PASRR) Level II, dated 2/10/23, indicated, Recommendation for Specialized Services for mental illness treatment: Please continue to monitor and assess mental health symptoms as well, especially if there are increased depressive symptoms. Please also continue to monitor and assess any possible cognitive concerns. An annual Minimum Data Set (MDS) assessment, dated 2/13/25, indicated a Brief Interview for Mental Status (BIMS) score of 10. A BIMS score of 8-12 indicated a moderate cognitive impairment. It further indicated resident 28 expressed little interest or pleasure in doing things 2-6 days (several days); felt down, depressed, or hopeless 2-6 days (several days); and displayed isolation sometimes. A Nurses Note, dated 10/2/24 at 12:51 PM, indicated, BIOPSY RESULTS: Biopsy results received from [health facility name redacted]. Final Diagnosis: 1- Lymph node, right axillary, core biopsy: Positive for metastatic carcinoma. 2- Breast, right, UQ MASS, CORE BIOPSY: Invasive grade 2 ductal carcinoma. [Physician Assistant name redacted] and [medical doctor name redacted] notified of results. A Nurses Note, dated 10/24/24 at 10:55 AM, indicated, Give [sic] pt [patient] AM meds. Pt laying in bed. Assist to sit up. Pt took 1/2 her pills, looked at the rest and started getting teary eyed and stated, 'She doesn't want to take pills anymore. She hates taking so many meds [medications]. She just wants to die. RN [Registered Nurse] sitting and talking to pt about her feelings. She states she's just tired and there's no point to being here. Pt talks about her family, parents sisters and children growing up in [state redacted] and moving to USA and eventually coming to [state redacted] with her family. Pt smiles and laughs when recalling memories of raising her children. Pt eventually took the rest of her meds. Turn on a show for her to watch while in bed. A Nurses Note, dated 10/24/24 at 3:42 PM, indicated, Attempted to give pt brown cow, prune juice and MOM [milk of magnesia]. Pt stated she didn't like it and wouldn't drink it. Educate pt it has been 4 days since last recorded BM [bowel movement] and she has been refusing suppositories at noc [night]. Pt states she doesn't like it and she hasn't been eating to have BM. Encourage ot [sic] to drink H2O [water] and rest. Alert social Worker of pt not wanting to take anymore meds, food and wanting to die. States she will talk to pt and family. The December 2024 Medication Administration Record (MAR) indicated resident had an order for Lexapro Oral Tablet 5 MG (Escitalopram Oxalate) Give 2.5 mg by mouth at bedtime for depression with a start date of 11/22/24 at 7:00 PM. The December 2024 Treatment Administration Record (TAR) indicated resident 28 verbalized sadness one time on the night of 12/1/24 and three times on the night of 12/7/24. A Psychotropic IDT (Interdisciplinary Treatment) note, dated 12/19/24 at 5:09 PM, indicated, Patient was reviewed during psychotropic meeting today. [Medical Doctor name redacted] ordered to increase Lexapro from 2.5mg [milligrams] to 5mg QHS [every hour of sleep] for depression. A Psychotropic IDT, dated 1/23/25 at 3:11 PM, indicated, Patient was reviewed during today's psychotropic meeting. In attendance: [name redacted], RA [Resident Advocate] [name redacted] DON [Director of Nursing] [Medical Doctor name redacted] [name redacted], Pharmacist -Decrease Lexapro to 2.5mg QD [every day] Will review again in February. The February 2025 Treatment Administration Record (TAR) indicated resident 28 verbalized sadness once on the night of 2/15/25, once during the day and once on the night of 2/18/25, once on the night of 2/22/25, once during the day of 2/23/25, and once during the day and once on the night of 2/27/25. It further indicated that monitoring numbers of verbalizations of sadness every shift was discontinued on 2/28/25 at 4:00 PM. An Activity Participation Note, dated 2/11/25 at 5:22 PM, indicated, .Resident became tearful while answering 'getting to know you questions' about her family. By the end of the conversation, Resident was smiling and had a more calm and content demeanor and expressed gratitude for someone listening to them . A Social Work Note, dated 2/14/25 at 11:45 AM, indicated, .Residents psychosocial well-being goal is continue to be more open about how her day is going or how she is feeling with staff. She see's that she usually just says she is fine regardless of how she is truly feeling, and wants to be more open and honest when answering questions like that. When asked about an IDT Resident expressed that she does not want to do an IDT this quarter, but would be more open to doing one next quarter. RA will follow up then. A Nurses Note, dated 2/28/25 at 1:55 PM, indicated, Nurse reported to DON that patient made a comment to the nurse that she 'no longer wants to take medications and is ready to die'. It should be noted that a Certified Nursing Assistant (CNA) Task-Behavior Symptoms document indicated no Frequent Crying or Rejection of Care was observed on 2/28/25. A Nurses Note, dated 2/28/25 at 2:04 PM, indicated, [Medical Doctor name redacted] was notified of situation. A Nurses Note, dated 2/28/25 at 3:49 PM, indicated, Patient has been struggling to take her medications. DON spoke with sister [name redacted] about the situation. Patient has been refusing medications and making comments that she doesn't want to take medications anymore and is 'ready to die'. Sister [name redacted] said she will come visit her tonight and talk about her medications and the need for them. DON notified Social worker/Resident Advocate of comments made by patient. A Psychotropic IDT, dated 2/28/25 at 3:56 PM, indicated, Patient was reviewed during this month's psychotropic meeting. In attendance: [name redacted], MD [Medical Doctor], [name redacted] PharmD [name redacted], LCSW [Licensed Clinical Social Worker] [name redacted], DON [name redacted], RA Patient is taking a 2.5mg dose of lexapro. MD ordered to DC [discontinue] medication. A Social Work Note, dated 2/28/25 at 4:07 PM, indicated, RA was informed by DON that patient had mentioned to nurse that she is 'ready to die'. RA and DON spoke with Resident about why she has been refusing meds as well as why she made that statement. Resident expressed that she feels frustrated about the fact that her meds are making her not enjoy food, as well as making it so food does not taste good. She continued that food is a big part of who she is and her culture, which is why she has been frustrated and refusing meds. Resident also expressed that her statement that she is 'ready to die' is not true and came out of the situational frustration. RA and DON told Resident that they could reach out to Facility Doctor about her medications. Resident seemed very happy about this and again confirmed that she did not truly mean that she is 'ready to die'. RA will continue to follow up with any further tracking of sadness or behaviors like these. DON sent message to facility Doctor. A Nurses Note, dated 3/2/25 at 5:30 PM, indicated, Pt threatened to throw a flower pot at another resident today in the dining hall during dinner. Staff intervened before any physical assault occurred. Residents were separated and taken back to their rooms. It should be noted that a CNA Task-Behavior Symptoms document indicated no Yelling/Screaming, Abusive Language or Threatening Behaviors were observed on 3/2/25. A Clinical Provider note dated 3/5/25 indicated, 3/3/25: Nurse was asked to inform family of her refusal of meds so that they are aware. Pt educations given. If continues, we will reach out to oncology for other med delivery methods. It further indicated, .Mood disorder due to known physiological condition with depressive features Mood stable Lexapro 2.5 milligrams daily Medications will be reviewed in monthly psychotropic meeting at least quarterly 3/3/25: decreased to 2.5 mg on 1/24/25 and discontinued in monthly psychotropic on 2/27/25. Pt is not stating depression today. The Care Plan Report indicated: a. Mood disorder- At times I become depressed Date Initiated: 02/26/2024 Revision on: 02/26/2024. With the Goals of: My depression will not worsen or interfere with my recovery Date Initiated: 02/26/2024 Revision on: 08/27/2024 Target Date: 05/26/2025 and I do not want my score to increase on the next PHQ-9 [Patient Health Questionnaire instrument used for measuring depression severity] Date Initiated: 02/26/2024 Revision on: 08/27/2024 Target Date: 05/26/2025. Interventions included: Help me decorate my room so it says something good about me and my life. Date Initiated: 02/26/2024 Invite me to activities I might enjoy Date Initiated: 02/26/2024 Referral made by [name redacted] CSW [Certified Social Worker], SWCS for therapeutic recreation activities. Date Initiated: 02/13/2025 Remind me to spend time out of my room and to eat my meals in the dining room Date Initiated: 02/26/2024 Review my antidepressant at least quarterly and ask Dr. to be sure that it is the best dose for me. Date Initiated: 02/26/2024 Speak to me each day, and use validation techniques to help me feel like I am being heard Date Initiated: 02/26/2024 b. Anxiety I get anxious sometimes Date Initiated: 05/13/2024. With the Goal of: I want you to help me calm down within 10 minutes of my becoming anxious Date Initiated: 05/13/2024 Revision on: 08/27/2024 Target Date: 05/26/2025. Interventions included: Even if I can't tell you what is wrong, use validation techniques that might help to feel safer and more relaxed Date Initiated: 05/13/2024 If I am too anxious to go to sleep, offer to play some soft music or give me a warm beverage like tea or hot chocolate. Date Initiated: 05/13/2024 Referral made by [name redacted] CSW, SWCS for therapeutic recreation activities. Date Initiated: 02/13/2025 When I do become anxious, please help me calm down by going with me to a low stimulus area to calm down, or offer me a beverage of my choice, or walk with me and talk gently with me. Date Initiated: 05/13/2024 c. PASSR - Resident has PASRR Level 2 d/t [due to] dx [diagnosis] of: Depression and Anxiety with an LTC [long term care] Determination. Date Initiated: 08/11/2023 Revision on: 01/02/2025. With the Goal of: Patient will be appropriately screened. Date Initiated: 08/11/2023 Revision on: 01/02/2025 Target Date: 05/26/2025. Interventions included: Level 2 Recommendations (Specify to each patient): Date Initiated: 08/11/2023 Revision on: 01/02/2025 [Resident 28] would benefit from skilled nursing therapies and rehabilitation that will help to strengthen her. She used to be very independent prior to her stroke and the loss of this independence has been very difficult for her. She would benefit also from socialization and group activities as her son reported that if she is alone and not engaging in something, she will tend to isolate and ruminate on worries. She would benefit from activities that she can do in her room to also help keep her mind active. Date Initiated: 08/11/2023 Revision on: 01/02/2025. d. Resident has actual psychotropic med use of high-risk medication lexapro. Date Initiated: 02/25/2025 Revision on: 02/25/2025. With the Goal of: The resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. Date Initiated: 02/25/2025 Target Date: 05/26/2025. Interventions included: Administer ANTIDEPRESSANT medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT [every shift]. Date Initiated: 02/25/2025 Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of antidepressants. Date Initiated: 02/25/2025 Revision on: 02/25/2025 Monitor/document/report PRN [as needed] adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL [activities of daily living] ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt [weight] loss, n/v [nausea/vomiting], dry mouth, dry eyes Date Initiated: 02/25/2025. e. Resident at risk for impaired psychosocial wellbeing r/t [related to] presence of depressive symptoms. Date Initiated: 02/25/2025 Revision on: 02/25/2025. With the Goal of: The resident will verbalize feelings related to emotional state by review date. Date Initiated: 02/25/2025 Target Date: 05/26/2025. Interventions included: Encourage participation from resident who depends on others to make own decisions. Date Initiated: 02/25/2025 Provide opportunities for the resident and family to participate in care. Date Initiated: 02/25/2025 When conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. Date Initiated: 02/25/2025 It should be noted that resident 28's care plan did not include refusing medication and was not revised on: a. 10/24/24 when the statement that she wanted to die was made; b. 11/22/24 when Lexapro was started at a 2.5 mg dose; c. 2/28/25 when the statement that she was ready to die was made and Lexapro was discontinued; or d. 3/2/25 when the resident threatened another resident. On 3/5/25 at 10:48 AM, an interview was conducted with CNA 5. CNA 5 stated that resident 28 used to cry a few months ago but was in a pretty good mood most of the time now and that she would get up and go to activities every day. On 3/5/25 at 11:08 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated resident 28 had recently started having difficulty taking her pills because she did not like taking her medications. LPN 1 stated he would explain what they are for and then she would take them. LPN 1 stated resident 28 had not expressed sadness to him and was not aware of statements she had made of wanting to die. On 3/5/25 at 11:24 AM, an interview was conducted with the RA. The RA stated that she was not aware of the resident-to-resident incident that occurred and that it should have been reported to her, but might have been reported to the DON. The RA stated that if it was reported to her she would have reviewed the care plans and made changes if needed. The RA stated she completed the PHQ-9 evaluations and residents who had a high score would be consulted with the LCSW, but resident 28 scored a 1 and 2. The RA stated the PHQ-9 score was not the only thing that would be used to determine a need for a referral to the LCSW. On 3/5/25 at 11:27 AM, an interview was conducted with CNA 3. CNA 3 stated she observed resident 28 cry, usually when she took her medications. On 3/5/25 at 12:11 PM, an interview was conducted with the DON. The DON stated a nurse reported to her that she was having a hard time getting resident 28 to take her medications and that resident 28 stated she was ready to die. The DON stated she immediately spoke with the RA and then they both went and talked with the resident. The DON stated the resident was remorseful for saying that and that she was just frustrated about having to take so many medications because it ruined the taste of her food. The DON stated that the Physician Assistant (PA) saw her and they are trying to get her off any unnecessary medications. The DON stated they talked to her family too and that her family was going to come in to discuss her taking medications or, possibly, a palliative approach because resident 28 was not currently seeking treatment for her cancer. The DON stated she was diagnosed with cancer in October when she had verbalized that she wanted to die. The DON stated resident 28 would sometimes cry, but if you asked her if she was okay, she would say she was fine and smile. The DON stated that resident 28 had not been sad but occasionally she would remember that she had cancer and she would cry for 10 seconds and then she would forget again and be fine. The DON stated resident 28 was reviewed in the psychotropic meeting recently and was taken off of her Lexapro and the treatment for her depression was that she was meeting with the RA. The DON stated when an antidepressant was discontinued, the behavioral symptom monitoring was discontinued too. The DON stated if the resident was becoming more depressed, it would be based off of what staff reported. The DON stated they were not expecting to see any changes once resident 28 was taken off of the Lexapro because she was on a super low dose. The DON stated resident 28 was not meeting with a therapist right now. The DON stated that the RA does the PHQ-9 evaluation quarterly and if the score is above a 10 she would be reviewed in the psychotropic meeting but that resident 28 scores very low. The DON stated if a resident was consistently high she would be referred to behavioral health. The DON stated she was notified of the resident-to-resident incident where resident 28 stated that she was going to throw a centerpiece at the other resident because she was yelling a lot. The DON stated that was not typical behavior for resident 28 and seemed out of character. The DON stated she did not think that anyone spoke with resident 28 about the altercation and that the RA should follow up on that. The DON stated whoever witnessed the altercation should have reported that to the RA and possibly have the doctor follow up with resident 28. On 3/5/25 at 2:11 PM, a follow-up interview was conducted with the RA. The RA stated that she had not consulted with the LCSW for resident 28 and that she would typically reach out to the consultant with circumstances where she did not have any experience. The RA stated the LCSW consultant did not go to the facility but that she did monthly audits. The RA stated she did not think there was any documentation of a review of resident 28. The RA stated that if she was made aware of the resident-to-resident altercation she would have consulted with the LCSW. On 3/5/25 at 3:47 PM, an interview was conducted with the Administrator (ADM). The ADM stated that he was not aware that resident 28 had made statements about wanting to die and that it would be warranted as something to look at. The ADM stated staff told him that resident 28 said that she was going to throw a vase at resident 6 and that staff separated them. The ADM stated he had first heard about the incident today. The ADM stated the staff that witnessed the incident deemed that this was not abuse.

Based on observation, interview and record review, for 1 of 24 residents, the facility did not ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, a resident did not have a physician order for the use of oxygen, and residents did not have properly labeled oxygen tubing. Resident identifiers: 20. Findings include: Resident 20 was admitted to the facility on [DATE] with diagnoses of pericardial effusion, chronic obstructive pulmonary disease, morbid obesity, chronic respiratory failure with hypoxia, interstitial pulmonary disease, chronic respiratory failure with hypercapnia, obstructive sleep apnea and chronic congestive heart failure. Resident 20's medical record was reviewed 3/4/25 through 3/5/25. On 3/4/25 at 9:31 AM, an interview was conducted with resident 20. Resident 20 stated his oxygen did not work when it was going through the humidifier. An observation was made of the oxygen concentrator. The oxygen tubing to the nasal cannula was connected directly to the concentrator and not through the humidifier. Resident 20 stated his concentrator had not been working for about 2 weeks. Resident 20 stated it felt like his nose was dry. On 3/4/25 at 11:47 AM, an observation was made of the humidifier bottle not being connected to the concentrator and the nasal cannula was attached directly to the concentrator. Another humidifier with tubing observed to be sitting on the night stand. Resident 20 was observed to have a nasal cannula in place and oxygen was flowing at 4 L (liters) per minute. On 3/5/25 at 9:10 AM, an interview was conducted with resident 20. The resident stated the humidifier on his concentrator did not seal so when they hooked it up it would leak and there was not enough pressure to supply him with the oxygen he needed. The resident stated when it is hooked up to the bubbler he would get shortness or breath, lightheaded, headaches, occasional bloody noses and it felt like everything was closing in on him. The resident stated it had been going on for a couple of weeks and the CNAs had tried to change it but it was just a bad batch from the manufacturer. The resident stated the staff change out the bubbler and oxygen cannula every Sunday. On 3/5/25 at 9:13 AM, an observation was made of the humidifier bottle not being connected to the concentrator and the NC was attached directly to the concentrator. The tubing that attaches to the concentrator is sticking straight up in the air. Another humidifier with tubing observed to be sitting on the night stand. The order dated 2/1/25 documented, Change O2 humidifier every month on first Sunday every night shift starting on the 1st and ending on the 1st every month. March 1st fell on Saturday and the progress notes documented, Will be changed Sunday night. The Medication Administration Record (MAR) documented that the humidifier had not been changed on the first Sunday of March. On 3/5/25 at 10:33 AM, an interview was conducted with CNA 3. The CNA stated that the oxygen supplies were changed every Sunday night. CNA 3 stated if the humidifier did not work she would try to fix it. CNA 3 stated if she could not get it to work she would tell the nurse to see if they could help. CNA 3 stated she did not know of any trouble with them. On 3/5/25 at 10:39 AM, an interview was conducted with the Certified Nursing Assistant Coordinator (CNAC). The CNAC stated that the oxygen supplies were changed every Sunday. The CNAC stated if they could not get the bubbler to work, they would need to reach out to the administration to see what needed to be done. The CNAC stated if the oxygen is humidified it dries out their nose, throat, can cause them to cough and from experience got CNAC stated the resident's nose can get so dried out they had nose bleeds. The CNAC stated he had not been notified about a humidifier that was not working. The CNAC stated he did not know of any problems with the humidifiers, they had been working pretty well lately. On 3/5/25 at 10:58 AM, an interview was conducted with CNA 1, who was the CNA working on resident 20's hallway. CNA 1 stated that as far as she knew it was a night shift thing to take care of changing the oxygen supplies. CNA 1 stated that each shift the CNAs are supposed to check the oxygen set up for the residents on oxygen to make sure the tubing had been updated and it is working correctly. CNA 1 stated she was unaware of any complaints that a humidifier was not working. CNA 1 stated that there was not humidifier on the 300 hallway that was not working today. CNA 1 stated if the oxygen was not working correctly she would get the nurse to help her. CNA 1 stated she did not know it would do to the resident if the humidification was not working correctly. On 3/5/25 at 11:13 AM, an interview was conducted with Registered Nurse (RN)1. RN 1 stated she had not been told that any of the residents on the 300 hallway that their oxygen was not working. RN 1 stated she would usually check the oxygen set up to make sure it was functioning correctly if a resident was on oxygen. An immediate observation was made of RN 1 enter resident 20's room and administer a medication. RN 1 was observed to walk past the oxygen concentrator and did not check it. On 3/5/25 at 11:16 AM, The CNAC accompanied this survey to resident 20's room. Resident 20 informed the CNAC that the humidifier was not working. The CNAC was observed to apply gloves and check the oxygen concentrator and humidifier. The CNAC stated the CNAs should check the oxygen set up when they did their rounds. Resident 20 informed the CNAC that the CNAs had hooked up 3 bottles in one night but it still did not work. The CNAC stated that the CNAs should have let me know or someone in administration so we could have done something about it. The CNAC stated that they had hired a few new CNAs at night and that he had not been told anything about it. The CNAC was observed to leave resident 20's room without correcting the issue with the humidifier. On 3/5/25 at 2:54 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that every Sunday the residents are given new oxygen tubing and humidifier bottle. The DON stated she would expect the CNAs to remove the equipment that was not functioning correctly with working equipment. The DON stated if the humidification was not functioning correctly then the resident could get a dry nose and possibly cause a bloody nose. The DON stated she was unaware that the humidifer bottles were not functioning correctly. On 3/5/25 at 3:25 PM, a follow up observation was made of resident 20's oxygen set up. The oxygen tubing to the nasal cannula was connected directly to the concentrator and not through the humidifier. A follow up interview with the DON was conducted on 3/5/25 at 3:40 PM, the DON stated it was not required to have a humidifier bottle on every oxygen administration. The DON stated humidification was used to help with the dryness. The DON was unaware that resident 20 had experienced bloody noses when he received the unhumidified oxygen.

Based on interview and record review it was determined, for 1 of 24 sampled residents, that the facility did not ensure that a resident who was continent of bladder on admission received services and assistance to maintain continence. Specifically, a resident was assessed a candidate for scheduled toileting and was not provided the services. Resident identifier: 25. Findings include: Resident 25 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following a cerebral infarction affecting non-dominate side. On 3/3/25 at 11:31 AM, an interview was conducted with resident 25. Resident 25 stated after she pushed her call light she wet her pants while waiting for staff. Resident 25 stated she was not on a toileting schedule but would like to be on one especially in the evenings and at night time because there were less staff to help her to the bathroom. Resident 25's medical record was reviewed 3/3/25 through 3/5/25. A quarterly Minimum Data Set (MDS) dated [DATE] revealed resident 25 was frequently incontinent. Resident 25 was not currently on a trial toileting program. There was no care plan regarding bowel and bladder incontinence. There was a care plan dated 7/27/24 with an admitting diagnosis of overactive bladder. Interventions included giving medications and treatments as ordered; by the Medical Doctor, dietary activities, Social Services and consultant visits; and therapies as ordered. A bowel and bladder program screener in the assessment section dated 11/4/24 revealed a score of 12 which indicated resident 25 was a candidate for scheduled toileting (timed voiding). A Long Term Care Evaluation dated 9/18/24 at 7:51 PM documented, resident 25 was incontinent of urine and was on a check and change program with a scheduled toileting program in place. Resident 25 used adult briefs with no new onset of incontinence. Resident 25 was frequently incontinent with 7 or more episodes of urinary incontinence, but at least one episode of continent voiding. Resident 25 voided via the toilet. A Long Term Care Evaluation progress note dated 1/22/25 at 11:37 PM, revealed resident 25 was incontinent of urine and used adult briefs. There was no new onset of incontinence and was always incontinent (no episodes of continent voiding). A Long Term Care Evaluation progress note dated 1/29/25 at 11:21 PM, revealed resident 25 was incontinent of urine and used adult briefs. In addition, there was no new onset of incontinence and resident was always continent. A Long Term Care Evaluation progress note dated 2/26/25 at 11:06 PM, revealed resident 25 was incontinent of urine and used adult briefs. In addition, no new onset incontinence and resident was always incontinent (no episodes of continent voiding). The CNA (Certified Nursing Assistant) documentation in the tasks section revealed frequent toileting/monitor for incontinence. There was a check mark documented 2 to 3 times per day. There was no specific timed voiding documented. It was documented that resident 25 was continent of bladder on 2/17/25, 2/24/25, 2/26/25 and 2/27/25. On 3/5/25 at 11:56 AM, an interview was conducted with CNA 7. CNA 7 stated she was not sure what a bowel and bladder program was. CNA 7 stated she completed rounds for all residents every 2 hours. CNA 7 stated resident 25 was not on a bladder program. On 3/5/25 at 12:00 PM, an interview was conducted with CNA 8. CNA 8 stated he would have to ask the nurse what a bowel and bladder program was. CNA 8 stated he was not aware of anyone on a bowel and bladder program. On 3/5/25 at 12:01 PM, an interview was conducted with CNA 3. CNA 3 stated she had not heard of a bowel and bladder program. CNA 3 stated there were residents that need to be checked on every 2 hours. CNA 3 stated resident 25 knew when she needed to use the restroom and used her call light. CNA 3 stated she checked on resident 25 every 2 hours or resident 25 used the call light if she needed assistance more often than 2 hours. CNA 3 stated resident 25 took water pills so she had to use the restroom more often. On 3/5/25 at 12:06 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated there was a bowel and bladder assessment the nurse completed to determine if the resident would be appropriate for a bowel and bladder retraining program. LPN 1 stated after filling out the assessment, he was not sure what happened. LPN 1 stated he was generally aware if a resident was continent or incontinent of bowel and bladder because the residents were at the facility long term. LPN 1 stated resident 25 was continent and staff used a hoyer lift to get her into the bathroom. LPN 1 stated resident 25 was very good about using her call light to ask staff to get her to the bathroom. LPN 1 stated if a resident was on frequent toileting, then he would expect staff to ask the resident if they needed to use the restroom more frequently than every 2 hours. On 3/5/25 at 11:11 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the facility had a bladder retraining program. The DON stated there was an assessment and if the resident was a candidate, then staff did that. The DON stated the program consisted of toileting residents every 2 hours to see if they had that urge to urinate. The DON stated the facility had a bladder scanner the staff used to find out how much urine a resident had. The DON stated the nurses managed the bladder retraining program. The DON stated the program was listed in the CNA's tasks section and was on the CNA report sheets. The DON stated frequent toileting was toileting a resident every 2 hours. At 3:15 PM, a follow up interview was conducted. The DON stated usually there was a physician's order for a retraining program. The DON stated resident 25 usually used a commode for toileting but sometime resident 25 did not want to get out of bed so a brief change was done by the CNA's. The facility provided a Behavioral Programs and Toileting Plans for Urinary Incontinence Policy and Procedure revised October 2010 that revealed the purpose of this procedure was to provide guidelines for the initiation and monitoring of behavioral interventions and/or a toileting plan for the resident with urinary incontinence. The preparation section revealed the following steps: the resident care plan was to be assessed for any special needs for the resident; a thorough assessment was to be completed; treatment and services to address factors that were potentially modifiable; monitor, record and evaluate information about the resident's bladder habits; and assess the resident for appropriateness of behavioral programs which promote urinary continence. The habit training/scheduled voiding was a technique that called for scheduled toileting at regular intervals on a planned basis to match the resident's voiding habits. There was no systemic effort to encourage the resident to delay voiding, included timed voiding with interval based on the resident's usual voiding schedule or patter, timed voiding was every three to four hours while awake and resident who could not self-toilet may be candidates for habits training or scheduled voiding programs. Staff were to document the results of the behavioral/toileting training in resident's medical record and if the resident responded then the program should continue.

Based on interview and record review it was determined, for 2 of 23 sampled residents, that the facility did not ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences which indicated that the dose should be reduced or discontinued. Specifically, resident's blood pressure (BP) support medication was administered outside of the physician's ordered parameters. Resident identifier: 20 and 238. Findings included: 1. Resident 20 was admitted to the facility on [DATE] with diagnoses of essential hypertension. Resident 20's medical record was reviewed 3/4/25 through 3/5/25. A physician's order dated 11/27/24 documented, Toprol XL (extended release)Tablet 24 Hour 25 MG (milligram) (Metoprolol Succinate ER (extended release) Give 1 tablet by mouth one time a day for HTN (hypertension) HOLD FOR SBP (systolic blood pressure)<(less than) 105 OR HR (heart rate) < 55. The January 2025 Medication Administration Record (MAR) was reviewed and revealed Toprol XL was held when it should have been administered on: a. 1/24/25 B/P 106/63 b. 1/27/25 B/P 109/64 c. 1/29/25 B/P 106/62 The January 2025 MAR revealed Toprol XL was administered and should have been held on the following date: a. 1/25/25 B/P 101/59 On 3/5/24 at 12:15 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated the nurses should always follow the doctors orders and administer or hold the blood pressure medication if it falls into those parameters. RN 1 stated it could cause the resident's blood pressure to increase or lower incorrectly if the parameters were not followed. On 3/5/35 at 2:50 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the nurses were expected to make sure to follow the physician ordered parameters and enter the vital signs of each resident into the medical record before administering the medication. 48709 2. Resident 238 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included hypotension, disorder of kidney and ureter, and dementia. Resident 238's medical record was reviewed 3/3/25 through 3/5/25. A physician's order, dated 2/28/25, indicated, Midodrine HCl Oral tablet 2.5 MG (Midodrine HCl) Give 2.5 mg by mouth two times a day for HYPOtension HOLD for SBP greater than 110 or DPB [diastolic blood pressure] greater than 90. The February 2025 MAR was reviewed and indicated Midodrine HCl was administered when it should have been held on 2/28/25 with a blood pressure (B/P) of 145/68. The March 2025 MAR was reviewed and indicated Midodrine HCl was administered when it should have been held on: a. 3/3/25 B/P 138/76 b. 3/3/25 B/P 136/75 c. 3/4/25 B/P 132/69 On 3/5/25 at 2:40 PM, an interview was conducted with RN 1. RN 1 stated a check mark on the MAR indicated the resident was administered the medication. RN 1 stated the Midodrine should be held when the B/P was greater than 110 because the medication increases B/P. On 3/5/25 at 2:59 PM, an interview was conducted with the DON. The DON stated nurses were expected to follow the parameters and document the vitals that were required. The DON stated the Midodrine should have been held when the blood pressure was outside the ordered parameters.

Based on interview, and record review, for 3 of 24 residents sampled, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency. Specifically, a resident had an assisted fall out of bed during cares, the same resident had a fall which resulted in a bilateral femur fractures, a resident threatened another resident with physical harm, and a resident choked on a plastic ring and the State Survey Agency was not notified after the allegation was identified. Resident identifiers: 5, 28, 35, Findings include: 1. Resident 35 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease with late onset, lymphedema, morbid obesity, abnormalities of gait and mobility, chronic pain, and epilepsy. Resident 35's medical record was reviewed 3/4/25 through 3/5/25. An incident report dated 1/12/25 documented, [Resident 35] was turned on her left side in bed for CNA [certified nursing assistant] to change her chuck, as the CNA was pulling on the chuck, her right leg moved forward towards the edge of the bed. CNA was able to go to the other side of the bed and hold her legs until assistance arrived to assist [resident 35] to the floor. She was placed in sling and lifted via hoyer lift back into bed. Only her legs were coming off the bed. Due to her weight it was safer for [resident 35] and staff to lower her to the floor and put her back in bed with the hoyer lift. My leg slipped. No injuries were documented on the incident report. An incident report dated 1/17/25 documented, [Resident 35] was calling out for help, when aide entered the room she was on her knees at the side of the bed holding onto the and position bar. She had a bowel movement and urinated. Additional staff came in to assist her to the floor. She was layed down on the hoyer sling and assisted back into bed. On 3/4/25 a review of resident 35's physician progress note dated 1/18/25 revealed the following, patient with fall from bed, yesterday, during cares. subsequently sent to the ER [emergency room ] for evaluation where she was found to have bilateral femoral fractures . There was no additional information regarding the incident or an investigation into the incident provided. On 3/5/25 at 3:32 PM, an interview was conducted with the Administrator (ADM). The ADM stated he was the abuse coordinator for the facility and the staff reported allegations of abuse or neglect to the nurse and then it was reported to him. The ADM stated if there was not a signifiant injury then the allegation would not necessarily be reported to him. The ADM stated he would report any allegations of abuse or neglect to the State Survey Agency. The ADM stated with the assisted fall he would not have expected them to report it to him because they knew exactly what had happened and the CNA was with the resident. The ADM stated with the second fall, it was the exact same thing that happened with the first fall except staff were not in the room. The ADM stated resident 35 liked to be left alone, so the CNAs would place her on her side and leave the room. The ADM stated those who were in the room deem whether the incident would be reported to him or not, if it was reported to him then we talk about it. The ADM stated he did not think these incidents were reportable. The ADM stated we just knew there was not abuse or neglect because it was the way it had always been done. On 3/10/25 at 10:00 AM, a conference call was conducted with the ADM, Director of Nursing (DON), and the Regional Nurse Consultant (RNC). The RNC stated because there was a fracture it was reported to red cap and not to the State Survey Agency because it was not abuse. The ADM stated there was no cause for concern and they knew exactly what happened. The RNC stated within the investigation, if there was a concern, then they would report it. The RNC stated an investigation was completed for interventions but not to determine if there was abuse or neglect. The ADM stated the CNA's were interviewed on 3/6/25. It should be noted on 3/6/25 the CNA's were interviewed and the incident took place on 1/12/25 and 1/17/25. 48709 2. Resident 28 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included intraductal carcinoma in situ of right breast, dysphagia, type 2 diabetes mellitus with diabetic neuropathy, aphasia, cerebral infarction, depression, acute kidney failure, and generalized anxiety disorder. Resident 28's medical record was reviewed 3/3/25 through 3/5/25. A Nurses Note, dated 3/2/25 at 5:30 PM, indicated, Pt [patient] threatened to throw a flower pot at another resident today in the dining hall during dinner. Staff intervened before any physical assault occurred. Residents were separated and taken back to their rooms. An annual Minimum Data Set (MDS) assessment, dated 2/13/25, indicated a Brief Interview for Mental Status (BIMS) score of 10. A BIMS score of 8-12 indicated a moderate cognitive impairment. Resident 6 was admitted to the facility on [DATE] with diagnoses which included generalized anxiety disorder, chronic kidney disease, major depressive disorder, hypertension, and intellectual disabilities. Resident 6's medical record was reviewed 3/3/25 through 3/5/25. A Nurses Note, dated 3/2/25 at 5:29 PM, indicated, Pt got into a verbal altercations [sic] with another pt in the dining hall where the other patient threatened to throw a flower pot at her. Pt stated 'go ahead'. Staff intervened before any physical assault occurred. Pt taken back to her room. A Quarterly MDS assessment, dated 1/29/25, indicated a BIMS score of 7. A BIMS score between 0-7 indicated severe cognitive impairment. On 3/5/25 at 11:24 AM, an interview was conducted with the Resident Advocate (RA). The RA stated that she was not aware of the incident that occurred between residents 28 and 6 and that it should have been reported to her but might have been reported to the DON. The RA stated that if it was reported to her she would have reviewed the care plans and make changes if needed. On 3/5/25 at 11:37 AM, an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated that she had heard about an incident that happened in the dining room where resident 28 got frustrated with resident 6 and that she picked up an object but that nothing happened and they were separated. On 3/5/25 at 12:11 PM, an interview was conducted with the DON. The DON stated it was reported to her that resident 6 was yelling a lot and resident 28 said that she was going to throw a centerpiece at resident 6, so staff separated them. The DON stated that is not typical behavior for resident 28 and seemed out of character. The DON stated she did not think anyone spoke to either of the residents after the altercation and that the RA should have followed up on that. The DON stated she would want to put an intervention into place after a resident-to-resident altercation to protect the resident. On 3/5/25 at 2:11 PM, a follow-up interview was conducted with the RA. The RA stated that if the resident-to-resident altercation was reported to her she would have met with both of the residents and make sure interventions were put into place to prevent any future incidents. On 3/5/25 at 2:58 PM, a follow-up interview was conducted with the DON. The DON stated that any suspicions of physical, sexual or verbal abuse, staff-to-resident or resident-to-resident needed to be reported to the Administrator immediately. On 3/5/25 at 3:47 PM, an interview was conducted with the Administrator (ADM). The ADM stated staff told him that resident 28 said that she was going to throw a vase at resident 6 and that staff separated them. The ADM stated he had first heard about the incident today. The ADM stated the staff that witnessed the incident deemed that this was not abuse and that he agreed so it did not need to be reported to the state agency. 30563 3. Resident 5 was admitted to the facility on [DATE] with diagnoses which included dementia, major depressive disorder, severe intellectual disabilities, dysphagia, and schizoaffective disorder. On 3/3/25 at 12:19 PM and 3/4/25 at 12:10 PM, observations were made of the resident 5. Resident 5 was observed to be sitting at a table by himself drinking thin liquids and coughing after each sip. Resident 5's medical record was reviewed 3/3/25 through 3/5/25. A physician's order dated 1/17/24 revealed regular, diet easy to chew textures, thin/regular liquids consistency. A nursing progress note dated 12/24/24 at 12:02 PM revealed, Patient was given a cupcake today during a Christmas activity. Patient began to choke on the cupcake. He got up and went to his room, CNA followed. Patient was struggling to breath. CNA performed the Heimlich maneuver, patient began coughing up and vomiting saliva. Patient began breathing normal, and wanted to lie down in bed. PA [Physician's Assistant] ., assessed lung sounds. Lung sounds are congested at this time. Patient breathing normal. Vital signs all within normal ranges for patient's baseline. Family notified of incident. The incident was not reported to the State Survey Agency. On 3/5/25 at 3:32 PM, an interview was conducted with the ADM. The ADM stated the incident with resident 5 chocking on the plastic ring was not reported to the SSA because there was no suspicion of abuse or neglect because they knew what happened.

Based on interview and record review, it was determined that the facility did not employ a clinically qualified full-time dietitian or other clinically qualified nutrition professional to serve as the director of food and nutrition services. Specifically, the facility did not employ a full time Registered Dietitian (RD) and the Dietary Manager (DM) did not meet the requirements to serve as the director of food and nutrition services. Findings included: On 8/2/21 at approximately 11:28 AM, an interview was conducted with the facility's DM. The DM stated he was enrolled in classes to complete the certification for Dietary Manager. He stated he was enrolled in a fast track program that would take about 5 months to be completed. The DM stated he had been at the facility for 2 ½ years. The DM stated the facility had a Registered Dietitian (RD) consultant that came to the facility at least once per week, sometimes more frequently. The DM stated the RD participated in weekly skin and weight meetings at the facility. On 8/3/21 at approximately 4:00 PM, the date of hire and certifications for the DM were requested from Human Resources (HR). The correspondence from HR included the DM's hire date of 8/3/19 and current Serve Safe certificate. On 8/5/21 at approximately 11:30 AM, an interview was conducted with the facility RD. The RD stated she came to the facility every Wednesday for meetings, but mostly worked remotely from home. The RD stated the facility had a Dietary Technician (DT) that worked part time at the facility. She stated that the DT was in touch with her on a daily basis regarding resident needs. The RD stated the DT did resident assessments, including risk assessments and preferences. The RD stated the DM was also in touch with her regularly regarding residents and dietary needs. The RD stated assessments were completed within 10 days of a resident's admission to the facility, unless the resident was on a tube feed, had a pressure ulcer, low intake, or was on [CONDITION(S)]. The RD stated those assessments were completed within 72 hours with the goal being 48 hours. The RD stated the DM and the DT did not make recommendations on their own, but consulted with her about needs for the resident. The RD stated recommendations for supplements were approved by the Medical Doctor (MD). The RD stated the DM did not have any current credentials and had been falling behind in his schooling. The RD stated the facility was considering giving the DM some time off to finish the certification program.

Based on interview and record review it was determined, for 3 out of 28 sampled residents, that the facility did not ensure that the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist, and any irregularities were reported to the attending physician, the facility's medical director and the Director of Nursing (DON) and these reports were acted upon. Additionally, the attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. Specifically, the pharmacist made recommendations to the attending physician that were not acted upon nor documented in the resident's medical record. Resident identifier: 2, 8, and 28. Findings included: 1. Resident 8 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type 2, adjustment disorder with depressed mood, pseudobulbar affect, [CONDITION(S)], anxiety disorder, [CONDITION(S)], dry eye syndrome, protein-calorie malnutrition, interstitial pulmonary disease, muscle spasm, [CONDITION(S)], hypertension, gastro-[CONDITION(S)] reflux disease, [CONDITION(S)], and [CONDITION(S)]. On 8/03/21 resident 8's medical records were reviewed. Review of resident 8's Monthly Medication Review (MMR) by the licensed pharmacist revealed the following recommendations: a. February 2021 - Increase [MEDICATION(S)] to 32 units every (Q) evening at bedtime (HS) (2 unit increase) and discontinue (DC) the sliding scale; or increase [MEDICATION(S)] to 31 units (QHS) (1 unit increase) and DC the sliding scale; or DC the sliding scale. A check mark was noted next to Increase [MEDICATION(S)] to 32 units QHS (2 unit increase) and the DC sliding scale was crossed off and initialed as noted, initials were not identified. The physician signed the recommendation on 2/17/21 and the form was also signed by the same individual who crossed off DC sliding scale. This unknown individual signed the form on 2/19/21. b. April 2021 - This resident takes [MEDICATION(S)] 5 mg (milligram), [MEDICATION(S)] 45 mg daily, [MEDICATION(S)] 32 units daily and sliding scale insulin. A review of the MAR (Medication Administration Record) shows that the patient requires sliding scale insulin about 30% of the time, for an average of almost 7 units per day, mostly due to several high doses given at lunch time in April. The most recent A1c in February was 5.6 % and the target for this patient, based on age and comorbidities, is 8% or lower. Sliding scale insulin is classified as a high risk in the elderly due to risk of [CONDITION(S)], and it requires expensive testing supplies, and significant nursing time. The lowest blood glucose on record in April was 85. This was discussed with the medical team, and the following has been approved: 1. DC sliding scale insulin. It should be noted that the Physician's Assistant (PA) signed the recommendation but did not indicate if they agreed or disagreed with the recommendation. c. August 2021 - Increase [MEDICATION(S)] to 35 units daily and DC the sliding scale. The PA also documented in the response section to continue the morning fasting blood glucose level and discontinue all other checks. The recommendations were signed by the PA. On 8/04/21 at 11:37 AM, an interview was conducted with the Corporate Resource Nurse (CRN) who was also the acting DON. The CRN stated that the process for the monthly pharmacist review was that the pharmacist had already spoken with the physician prior to sending the recommendation to the facility. The CRN stated that the PA signed the August recommendation today. The CRN stated that the pharmacy reports were signed by the provider and sent to medical records to be scanned into each resident's miscellaneous section of the electronic medical records. The CRN stated that the previous Administrator was the person receiving the pharmacy recommendations and not the clinical staff. On 8/05/21 at 8:28 AM, a follow-up interview was conducted with the CRN. The CRN stated that if the provider signed the pharmacy recommendation then that meant they were agreeing to the recommendations. The CRN stated she was not aware of who the initials belonged to on the February 2021 recommendations next to the DC sliding scale that was crossed off. The CRN stated that it was not possible to identify if the physician or the unknown individual crossed off that portion of the recommendation. The CRN stated that she did not believe that the physician wanted the sliding scale discontinued because he liked ordering sliding scales for insulin. The CRN stated that the [MEDICATION(S)] dose was increased per the pharmacist's recommendations. The CRN stated that the April 2021 had the same recommendation to discontinue the sliding scale for the insulin and based off her knowledge of the recommendation having a signature, the sliding scale should have been discontinued per the providers agreement with the recommendation. The CRN stated that the sliding scale was finally discontinued yesterday after the third recommendation was made in August 2021. 2. Resident 28 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type 2, dysphagia, dementia, localized [CONDITION(S)], [CONDITION(S)], retention of urine, left bundle branch block, metabolic [CONDITION(S)], urinary tract infection, [CONDITION(S)], [CONDITION(S)], [MEDICATION(S)], chronic kidney disease, pneumonitis, [CONDITION(S)], gastro-[CONDITION(S)] reflux disease, major depressive disorder, protein-calorie malnutrition, chronic pain, and hypertension. On 8/03/21 resident 28's medical records were reviewed. Review of resident 28's MMR by the licensed pharmacist revealed the following recommendations: a. March 2021 - Increase [MEDICATION(S)] to 16 units daily and discontinue sliding scale insulin; or Increase [MEDICATION(S)] to 15 units daily and discontinue sliding scale insulin; or Increase [MEDICATION(S)] to 16 units daily and maintain sliding scale for now; or Increase [MEDICATION(S)] to 15 units daily and maintain sliding scale for now; or Other; or No changes at this time. The form did not indicate the physician response to the recommendations and did not contain a physician or provider signature. b. April 2021 - Discontinue Pantoprazole; Start [MEDICATION(S)] 20 mg two times a day as needed for rebound reflux; Increase [MEDICATION(S)] to 17 units daily; and discontinue the sliding scale insulin. The recommendations documented that this was discussed with the medical team for this facility and it was approved. A signature was noted on the recommendations with an Ok next to it. c. July 2021 - Discontinue Pantoprazole; Start [MEDICATION(S)] 20 mg two times a day as needed for rebound reflux; Increase [MEDICATION(S)] to 17 units daily; and discontinue the sliding scale insulin. The recommendations documented that this was discussed with the medical team for this facility and it was approved. The PA response was signed on 7/6/21. It should be noted that this was the same recommendation that was made in April 2021. On 8/05/21 at 8:47 AM, an interview was conducted with the CRN. The CRN stated that the March 2021 recommendations that was implemented was that the [MEDICATION(S)] was increased to 16 units daily on 3/11/21 and the sliding scale insulin was maintained. The CRN stated that the physician did not document the response to the recommendation on the form nor did he sign the recommendation form. The CRN stated that the recommendations in April 2021 was signed Ok by the Medical Director, but the recommendations were not implemented until July 2021 when the PA signed the recommendations again. 3. Resident 2 was admitted to the facility on [DATE] then readmitted on [DATE] with diagnoses which included but were not limited to, essential hypertension, type 2 diabetes with [CONDITION(S)], dementia without behavioral disturbance, chronic kidney disease, gastro-[CONDITION(S)] reflux disease, generalized anxiety disorder, interstitial [MEDICATION(S)], pain, nausea and vomiting. Resident 2's medical record was reviewed on 8/3/21. a. The Consultation Pharmacist's Medication Regimen Review (MRR) Report dated 4/13/21, documented that resident 2 was on [MEDICATION(S)] and sliding scale insulin. The MRR revealed This resident takes [MEDICATION(S)] 32 units daily and sliding scale insulin, the [MEDICATION(S)] was increased last month from 25 units daily. A review of the MAR shows that the patient requires sliding scale insulin about 43% of the time, or an average of about 3 units per day (previously used 80% for average of 10 units daily, before [MEDICATION(S)] increased). The most recent A1C in November was 6.3%, and the target for this patient based on age and comorbidities, is 8% or lower. Sliding scale Insulin is classified as a high risk in the elderly, due to high risk of [CONDITION(S)], and it requires expensive testing supplies, and significant nursing time. The lowest blood glucose on record in April was 100 (previously 104 before [MEDICATION(S)] increase), and about 57% of measurements were below 150 (previously 7% before [MEDICATION(S)] Increase), and most doses of sliding scale occur at dinner time. There are no oral agents on board, and the American Diabetes Association recommends utilizing three oral agents before the use of rapid acting insulin. This was discussed with the medical team and the following has been approved: Discontinuation of the sliding scale insulin and initiation of [MEDICATION(S)] 500mg once daily at lunchtime was recommended. The form indicated that the medical director had signed the form and agreed with the Pharmacist recommendations but the recommendations were never executed. b. Review of resident 2's medication administration record (MAR) for May, June, July and August revealed no active order for [MEDICATION(S)] and an active order to continue using the following sliding insulin scale: Novolog solution 100 unit/milliliter (ml), inject subcutaneously before meals as per sliding scale: if blood sugar (BS) 0-150 = 0 units, if <60 notify medical doctor (MD) and offer juice, protein, glucose tabs, recheck BS in 15 minutes; if resident unresponsive call 911. If BS 151-180 administer 2 units; if BS 181-200 administer 4 units; if BS 201-250 administer 6 units; if BS 251-300 administer 8 units; if BS 301-350 administer 10 units; if BS 351-400 administer 14 units; if BS 401 or greater administer 14 units and notify MD. On 8/3/21, during survey, the insulin sliding scale for resident 2 was discontinued by the Physician's Assistant (PA). On 8/5/21 at 9:15 AM, an interview was conducted with the acting director of nursing (DON/CRN). DON/CRN stated the signature that approved the initiation of [MEDICATION(S)] and the discontinuation of the sliding scale on the 4/13/21 pharmacology review was that of the facility's medical director. DON/CRN stated she was also unable to find the [MEDICATION(S)] in the MAR for May, June, July or August. On 8/05/21 at 12:26 PM, an interview was conducted with the DON/CRN. DON/CRN stated the [MEDICATION(S)] order was never acted upon and put into place for resident 2.

Based on observation, interview, and record review it was determined, for 4 out of 28 sampled residents, that the facility did not 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 [CONDITION(S)]-CoV-2. Specifically, observations were made of staff entering rooms on Transmission Based Precautions (TBP) without determining if aerosolized generating procedures (AGP) were in use and the necessary Personal Protective Equipment (PPE) was not donned, resident's Continuous Positive Airway Pressure ([CONDITION(S)]) machines were not cleaned by staff, staff were observed not performing hand hygiene and changing gloves during wound care, and staff were observed not performing hand hygiene during meal delivery. Resident identifiers: 11, 14, 22, and 24. Findings included: 1. Resident 14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/02/21 at 2:52 PM, an interview was conducted with resident 14. Resident 14 stated that he needed a new [CONDITION(S)] machine because his current one was on recall. Resident 14 stated that he operated the machine independently and cleaned the machine himself. Resident 14 stated that he filled up the water reservoir, and that he should receive new supplies soon. An observation was made of signs posted on resident 14's door that stated on droplet precautions during aerosolized procedure. Upon initiation of [CONDITION(S)]/Bilevel Positive Airway Pressure ([CONDITION(S)]), during all duties and cares with [CONDITION(S)], and for 30 minutes after removal of [CONDITION(S)] wear gloves, gown, N95, and face shield, and discard upon exiting room. The PPE was observed to be located inside the resident's room by the door hanging in a bag on the glove dispenser. The PPE bag contained disposable gowns, face shields, and N95 masks. On 8/3/21 resident 14's medical records were reviewed. Review of resident 14's July 2021 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no documentation for cleaning and care of the [CONDITION(S)] equipment. On 8/4/21 at approximately 4:15 AM a continuous observation was started outside of resident 14's room. No observations were made of the licensed nurses or Certified Nursing Assistants (CNA) from night shift entering the resident room. On 8/04/21 at 5:52 AM, an interview was conducted with CNA 1. CNA 1 stated that the day shift staff were responsible for cleaning the [CONDITION(S)] machines, but some residents were able to do this themselves. CNA 1 stated that for residents that had a [CONDITION(S)] machine running she would donn a gown, goggles, gloves, and N95 mask when she entered the room. CNA 1 stated that she would place a face shield over her goggles and then discard it afterwards. CNA 1 stated that the face shields were used one time only and then discarded, and that the facility had sufficient supply to do this. The CNA stated the PPE was located just inside the door of resident 14's room. On 8/04/21 at 6:18 AM, an observation was made of CNA 2 entering resident 14's room. CNA 2 was observed to donn a pair of gloves at the residents doorway and close the door. An immediate interview was conducted with the CNA 2 upon exit of resident 14's room. CNA 2 stated that the resident needed assistance to the restroom. The CNA stated that the resident was up and seated at the bedside when she entered. The CNA stated that the [CONDITION(S)] machine was not running when she entered the room, that the resident was independent with operating the machine, and he put it on and took it off independently. CNA 2 was observed wearing a surgical mask and goggles inside the resident room. On 8/04/21 at 6:29 AM, an observation was made of CNA 2 entering resident 14's room again to answer the call light. The CNA had a stack of clean linen with her when she entered the room, and no additional PPE was donned. CNA 2 was observed wearing a surgical mask and goggles inside the resident room. On 8/04/21 at 6:34 AM, an interview was conducted with CNA 2. CNA 2 stated that when she entered resident 14's room earlier for toileting assistance she only donned gloves and no other PPE. The CNA stated that she did not know when the resident had turned off the [CONDITION(S)] machine and she did not ask. The CNA stated that the nightshift staff were responsible for cleaning the [CONDITION(S)] equipment. On 8/04/21 at 6:38 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she was not sure of the process for cleaning the [CONDITION(S)] machine, but that the staff on the night shift should be doing it. On 8/04/21 at 6:40 AM, an interview was conducted with Registered Nurse (RN) 1 and CNA 3. RN 1 stated that resident 14 cleaned his own [CONDITION(S)] machine. CNA 3 stated that she filled the water reservoir on day shift and then wiped the machine down with a disinfecting wipe on the outside only. RN 1 stated that resident 14 was independently using his [CONDITION(S)] machine. RN 1 stated that she did not know when he had removed the machine this morning and she did not ask him. RN 1 stated that when the [CONDITION(S)] was running the staff were to wear an N95 mask, gown, gloves and goggles or face shields when it was operating and for 30 minutes afterwards. That's a good question. How do I know when he took it off? RN 1 stated that usually resident 14's door was closed when he was using the [CONDITION(S)] machine. RN 1 stated that by the time she entered the resident's room in the morning he had been up for awhile, because he was an early riser. On 8/04/21 at 6:47 AM, an interview was conducted with the Corporate Resource Nurse (CRN) who was also the acting Director of Nursing (DON). The CRN stated that she would print the facility process for cleaning the [CONDITION(S)] machines. On 8/04/21 at 7:25 AM, an interview was conducted with the CRN. The CRN stated that she had an email with the cleaning process for the [CONDITION(S)] machines and a policy for the cleaning process. The CRN stated that the CNAs were responsible for this task, probably the night shift, but should be the day shift. The CRN stated that she did not know where it was documented as completed or if it was even being documented at all. The CRN stated that for rooms on TBP for the [CONDITION(S)] machine and for 30 minutes after discontinuation of use staff should be asking the resident when they removed the [CONDITION(S)] to determine if the additional PPE was still required. The CRN stated that other residents nap during the day and use the [CONDITION(S)] during the day. The CRN stated that on the Long Term Care side the residents were very routine so the CNAs knew that by breakfast they were fine. Review of the [CONDITION(S)] cleaning recommendations contained in an email on 6/23/2020 from the CRN documented that the staff were to do the following: 1. Wipe off with a damp cloth (outside) 2. Change filter every 3 - 6 months 3. 1 x per week wash the reservoir, face mask and tubing with warm soapy (mild detergent) water. a. If it isn't coming clean you can use 1 part vinegar with 3 parts water to clean. b. Repeat with warm soapy water. c. Rinse d. Air dry Review of the facility Policy and Procedure for [CONDITION(S)]/[CONDITION(S)] Support documented under the General Guidelines for Cleaning that specific instructions were obtained from the manufacturer of the device. The machine cleaning stated to wipe the machine with warm, soapy water and rinse a least once a a week and as needed. The humidifier (if used) stated to use clean distilled water only in the humidification chamber, clean humidifier weekly and air dry, and to disinfect to place in a vinegar-water (1:3) and soak for 30 minutes followed by a thorough rinse. The washable filters were to be cleaned by running under water once a week to remove dust and debris, and replaced at least once a year. Disposable filters needed to be replaced monthly. The policy stated to clean the masks, nasal pillows, and tubing daily by placing in warm, soapy water and soaking/agitating for 5 minutes. Mild dish detergent was recommended. Rinse with warm water and allow to air dry between uses. The headgear strap stated to wash with warm water and mild detergent as needed and allow to air dry. The policy was revised in March 2015. On 8/4/21 at 7:36 AM, an observation was made of CNA 4 inside resident 14's room obtaining vital signs. CNA 4 was observed wearing a surgical mask and face shield. CNA 4 stated she did not ask resident 14 about the [CONDITION(S)] machine, nor the time it was turned off. CNA 4 stated she was not present when the resident removed his [CONDITION(S)] machine, and did not know who did it. CNA 4 stated that she donned gloves in addition to her face shield and surgical mask when she obtained the vital signs. On 8/5/21 at 9:04 AM, a follow-up interview was conducted with the CRN. The CRN stated staff should be adhering to the TBP that were posted on the sign outside the door. The CRN stated that the day shift should be determining when the device was removed before entering the room. The CRN stated that for those residents that were independent with the [CONDITION(S)] it would be appropriate for staff to ask the resident when they removed the device. The CRN stated that the location of the PPE did not make sense. It needed to be located on the outside of the room. That was why the door was closed, the droplets were in the air. The CRN stated that the staff should be donning the PPE outside of the room. Review of the Centers for Disease Control and Prevention (CDC) on Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic documented under Implement Universal Use of Personal Protective Equipment stated that healthcare personnel (HCP) working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with [CONDITION(S)]-CoV-2 infection. The guidance further recommended that HCP should follow Standard Precautions and TBP if required, a N95 respirator or equivalent should be used for all aerosol-generating procedures, and eye protection should be worn during patient care encounters to protect from exposure to respiratory secretions. The guidance was last updated on February 23, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html 2. Resident 22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/2/21 at 1:39 PM, an interview was conducted with resident 22. Resident 22 stated that she had been using a [CONDITION(S)] machine for many years and could operate it independently. Resident 22 was observed seated at the bedside with 1.5 liters of supplemental oxygen being administered via a nasal cannula. The [CONDITION(S)] machine was observed on the bedside table with a gallon bottle of distilled water next to it. The water was labeled with an open date of 7/1/21, and was initialed by a staff member. An observation was made of signs posted on resident 22's door that stated on droplet precautions during aerosolized procedure. Upon initiation of [CONDITION(S)]/[CONDITION(S)], during all duties and cares with [CONDITION(S)], and for 30 minutes after removal of [CONDITION(S)] wear gloves, gown, N95, and face shield, and discard upon exiting room. The Personal Protective Equipment (PPE) was observed to be located inside the resident's room by the door hanging in a bag on the glove dispenser. The PPE bag contained disposable gowns, face shields, and N95 masks. On 8/3/21 resident 22's medical records were reviewed. Review of resident 22's July 2021 MAR and TAR revealed no documentation for cleaning and care of the [CONDITION(S)] equipment. On 8/4/21 at approximately 4:15 AM, a continuous observation was started outside of resident 22's room. The door to resident 22's room was observed open and the privacy curtain was observed closed. Resident 22's roommate's privacy curtain was also observed to be closed. On 8/4/21 at 5:46 AM, an interview was conducted with CNA 1. CNA 1 stated that resident 22 had refused the use of the [CONDITION(S)] machine and had not used it since she had been at the facility. CNA 1 stated that she had never assisted resident 22 with the device. CNA 1 stated that resident 22 had told her that it did not work correctly and because of this she did not want to use it. CNA 1 stated that she reported it to the nurse, but could not recall who as it was a long time ago. CNA 1 stated that she assisted the residents with applying the [CONDITION(S)] device at nighttime. On 8/4/21 at 8:03 AM, an interview was conducted with CNA 3. CNA 3 stated that she was just inside resident 22's room assisting the roommate with transferring to a wheelchair with CNA 2. CNA 3 stated that she only wore a surgical mask and face shield while inside the resident room. On 8/4/21 at approximately 8:05 AM, an observation was made of the facility Administrator stopping CNA 3 from entering resident 22's room. The Administrator was heard to ask CNA 3 if resident 22's [CONDITION(S)] was running. CNA 3 responded that she did not know. The Administrator stated that CNA 3 had to follow the droplet precaution sign that was posted on the door and donn all the required PPE. The Administrator was observed placing a bedside table outside resident 22's door in the hallway. The table contained alcohol based hand rub, biohazard bags, gloves, disposable gowns, face shields, and N95 masks. On 8/04/21 at 8:21 AM, an interview was conducted with CNA 2 and CNA 4. CNA 2 stated that the resident was not using the [CONDITION(S)] machine. CNA 2 stated that she had never seen resident 22 with the [CONDITION(S)] device on. CNA 2 stated that the night shift staff had reported that resident 22 did not like to wear it. CNA 2 stated that she provided care to the resident and did not donn any additional PPE prior to entering the residents room for the first time. CNA 4 stated that when she obtained vital signs the resident was not wearing a [CONDITION(S)] machine. On 8/05/21 at 9:12 AM, a follow-up interview was conducted with the CRN. The CRN stated that the Medical Director reported that resident 22 wanted to keep the [CONDITION(S)] machine to utilize on an as needed (PRN) basis. The CRN stated that the resident reported that she did not like it but wanted to have it available should she choose to use it. The CRN stated that resident 22 having a roommate with an aerosol generating procedure was not a concern for them because neither residents were symptomatic, both were vaccinated, and the equipment was not currently being utilized. 3. Resident 11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/03/21 at 9:48 AM, an interview was conducted with resident 11. Resident 11 was observed to be seated in a wheelchair at the bedside, a roho cushion was not observed present in the wheelchair. An air mattress was observed on the bed. Resident 11 stated she had a bandage on her [NAME], and sometimes it hurts with sitting. Resident 11 stated that the nurses changed the bandage, and she was not aware if the wound was open. Resident 11 stated that the wound developed at the facility. Resident 11 was observed with a brace on the right lower extremity, and the device was secured around the foot, ankle, and calf. Resident 11 was not able to tell me what the device was for. The resident stated that she was not able to ambulate and that upset her. On 8/3/21 resident 11's medical records were reviewed. Review of resident 11's physician orders revealed the following: a. Coccyx Treatment Friction Wounds: Cleanse wounds with normal saline, pat dry. Apply Skin prep to peri wound, place calcium alginate to open wound bed and cover with island dressing. Change 3 times per week on Monday, Wednesday, and Fridays after showers and as needed to aid in wound healing until resolved. Monitor placement daily. The order was initiated on 7/30/21. b. Treatment to the Right Heel SDTPI (suspected deep tissue pressure injury): Apply skin prep to heel and bony prominence of foot and leave open to air. Place Podus Boot on right foot at all times to aide in wound healing until resolved. The order was initiated on 7/29/21. c. Place wheelchair air cushion in recliner chair for comfort and to aide in wound healing. Monitor for proper placement. The order was initiated on 7/26/21. d. Treatment to the Left Heel: Apply skin prep to heel and bony prominence of foot for protection of skin integrity every shift. The order was initiated on 7/20/2021. e. Alternating pressure mattress to bed for comfort/protection of skin integrity. The order was revised on 7/20/21. f. Float Heels for protection of skin integrity. The order was revised on 6/21/21. Review of resident 11's Weekly Skin Assessments revealed the following: a. On 7/25/21 Pitting [CONDITION(S)] noted +3 in bilateral lower extremities. Open friction wound on coccyx. Blister on right heel. b. On 8/2/21 Pitting [CONDITION(S)] noted +3 in bilateral lower extremities. Open friction wound on coccyx. Blister on right heel. Review of resident 11's progress notes revealed: a. On 7/26/2021 at 2:24 PM, the Skin/Wound Note documented, Pt (patient) continues to have two friction wounds to her coccyx region. One on the right and one on the left of the bony prominence on each buttock near gluteal cleft. Right buttock wound: Total compromised area measures 3.0 x (by) 1.8 cm (centimeters). Outer layer of dark purple skin has come off leaving two open sites visible with blanching pink epithelial tissue between the two. Proximal wound measures 0.5 x 0.5 cm. Wound bed is red, moist intact dermal tissue. Peri wound is blanching red, moist, intact tissue. Surrounding skin is pink, dry, and intact. Distal wound measures 1.3x1.8cm. Wound bed is red, moist, intact dermal tissue. Minimal light yellow mucousy drainage was cleansed from site, without odor. Peri wound is blanching red, moist, sloughing flaky tissue. Surrounding skin is pink, warm, and dry. Left buttock: Wound measures 1.5x1.5cm. Wound bed is red, moist, dermal tissue with minimal light yellow mucousy drainage without odor cleansed from site. Peri wound is blanching red, moist, flaky sloughing tissue. Surrounding skin is pink, warm, and dry. Pt continues to have a SDTPI to her right heel. Wound now measures 2.1x2.4cm. Wound continues to appear as a serous fluid filled raised blister with dark purple discoloration at the medial edge. Outer layer of skin is intact. Peri wound is blanching red, dry, intact tissue. Surrounding skin is pink, warm, and dry. Pt was more alert and oriented today than at last assessment. I reported my findings as well as discussed tx (treatment) options with pt. Following our discussion, and per pt permission, an order was obtained to place w/c (wheelchair) air cushion to recliner chair for comfort and to aide in wound healing. All tx completed as ordered. It was reported that pt coccyx wound is a PU (pressure ulcer). Upon assessment, it is determined that wound continues to be friction wound, there is no new PU to coccyx, and wounds to buttock near coccyx are not pressure related. There is increased moisture exposure to site as it is near gluteal cleft, and that site on pt is very tight, so there is increased moisture at site, and therefore may also be Moisture associated skin damage, but wounds started as friction, therefore will continue to be classified as friction wounds. Pt denied any other skin concerns; no others reported by nursing. No other skin was assessed. b. On 7/18/2021 at 5:05 AM, the progress note documented that the resident developed a blister on right heel and large reddened area with apparent blister on coccyx. Areas cleaned and padded dressings applied. On 8/4/21 at 5:39 PM the Wound Nurse (WN) provided the following documentation of the wound care that was provided on 8/2/21. Pt continues to have a SDTPI to her right heel. Wound now measures 2.1x2.1cm. Wound continues to appear as a serous fluid filled raised blister with dark purple discoloration at the medial edge. The perimeter is a light-yellow color. Outer layer of skin remains intact. Peri wound is blanching pink, dry, intact tissue. Surrounding skin is pink, warm, and dry. Pt now has only one friction wound to her coccyx region. The one on the right side has resurfaced. The one on the left of the bony prominence remains in place on the buttock near gluteal cleft. Right buttock site now has blanching pink epithelial tissue noted. Surrounding skin is pink, warm, and dry. Left buttock: Wound now measures 1.2x1.3cm. Wound bed is red, moist, dermal tissue with trace serous drainage without odor noted to dressing when removed. Peri wound is blanching red, moist, intact tissue. Surrounding skin is pink, warm, and dry. On 8/04/21 at 11:27 AM, an interview was conducted with RN 1. RN 1 stated that she completed the dressing change on resident 11 coccyx as the dressing had come off during the shower. RN 1 stated that she did not see me in the hallway so she went ahead and conducted the dressing change without me. On 8/04/21 at 11:52 AM, RN 1 stated that resident 11 had a suspected deep tissue pressure injury (SDTPI) on the back of the heel. The brace was placed to keep pressure off of the heel. The RN stated that she had a treatment order for that wound that was skin prep right now, and that she still needed to provide that treatment. On 8/04/21 at 1:56 PM, an observation was made of resident 11's wound care that was provided by the WN. The resident was seated in the wheelchair with a pillow positioned behind her back. The WN donned new gloves and assisted RN 1 with transferring resident 11 to the bed for the dressing change. RN 1 assisted the WN with position changes during the dressing change. Resident 11 was positioned on their back. The WN pulled resident 11's pants down, and proceeded to remove the tab brief. Resident 11's brief was changed. The WN removed the old composite dressing with a calcium alginate 2 by 2 square. The surrounding wound bed was cleaned with an adult wash cloth. The WN radioed for wound care supplies from another nurse. The wound care nurse stated that the wound had improved since Monday. The wound bed was observed pink, no exudate or eschar was noted. The WN doffed her gloves and new gloves were applied, no hand hygiene was performed. The WN removed the boot from resident 11's right foot. The WN cleansed the heel with skin prep, no dressing was applied. The right heel was observed with a large purple blister, and the skin was intact. The WN doffed her gloves and new gloves were donned, no hand hygiene was performed. The WN applied skin prep to the surrounding skin of the coccyx wound. A calcium alginate 2 by 2 dressing was applied to the wound bed and then a composite island dressing was applied over the top. The WN stated that wound measurements were obtained on Monday. The WN was observed to wash her hands upon completion of dressing change. 4. Resident 24 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/02/21 at 1:53 PM, an observation was made of resident 24. The resident was seated in a wheelchair at the bedside. Signs were observed posted on the wall next to the head of the bed that stated to put heel protectors on while in bed and to turn every 2 hours. The bed did not have an air mattress on it. Resident 24 was observed with heel protectors on bilateral feet and elbow cushions were noted under both elbows on the wheelchair armrests. Resident 24 stated that he previously had [CONDITION(S)]-resistant Staphylococcus aureus (MRSA) infection in the heel wounds prior to being admitted to the facility. Resident 24 stated that he had dressing changes every 2 days to the wounds on his feet. Resident 24 reported a history of wounds on the bilateral feet that he received poor care for at a hospital in another state. Resident 24 spoke with great regard towards the WN and the care he had received in healing his wounds on his feet while at the facility. On 8/3/21 resident 24's medical records were reviewed. Review of resident 24's physician orders revealed the following: a. Treatment to Right Heel Split: Cleanse with normal saline and pat dry. Apply Skin prep to peri wound. Apply Calcium Alginate over wound. Cover with Silicone Bordered Foam Dressing 3 times a week on Tuesday, Thursday, and Saturday and as needed to aide in wound healing until resolved. The order was initiated on 8/4/2021. b. Treatment to L heel Stage III PU: 1. Remove old dressing. 2. Soak 4 x 4 gauze with Puracyn. Apply to wound for 10 minutes. Then remove, and pat dry. 3. Apply Collagen sheet to wound bed. 4. Apply Silver Hydrogel over Collagen. 5. Cover with a Gentle Bordered Foam 3 times a week on Tuesday, Thursday, and Saturday and as needed to aide in wound healing until resolved. Monitor daily for placement. *Set a timer if you need to ensure you leave the Puracyn on long enough* I peel back the current dressing, put the gauze on, and then reapply the current dressing so it stays in place. The order was initiated on 4/20/2021. c. Pressure relieving boots to left foot at all times and right foot at all times when in bed for protection of skin integrity and to aide in wound healing. *Ensure aides are placing boots on*. The order was initiated on 3/29/2021. d. Foam pad over mattress to bed for comfort/protection of skin integrity. No directions specified for order. The order was revised on 3/15/21. e. ROHO cushion-pressure relieving on wheelchair to coccyx. The order was revised on 12/4/19. On 8/4/21 at 5:39 PM the WN provided the following documentation of the wound care that was provided on 8/2/21. The left heel documented Pt continues to have a healing Stage III PU to his left heel that has slight decline since last assessment. Total compromised area now measures 1.1x1.5cm with 2 open areas remaining. Proximal and medial open site now measures 0.4x0.6cm. Proximal and lateral open site now measures 0.1x0.2cm. Red moist dermal tissue is exposed to wound beds. No drainage or odor was noted to dressing when removed. Blanching pink epithelial tissue is present in between each open site and to peri wound. Surrounding skin is pink, warm, dry intact epithelial tissue. The right heel documented Pt continues to have the split open wound to his right heel. Wound now measures 0.3x1.0cm. Wound bed is red moist dermal tissue. Peri wound white macerated tissue. Surrounding skin is light brown, hard, dry, calloused tissue. On 8/04/21 at 2:29 PM, an observation was made of the WN performing wound care on resident 24's bilateral heel wounds. The WN stated that resident 24 was able to ambulate independently and could transfer independently. The resident was observed to stand and transfer himself from the wheelchair to the bed with stand by assist. The WN stated that the resident's wounds had healed and resurfaced on the left heel. The wound nurse stated that the resident at one point stopped wearing his Podus boots because he thought he was finished with them. His healed wounds subsequently resurfaced. The WN stated that the resident had peripheral [CONDITION(S)] and could not feel anything in his lower extremities so she educated him on the need to continue to wear the boots to protect his feet. The resident was compliant afterwards. The WN stated that the resident developed the PU while at the facility, but has had a long history of wounds in his bilateral lower extremities prior to being admitted . The WN stated that they suspected that the resident had some venous insufficiency, but the resident refused to have the testing done to confirm this diagnosis. The WN was observed to remove the bilateral Podus boots. The WN assisted resident 24 with foot placement in bed. The WN doffed gloves and new gloves were donned. The WN was observed to [NAME] back the sock and old dressing from the left heel, and apply a 2x 2 gauze soaked in Puracyn to the wound bed under the existing bandage. The sock and bandage was placed back over the wound. The WN then mixed collagen powder and silver hydrogel with a cotton tipped applicator. The WN doffed the gloves and new gloves were applied. The WN stated that the dressing for the left heel was to let the Puracyn sit for 10 minutes and then apply the collagen and silver hydrogel mixture to the wound bed and cover with a bordered foam dressing. The WN then removed the old dressing from the right heel. The WN stated that the heel was now macerated, and she would need to change the orders to apply calcium alginate now. The WN was observed to cleanse the wound with a 4 x 4 gauze soaked with normal saline. The WN doffed her gloves and hand hygiene was performed. New gloves were applied. The WN applied skin prep to the surrounding skin of the right heel wound, calcium alginate 2x2 was applied to the wound bed, and the wound was covered with a bordered gauze dressing. The WN doffed her gloves, and new gloves were donned. The WN removed the left sock and wound dressing. The WN was observed to apply a collagen sheet with silver hydrogel applied on top to the wound bed. The wound was covered with a bordered gauze dressing. Both dressings were dated and initialed by the WN. An immediate interview was conducted with the WN upon completion of the dressing change. The WN stated that she usually performed hand hygiene between wounds and every time she doffed and donned new gloves. I didn't this time. The WN stated that she typically doffed and donned new gloves between dressings and not between the old dressings removal and the new dressings application. On 8/05/21 at 9:19 AM, an interview was conducted with the CRN. The CRN stated that hand hygiene and doffing and donning of gloves should be performed when going from dirty to clean. 5. On 8/02/21 at 12:02 PM, the following observation was made of the lunch meal service in the main dining room: a. At 12:07 PM CNA 5 delivered the meal tray to resident 28. CNA 5 was observed to remove resident 28's face mask and draped it on the handle of the wheelchair. CNA 5 did not perform hand hygiene. b. At 12:08 PM CNA 5 delivered the meal tray to resident 7. c. At 12:08 PM CNA 5 delivered the meal tray to resident 16. d. At 12:08 PM CNA 5 delivered the meal tray to resident 8. CNA 5 was observed to remove resident 5's face mask and draped it on the handle of the wheelchair. CNA 5 was observed to perform hand hygiene after all meal trays were passed.

Based on observation, interview, and record review it was determined, for 2 out of 28 sampled residents, that the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, two residents who utilized a Continuous Positive Airway Pressure ([CONDITION(S)]) machine did not have orders for their [CONDITION(S)] equipment and treatment, and there was no resident monitoring for the use of the devices in place. Resident identifiers: 14 and 22. Findings included: 1. Resident 14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/02/21 at 2:52 PM, an interview was conducted with resident 14. Resident 14 stated that he needed a new [CONDITION(S)] machine because his current one was on recall. Resident 14 stated that he operated the machine independently and cleaned the machine himself. Resident 14 stated that he filled up the water reservoir, and that he should receive new supplies soon. An observation was made of signs posted on resident 14's door that stated on droplet precautions during aerosolized procedure. Upon Initiation of [CONDITION(S)]/Bilevel Positive Airway Pressure ([CONDITION(S)]), during all duties and cares with [CONDITION(S)], and for 30 minutes after removal of [CONDITION(S)] wear gloves, gown, N95, face shield, and discard upon exiting the room. The Personal Protective Equipment (PPE) was observed located inside the resident room by the door hanging in a bag on the glove dispenser. The PPE bag contained disposable gowns, face shields, and N95 masks. On 8/3/21 resident 14's medical records were reviewed. Review of resident 14's physician orders revealed no order for the use of the [CONDITION(S)] machine, nor the equipment settings for the prescribed flow rate and pressure settings, when to use the equipment and the humidification level. Review of resident 14's July 2021 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no documentation for monitoring of the resident's response to [CONDITION(S)] therapy or monitoring of the therapy with the equipment settings. On 3/8/21 resident 14's care plan for a focus area for altered respiratory status related to sleep apnea and shortness of breath (SOB) was initiated. The care plan interventions did not address the use of a [CONDITION(S)] machine, the type of equipment and settings utilized, when to administer, and any required monitoring for complications. No documentation could be found of a care plan that addressed the use of the [CONDITION(S)] machine. Review of the facility Policy and Procedure for [CONDITION(S)]/[CONDITION(S)] Support stated to document the following in the resident's medical record: 1. General assessment (including vital signs, oxygen saturation, respiratory, circulatory and gastrointestinal status) prior to procedure; 2. Time [CONDITION(S)] was started and duration of the therapy; 3. Mode and setting for the [CONDITION(S)]/IPAP/EPAP; 4. Oxygen concentration and flow, if used; 5. How the resident tolerated the procedure; and 6. Oxygen saturation during therapy. The policy also stated to notify the physician if the resident refused the procedure, experienced any adverse consequences, including (but not limited to) respiratory distress and marked change in vital signs. The policy was last revised in March 2015. On 8/05/21 at 9:04 AM, an interview was conducted with the Corporate Resource Nurse (CRN) who was also the acting Director of Nursing (DON). The CRN stated that there should be a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The CRN stated that the licensed nursing staff would document the monitoring on the TAR. 2. Resident 22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/02/21 at 1:39 PM, an interview was conducted with resident 22. Resident 22 stated that she had been using a [CONDITION(S)] machine for many years and could operate it independently. Resident 22 was observed seated at the bedside with 1.5 liters of supplemental oxygen being administered via a nasal cannula. The [CONDITION(S)] machine was observed on the bedside table with a gallon bottle of distilled water next to it. The water was labeled with an open date of 7/1/21, and was initialed by a staff member. An observation was made of signs posted on resident 22's door that stated on droplet precautions during aerosolized procedure. Upon Initiation of [CONDITION(S)]/[CONDITION(S)], during all duties and cares with [CONDITION(S)], and for 30 minutes after removal of [CONDITION(S)] wear gloves, gown, N95, face shield, and discard upon exiting the room. The Personal Protective Equipment (PPE) was observed located inside the resident room by the door in a bag hanging on the glove dispenser. The PPE bag contained disposable gowns, face shields, and N95 masks. On 8/3/21 resident 22's medical records were reviewed. Review of resident 22's physician orders revealed an order that stated, [CONDITION(S)] at night per home regimen at bedtime for sleep apnea AND as needed for sleep apnea *while napping during the day*. The order was initiated on 3/10/19 and was discontinued on 4/30/2020. There was no current order for the [CONDITION(S)] equipment. Review of resident 22's July 2021 MAR and TAR revealed no documentation for monitoring of the resident's response to [CONDITION(S)] therapy or monitoring of the therapy with the equipment settings. On 7/2/21 resident 22's care plan for Oxygen Therapy related to CHF was initiated. The care plan interventions did not address the use of a [CONDITION(S)] machine, the type of equipment and settings utilized, when to administer, and any required monitoring for complications. No documentation could be found of a care plan that addressed the use of the [CONDITION(S)] machine. On 8/04/21 at 5:46 AM, an interview was conducted with Certified Nurse Assistant (CNA) 1. CNA 1 worked the night shift and stated that the resident had refused to wear her [CONDITION(S)] and had not ever used it since she had been at the facility. CNA 1 stated she had never assisted her with it. CNA 1 stated that the resident had told her that the machine did not work correctly and she did not want to use it. CNA 1 stated that she reported it to the nurse, but could not recall who as it was a long time ago. CNA 1 stated that they assisted the residents with applying the [CONDITION(S)] machine at nighttime. On 8/04/21 at 7:25 AM, an interview was conducted with the CRN. The CRN stated that she would check with the Physician's Assistant (PA) about the [CONDITION(S)] needing to be replaced. On 8/04/21 at 9:55 AM, observed the CRN to ask the Medical Director to assess resident 22's need for the [CONDITION(S)] and the possibility of discontinuing the order. The CRN stated that if the machine was broken she would obtain a new one for the resident. On 8/05/21 at 9:12 AM, a follow-up interview was conducted with the CRN. The CRN stated that the Medical Director reported that resident 22 wanted to keep the [CONDITION(S)] machine to utilize on an as needed (PRN) basis. The CRN stated that the resident reported that she did not like it but wanted to have it available should she choose to use it. The CRN stated that resident 22 having a roommate with an aerosol generating procedure was not a concern for them because neither residents were symptomatic, both were vaccinated, and the equipment was not currently being utilized.

Based on observation, interview, and record review it was determined, for 2 out of 28 sampled residents, that the facility did not develop and implement a comprehensive person-centered care plan for each resident that included the services that were to be furnished to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, two resident's utilized a Continuous Positive Airway Pressure ([CONDITION(S)]) machine and did not have a care plan in place to address this aerosol generating procedure. Resident identifiers: 14 and 22. Findings included: 1. Resident 14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/02/21 at 2:52 PM, an interview was conducted with resident 14. Resident 14 stated that he needed a new [CONDITION(S)] machine because his current one was on recall. Resident 14 stated that he operated the machine independently and cleaned the machine himself. Resident 14 stated that he filled up the water reservoir, and that he should receive new supplies soon. An observation was made of signs posted on resident 14's door that stated on droplet precautions during aerosolized procedure. Upon initiation of [CONDITION(S)]/Bilevel Positive Airway Pressure ([CONDITION(S)]), during all duties and cares with [CONDITION(S)], and for 30 minutes after removal of [CONDITION(S)] wear gloves, gown, N95, and face shield, and discard upon exiting room. The Personal Protective Equipment (PPE) was observed to be located inside the resident's room by the door hanging in a bag on the glove dispenser. The PPE bag contained disposable gowns, face shields, and N95 masks. On 8/3/21 resident 14's medical records were reviewed. On 3/8/21 resident 14's care plan revealed a focus area for altered respiratory status related to sleep apnea and shortness of breath (SOB) was initiated. The care plan interventions did not address the use of a [CONDITION(S)] machine. No documentation could be found of a care plan that addressed the use of the [CONDITION(S)] machine. 2. Resident 22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/02/21 at 1:39 PM, an interview was conducted with resident 22. Resident 22 stated that she had been using a [CONDITION(S)] machine for many years and could operate it independently. Resident 22 was observed seated at the bedside with 1.5 liters of supplemental oxygen being administered via a nasal cannula. The [CONDITION(S)] machine was observed on the bedside table with a gallon bottle of distilled water next to it. The water was labeled with an open date of 7/1/21, and was initialed by a staff member. An observation was made of signs posted on resident 22's door that stated on droplet precautions during aerosolized procedure. Upon Initiation of [CONDITION(S)]/[CONDITION(S)] during all duties and cares with [CONDITION(S)], and for 30 minutes after removal of [CONDITION(S)] wear gloves, gown, N95, face shield, and discard upon exiting room. The Personal Protective Equipment (PPE) was observed located inside the resident's room by the door hanging in a bag on the glove dispenser. The PPE bag contained disposable gowns, face shields, and N95 masks. On 8/3/21 resident 22's medical records were reviewed. On 7/2/21 resident 22's care plan for Oxygen Therapy related to CHF was initiated. The care plan interventions did not address the use of a [CONDITION(S)] machine. No documentation could be found of a care plan that addressed the use of the [CONDITION(S)] machine. On 8/05/21 at 9:04 AM, an interview was conducted with the Corporate Resource Nurse (CRN) who was also the acting Director of Nursing for the facility. The CRN stated that resident 14 and resident 22 should have a care plan that included the use of the [CONDITION(S)] machine. The CRN stated that the medical records were located in three different locations; the electronic medical records, the hard chart, and a folder in medical records. The CRN stated that she would check to see if any of these locations contained a care plan where the [CONDITION(S)] machine was addressed. No other additional information was provided by the CRN for the care plans.

Based on interview and record review it was determined, for 2 out of 28 sampled residents, that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any of these combinations. Specifically, medications were not administered per the physician ordered parameters and a resident was not monitored for complications associated with an anticoagulant use. Resident identifiers: 2 & 11. Findings included: 1. Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident 2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. [MEDICATION(S)] tablet 40 milligrams (mg), give 1 tablet by mouth one time a day for hypertension. Hold [MEDICATION(S)] for (systolic blood pressure) SBP less than 105 and to hold the Potassium if the [MEDICATION(S)] was held. The medication was initiated on 5/2/2020. b. Potassium Chloride (extended release) ER tablet 20 milliequivalents (meq), give 1 tablet by mouth one time a day for supplement with [MEDICATION(S)]. The medication was initiated on 5/2/2020. Review of the July 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The [MEDICATION(S)] should have been held per the physician ordered parameters to hold for a SBP of <105. On 7/24/21 resident 5's blood pressure (B/P) was recorded as 98/46. Review of the August 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] <105. On 8/3/21 resident 5's blood pressure (B/P) recorded as 100/58. However, the Potassium 20 meq was documented as administered on 8/3/21. The Potassium should have been held per the physician ordered parameter to not administer the Potassium if the [MEDICATION(S)] was held. On 8/3/21 resident B/P was recorded as 100/58. On 8/4/21at 8:55 AM, an interview was conducted with a licensed practical nurse (LPN)1. LPN1 stated before blood pressure medications were given a blood pressure must be taken and be within the parameters ordered by the medical doctor. The potassium should have been held on 8/3/21 and both [MEDICATION(S)] and potassium should have been held on 7/24/21. If a resident's blood pressure was too low the doctor should be informed. On 8/05/21 at 11:34 AM, an interview was conducted with the Corporate Resource Nurse (CRN) who was also the acting Director of Nursing for the facility. The CRN stated she had never seen an order where [MEDICATION(S)] would be given in regards to blood pressure parameters. The CRN stated after reviewing the July and August MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The CRN stated the potassium order parameters are in the [MEDICATION(S)] order and should not be there, if a medication had a parameter it should be on that specific medications order. 2. Resident 11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/03/21 at 9:38 AM, an interview was conducted with resident 11. Resident 11 was observed seated in a wheelchair at the bedside. A saturated bloody tissue was observed on the bedside table. Resident 11 stated that they had a nose bleed and it was from the [MEDICATION(S)] they were taking. Resident 11 stated that this happened when the [MEDICATION(S)] dosage was changed. On 8/3/21 resident 11's medical records were reviewed. Review of resident 11's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the July 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/04/21 at 12:47 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that with any resident that was receiving an anticoagulant they tracked any signs and symptoms of bleeding and documented it on the TAR. On 8/04/21 at 2:21 PM, an interview was conducted with RN 2. RN 2 stated that the Certified Nursing Assistanct (CNA) yesterday reported that resident 11 had a bloody nose. RN 2 stated that he monitored the resident for signs and symptoms of bleeding with the [MEDICATION(S)] medication, and that it was documented on the TAR. RN 2 proceeded to look up the documentation of monitoring for bleeding for resident 11 and stated that it was not located on the TAR. RN 2 stated that if it was not in there then he probably did not document any place else. RN 2 proceeded to look at other residents receiving anticoagulants and verified that they had orders in the TAR for monitoring for signs and symptoms of bleeding. On 8/05/21 at 8:23 AM, an interview was conducted with the CRN. The CRN stated that the licensed nursing staff should be monitoring for signs and symptoms of bleeding when a resident was taking an anticoagulant medication for potential complications of that medication. Bleeding could include nose bleeds, bleeding from the gums or blood in the urine. The CRN stated that the nurses should be documenting the monitoring every day or every shift and it should be located in the TAR. It should be documented somewhere.

Based on interview, record review, and observation, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the dishmachine did not reach the appropriate temperature to properly sanitize dishes. In addition, multiple areas in the facility kitchen were noted to be soiled. Findings include: 1. On 6/3/19 at 2:30 PM, an observation was made of the dishmachine as it was processing soiled dishes. The temperatures were as follows: a. 147 degrees Fahrenheit (F) wash, 182 degrees F rinse. b. 148 degrees F, 181 degrees F rinse. c. 146 degrees F, 181 degrees F rinse. Dietary Staff Member (DSM) 1 was immediately interviewed. DSM 1 pointed to a label attached to the dishmachine and stated that the wash temperature was supposed to reach 150 degrees F, and the rinse temperature was supposed to reach 180 degrees F. DSM 1 was observed to look at the temperature reading on the dishmachine, and continue to wash dishes despite the low temperature. There was no dishmachine temperature log posted for (MONTH) 2019. The (MONTH) 2019 dishmachine temperature log was reviewed. Of the 93 opportunities to record a temperature during each meal during the month of (MONTH) 2019, temperatures were only recorded on 42 occasions. 2. On 6/3/19 at 2:20 PM, a tour was conducted of the facility kitchen. The following was observed: a. The front of the dishmachine was observed to be nearly entirely covered in several layers of hard water mineral deposits. b. The floor throughout the entirety of the kitchen was noted to have a black grime buildup, especially towards the edges and corners, and under the black mats. c. The plate warmer had several dried spills on it. d. A black cart had several areas containing debris and dried spills. e. The flour and sugar bins were soiled with black grime and dried spills. f. The fronts of the refrigerators and freezers were sticky and soiled. g. The area around the steamer unit was soiled with food debris and dried spills. h. The floor in the dry storage area was sticky and soiled with food debris and black grime. On 6/6/19 at 1:40 PM, an interview was conducted with the Dietary Manager (DM). The DM stated that he had only been employed at the facility for one month, and that he was making plans to deep clean the kitchen, including the floors and dishmachine. The DM stated that he was aware the DSMs were not tracking the dishmachine temperatures on the log for (MONTH) 2019.

Based on observation, interview and record review, the facility did provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Specifically, meals were served later than the posted times, and residents were observed to wait long periods of time before being served. Resident identifiers: 3, 4, and 10. Findings include: 1. On 6/4/19, the breakfast meal was observed in the dining room. The posted start time for breakfast was 7:00 AM to 9:00 AM. a. Upon entrance to the dining room at 8:05 AM, seven residents were observed to be seated at table 1, waiting for breakfast to be served. The first breakfast meal was served to a resident at that table at 8:17 AM. The last meal served to a resident at this table was at 8:27 AM, approximately 10 minutes later. b. Residents 3 and 4 were present and seated at a table at 8:05 AM. At 8:24 AM residents 3 and 4 were served their breakfast trays. (Note: resident 3 and resident 4 were seated and waiting for breakfast for 19 minutes.) 2. On 6/5/19, the breakfast meal was observed in the dining room. a. At 6:45 AM, resident 10 was observed to be seated in the dining room. He was not served until 8:47 AM, nearly two hours later. b. At 7:04 AM, an observation was made of resident 3 wheeling herself down to the dinning room for breakfast. Registered Nurse (RN) 1 was observed telling resident 3 that breakfast wasn't until 8:00 AM. c. At 8:00 AM, resident 3 was observed to be in the dining room waiting for breakfast at table 2. At 8:11 AM, resident 4 arrived in the dining room and sat at table 2. These residents were not served breakfast until 8:57 AM, nearly an hour after arriving to the dining room. d. At 8:47 AM, the first resident was served at table 1. The last resident at this table was not served until 8:57, approximately 10 minutes later. 3. On 6/5/19, the lunch meal was observed in the dining room. The posted start time for lunch was 12:00 PM. Six residents were observed to be seated at table 1 at approximately 12:00 PM, but the first meal was not served until 12:42 PM, more than 40 minutes after the posted start time. In addition, the last meal served to a resident at table 1 was at 12:53 PM, approximately 11 minutes later. On 6/6/19 at 1:40 PM, an interview was conducted with the Dietary Manager (DM). The DM stated that residents typically preferred to eat a later breakfast, so typically meal service began between 8 and 9. When asked why residents were waiting long periods of time to be served after arriving in the dining room, the DM stated that they did not serve breakfast until facility staff were present to help the residents.

Based on interview and record review, the facility did not send a copy of resident 30-day discharge notices or hospitalization s to the Long-Term Care Ombudsman. Resident identifiers: 13, 26, 286. Findings include: 1. On 6/5/19 the facility provided surveyors with a letter dated 4/9/19 stating that the facility Administrator (ADM) had initiated a 30-day discharge of resident 26. The ADM did not provide a copy of the discharge notice that had been given to the resident. The ADM did not have documentation that he had provided a copy of the discharge notice to the Long-Term Care Ombudsman (LTCO) the same day that the notice was provided to the resident. 2. On 6/6/19, the facility ADM provided surveyors with a copy of a 30-day discharge notice to resident 286 dated 8/31/18. The ADM could not provide documentation that he had provided a copy of the discharge notice to the LTCO the same day that the notice was provided to the resident. 3. On 7/26/18, a progress note entered for resident 13 indicated that the facility social worker was going over (a) discharge plan. On 6/6/19, the Corporate Resource Nurse (CRN) stated that resident 13 had been issued a 30-day discharge notice, but stated she was unable to locate a copy of the discharge notice, or evidence that it had been provided to the LTCO on the same day that resident 13 received the notice. 4. On 6/5/19, the CRN provided surveyors with a list of residents who had been discharged to the hospital since (MONTH) (YEAR). There was a total of 37 residents on the list. The CRN could not provide documentation to indicate that the LTCO had been notified of the residents' hospitalization s in writing. On 6/5/19, the LTCO was contacted via email. The LTCO stated that she had not received notice from the facility regarding the 30-day discharge issued to residents 286 or 13. The LTCO also stated that she had not been notified in writing for any of the 37 residents that had been hospitalized since (MONTH) (YEAR). The LTCO stated that she had educated the facility staff about proper notification, but still had not received the appropriate written notices. On 6/6/19 at 1:00 PM, an interview was conducted with the facility ADM. The ADM stated that he thought the facility social worker had been notifying the LTCO regarding the 30-day discharges and the hospitalization s. The ADM stated that the social worker had been notifying the ombudsman by telephone regarding the hospitalization s, and was unaware that this did not meet the requirement.

Based on interviews and medical records review, it was determined, for 5 of 39 sampled residents, that the facility did not review and revise the comprehensive care plans. Specifically, there was no information about one residents infection on her care plan, one resident did not have an updated care plan for his Activities of Daily Living (ADLs). In addition, it was unclear which sections of residents care plans were updated on specific dates. Resident identifiers 2, 6, 10, 13, and 25. Findings include: 1. Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/4/19 during the breakfast meal, resident 10 was observed sitting in the dining room at the table close to the door. Resident 10 had 2 cups of coffee in a front of him. It was observed that resident 10's finger nails were long and dirty with brown debris underneath. It was also observed that his shirt and pants had multiple stains from spilled food and drinks. Resident 10 was unshaved. On 6/5/19 at 6:50 AM, resident 10 was observed again. He was observed sitting in the dining room and drinking his coffee. It was observed that he was unshaved, with his finger nails being long and dirty with brownish material underneath. On 6/5/19 resident 10's medical record was reviewed. Medical records revealed a physician order [REDACTED]. Medical records revealed that the facility did a Minimum Data Set (MDS) assessments on resident 10 on 4/18/19. Per the MDS assessment from 4/18/19, resident 10 required supervision with eating and toilet use. Resident 10 was also assessed as requiring 1 person extensive assist with personal hygiene and dressing, showers, etc. A comprehensive care plan dated 4/12/16 and updated on 5/8/17, indicated that resident 10 had self care deficits and required assistance with showers and hand hygiene. Per this care plan, the facility assisted resident 10 to shower daily, provided hand hygiene daily and as needed (PRN), and ensured that resident 10 wore clean clothes. Per this care plan, resident 10 participated in the RNP because he was at risk for potential ADL (Activities of Daily Living) performance deficit and had an actual ADL self-care performance deficit. Medical records revealed that resident 10's most current RNP assessment was done on 6/1/19, and that resident 10 was assisted with grooming and dressing. Nursing progress notes from 5/13/19 revealed that resident 10 was alert, oriented to person. He was unable to determine orientation to place, unable to determine orientation to time, and unable to determine orientation to situation. (Resident 10) has impaired decision making ability. (Resident 10) suffers from confusion. Nursing progress note from 6/2/19 revealed that resident 10 did not have recent change in ADL ability. On 6/5/19 at 8:14 AM, Certified Nursing Assistant (CNA) 1 was interviewed. She stated that resident 10 liked showers and received them every day. CNA 1 stated that resident 10 never refused showers and personal hygiene care. CNA 1 stated she cleaned resident 10's finger nails daily and that she shaved him once per week. She stated that resident 10 had his own electric razor and was able to shave himself often. CNA 1 stated that resident 10 was able to feed himself. She stated that resident 10 wore clean clothes every morning. On 6/5/19 at 8:20 AM, CNA 2 was interviewed. She stated that CNA 1 usually worked in the 300 hall on Tuesdays, Wednesdays and Thursdays and that she gave showers to resident 10 on these days. CNA 2 stated that all other days, the night shift aides gave showers to resident 10. CNA 2 stated that resident 10 never refused showers, but that sometimes due to his memory problems, he was not patient and wanted to finish showers quickly. CNA 2 stated that resident 10's finger nails were cut every other week, and that he was able to shave himself with own electric razor. On 6/5/19 at 9:20 AM the Director of Nursing (DON) was interviewed. The DON stated that resident 10 required assistance with showers and personal hygiene. She stated that they started using the current computer system in (MONTH) (YEAR). She stated that she started to work as the DON for the facility a few months ago. The DON stated that resident 10's care plan was updated in (MONTH) 2019, but she was not sure which section of the care plan was updated. 2. Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/4/19, medical records were reviewed. Medical records revealed that the facility created resident 6's care plan on 3/29/19. Per care plan, the facility initiated care areas for resident 6 such as ADL self-care deficit, altered bowel elimination, dehydration, safety device usage, fall risk, impaired physical mobility, risk for infection, nutrition, risk for pain, urinary incontinence and medications. The last page of the care plan was the sheet with signatures of all staff involved in the care plan creation. Per this page, the care plan was updated on 4/10/19. There was no other date present by any care areas mentioned above. On 6/5/19 at 10:15 AM, the Corporate Resource Nurse (CRN) was interviewed. The CRN stated that all residents assessments and care plans were reviewed and updated quarterly and as needed. She stated that resident 10's care plan was updated on 4/25/19. The CRN stated that she was not sure which section of resident 10's care plan was updated on this date. The CRN stated that she was not sure which section of resident 6's care plan was updated on 4/10/19. 3. Resident 13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/3/19 at 2:14 PM, an observation was made of room [ROOM NUMBER] with personal protective equipment (PPE) on the door, and a sign stating contact precautions with exceptions. The sign gave instructions to wear gloves and a gown for contact precautions, the sign did not specify what types of exceptions were included. On 6/5/19 resident 13's medical record was reviewed. A physician's orders [REDACTED]. A care plan dated 8/26/18 documented that resident 13 was at risk for infection related to Skin Alteration. fistula. Aspiration risk. The care plan documented Precautions: contact. There was no documentation of VRE on the care plan or explanation of exceptions related to resident 13's contact precautions. 4. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/3/19 at 2:14 PM, an observation was made of room [ROOM NUMBER] with PPE on the door, and a sign stating contact precautions with exceptions. The sign gave instructions to wear gloves and a gown for contact precautions, the sign did not specify what types of exceptions were included. On 6/5/19 resident 2's medical record was reviewed. A laboratory result dated 6/21/18 revealed resident 2 had a urinary tract infection [MEDICAL CONDITION] of E. Coli with ESBL. A care plan dated 6/1/18 documented a problem area of Infection. E. Coli UTI dated 6/18/18. One Plan of Approach listed was Contact Precautions dated 6/21/18. There was no explanation of exceptions related to resident 2's contact precautions. 5. Resident 25 was admitted to the facility on [DATE], she went to the hospital for a bowel obstruction and was re-admitted on [DATE] with [DIAGNOSES REDACTED]. On 6/6/19 resident 25's medical record was reviewed. A nurses note dated 5/16/19 documents .Pt has hx: Chronic urinary tract colonization with ESBL. Resident 25's [DIAGNOSES REDACTED]. A review of resident 25's care plans dated 4/13/19 and 5/16/19 did not contain any documentation or information related to resident 25's ESBL colonization. On 6/5/19 at 10:28 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 13 and resident 2 did not have active infections but that they were colonized which meant that they could still potentially infect someone else. The DON stated that because they were potentially infectious, resident 13 and resident 2 were still on contact precautions, but they each had exceptions so as they were not isolated in their rooms at all times. The DON stated that resident 13's exception was that she left her room three times a week for [MEDICAL TREATMENT], and resident 2's exception was that she was able to leave her room for meals. On 6/6/19 at approximately 12:00 PM, an interview was conducted with the CRN. The CRN stated that she was unsure why resident 25 did not have any interventions related to ESBL colonization; while resident 2 was on contact precautions for the same thing.

Based on observation, interview and record review, the facility did not treat residents with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, residents were not served by table during meals, were observed to wait long periods of time before being served meals, and were served their meals on trays. Resident identifiers: 3, 4, and 10. Findings include: 1. On 6/4/19, the breakfast meal was observed in the dining room. The posted start time for breakfast was 7:00 AM to 9:00 AM. a. Upon entrance to the dining room at 8:05 AM, seven residents were observed to be seated at table 1, waiting for breakfast to be served. The first breakfast meal was served to a resident at that table at 8:17 AM. The last meal served to a resident at this table was at 8:27 AM, approximately 10 minutes later. In addition, resident meals were being brought out on serving trays, but the trays were being left under the resident meals. b. Residents 3 and 4 were present and seated at a table at 8:05 AM. At 8:24 AM residents 3 and 4 were served their breakfast trays. (Note: resident 3 and resident 4 were seated and waiting for breakfast for 19 minutes.) Both meals were observed to be served on the meal trays by staff. Staff did not offer to remove the meal trays for resident 3 and resident 4. After staff walked away resident 3 and resident 4 removed their own food items from the trays and pushed the meal trays to the other side of the table. 2. On 6/5/19, the breakfast meal was observed in the dining room. a. At 6:45 AM, resident 10 was observed to be seated in the dining room. He was not served until 8:47 AM, nearly two hours later. b. At 7:04 AM, an observation was made of resident 3 wheeling herself down to the dinning room for breakfast. Registered Nurse (RN) 1 was observed telling resident 3 that breakfast wasn't until 8:00 AM. c. At 8:00 AM, resident 3 was observed to be in the dining room waiting for breakfast at table 2. At 8:11 AM, resident 4 arrived in the dining room and sat at table 2. These residents were not served breakfast until 8:57 AM, nearly an hour after arriving to the dining room. d. At 8:47 AM, the first resident was served at table 1. The last resident at this table was not served until 8:57, approximately 10 minutes later. 3. On 6/5/19, the lunch meal was observed in the dining room. The posted start time for lunch was 12:00 PM. Six residents were observed to be seated at table 1 at approximately 12:00 PM, but the first meal was not served until 12:42 PM, more than 40 minutes after the posted start time. In addition, the last meal served to a resident at table 1 was at 12:53 PM, approximately 11 minutes later. In addition, resident meals were being brought out on serving trays, but the trays were being left under the resident meals. On 6/6/19 at 1:40 PM, an interview was conducted with the Dietary Manager (DM). The DM stated that residents typically preferred to eat a later breakfast, so typically meal service began between 8 and 9. When asked why residents were waiting long periods of time to be served after arriving in the dining room, the DM stated that they did not serve breakfast until facility staff were present to help the residents.

Based on observation and interview it was determined that the facility did not ensure safe and secure storage of drugs and biologicals in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration date on the medication. Specifically, several multi-dose vials of insulin had no open dates and were available for use and administered to the residents. Additionally, medication bottles were unsecured in resident rooms and on top of the medication carts. One resident brought medication from home that was not in the original packaging and was being administered by staff. Finally, residents had unlabeled substances in medication cups in their rooms. Resident identifiers: 23, 24, 230, 232, and 278. Findings include: 1. On [DATE] an initial tour was conducted of the facility, the following observations were made: a. At 1:40 PM until 1:43 PM four full resident medication cards were left unattended and face up on top of the 200 hall medication cart. b. At 2:02 PM room [ROOM NUMBER] was observed to have three full pill bottles on the bedside table labeled Magnesium [MEDICATION NAME] Headache, and [MEDICATION NAME] Supplement. c. At 2:04 PM room [ROOM NUMBER] was observed to have an unlabeled medication cup on the back of the toilet, which contained a white cream. d. At 2:25 PM room [ROOM NUMBER] was observed to have an unlabeled medication cup with blue liquid sitting by the resident's sink. 2. On [DATE] at 3:50 PM, an audit was conducted of the 200 hall medication cart which revealed small re-sealable bags of Bone Broth Protein for resident 24. The Bone Broth Protein was not in the original packaging, and did not contain any expiration dates. 3. On [DATE] at 3:53 PM, an audit was conducted of the 100 hall medication cart which revealed the following: a. A vial of HumaLOG 100units (u)/milliliter (ml) for resident 230 with no open date or discard date. b. An injectable pen of [MEDICATION NAME] 0.6 milligrams (mg)/0.1ml for resident 230 with no open date or discard date. c. An injectable pen of [MEDICATION NAME] 100u/ml for resident 230 with no open date or discard date. d. A vial of HumaLOG 100u/ml for resident 232 with no open date or discard date. e. An injectable pen of Basaglar 100u/3ml for resident 232 with no open date or discard date. f. An injectable pen of Basaglar 100u/3ml for resident 23 with no open date or discard date. 4. On [DATE] at 8:49 AM, an observation was made of resident 278's room, which revealed a full bottle of L-[MEDICATION NAME] pills on the resident's bookshelf. 5. On [DATE] at 6:50 AM, an observation was made of a cup of white powder left unattended on top of the 200 hall medication cart. On [DATE] at 3:58 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that once opened, insulin was good for 28 days. RN 1 verified that all of the 100 hall medication cart insulin had no open dates or discard dates. RN 1 stated that all of the insulin should have had an open date or discard date. RN 1 stated that without an open date or discard date there was no way for staff to know when the insulin expired. On [DATE] at 9:40 AM, a follow up interview was conducted with RN 1. RN 1 stated that if a resident wanted to administer their own medication, the resident would have to pass a safety assessment. RN 1 stated that if the resident passed the safety assessment, then staff would contact the doctor for an order for [REDACTED]. RN 1 stated the resident then had to lock up their medications and keep them secure. RN 1 stated that at that time they did not have any residents in the facility approved to administer their own medication. RN 1 stated that the white creams in the medication cups were usually barrier cream, and that the cups should have been labeled with the date and room number. RN 1 also stated that the blue liquid in the medication cup in room [ROOM NUMBER] was prescription [MEDICATION NAME] for one of the resident's oral care. RN 1 stated that the cup should have been labeled with a date and room number. On [DATE] at 9:45 AM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated that if she found medications in a resident room that she would notify the nurse. CNA 2 stated that the facility did not have any residents at that time that were approved to keep medication in their room. On [DATE] at 2:06 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that when insulin was opened it should be dated so the nurses knew when the insulin expired. The DON stated that any medication brought from home should be in the original bottle with all of the manufacturer information. The DON stated that any medication kept in resident rooms must be locked up, and the resident had to be assessed for safety to administer their own medications. The DON also stated that there should be no cups of creams or liquids in resident rooms, even if the cup was dated and had a room number.

Based on observation, interview, and record review, it was determined that the facility did not keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, or safeguard medical record information. The facility also did not maintain medical records on each resident that were complete and accurately documented. Specifically, a computer screen on top of a medication cart was left open to a resident's name and medication list while facility staff was not around. The computer screen was accessible to anyone who walked by. Additionally, medications were not documented timely after they were administered. Resident identifiers: 231 and 17. Findings include: 1. On 6/3/19 at 1:40 PM, four resident medication cards were left unattended and face up on the 200 hall medication cart with resident health information visible to residents and visitors walking by. 2. On 6/3/19 at 3:34 PM, the 200 hall medication cart computer was left open and unattended with personal health information visible. 3. On 6/3/19 at 3:50 PM, the 200 hall medication cart computer was left open and unattended with personal health information visible. 4. On 6/3/19 at 3:50 PM, a clip board with resident names and vital signs was left unattended and face up on counter of the nurses' station. Resident health information was visible to residents and visitors walking by. 5. On 6/5/19 at 6:50 AM, a resident information sheet was left face up and unattended on the 200 hall medication cart. Resident names, diagnoses, allergies [REDACTED]. On 6/5/19 at 1:54 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that all resident information should be protected from viewing if staff were not immediately using it. The DON stated that the computer screens should be locked any time the staff member walked away, and that all paperwork should be on a clipboard that was flipped over when not in use. On 6/5/19 at 1:05 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that computer screens had to be locked or closed when the staff member walked away. RN 1 stated that all resident information had to be covered and not visible to other residents or visitors at all times. 6. Resident 231 was admitted to facility on 5/23/19 with [DIAGNOSES REDACTED]. On 6/5/19 at 7:30 AM, RN 2 was observed to prepare and administer medications to resident 231. RN 2 administered 19 pills at 7:36 AM which included: Eliquis 5 milligrams (mg), [MEDICATION NAME] Sodium Delayed Release 750mg, [MEDICATION NAME] 90mg, [MEDICATION NAME] 600mg, [MEDICATION NAME] Extended Release 30mg, [MEDICATION NAME] 40mg, [MEDICATION NAME] 100mg, [MEDICATION NAME] 500mg, [MEDICATION NAME] Chloride Extended Release 15mg, [MEDICATION NAME] 40mg, [MEDICATION NAME] 150mg, [MEDICATION NAME] 10/100mg, Multivitamin with Minerals, and a Senna-S 8.6/50mg. The Medication Administration Record [REDACTED]. The MAR further revealed orders for B Complex Vitamins 1 tablet every day, Magnesium Oxide 400mg 1 tablet every day, and [MEDICATION NAME] Powder 17 grams two times a day. All three of these medications were scheduled to be administered during the morning medication pass, and all three had been documented in the MAR indicated [REDACTED] On 6/5/19 at 8:39 AM, RN 2 was interviewed. RN 2 stated that she administered resident 231's Vitamin B Complex, Magnesium Oxide, and [MEDICATION NAME] prior to the observation at 7:30 AM. RN 2 stated that resident 231 did not like to take all of his medication at once so she administered those 3 medications separately. RN 2 stated that she did document that she had administered any medication to resident 231 until 8:00 AM. RN 2 stated that she usually documented all of her medication administrations later, which explained why all of the medication for resident 231 showed that they were administered at 8:00 AM when the actual administrations were earlier. 7. Resident 17 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 6/5/19 at 6:55 AM, RN 1 was observed to prepare and administer medications to resident 17. RN 1 administered 4 medications at 6:59 AM which included: [MEDICATION NAME] 40mg, [MEDICATION NAME] 4mg, [MEDICATION NAME] 17 grams, and an as needed [MEDICATION NAME] 5mg. The Medication Administration Record [REDACTED]. On 6/5/19 at 8:45 AM, RN 1 was interviewed. RN 1 stated that she had still not documented resident 17's [MEDICATION NAME] as being administered. RN 1 stated that she usually documented the [MEDICATION NAME] administration later in the morning when she administered the rest of resident 17's medications. On 6/5/19 at 8:58 AM, an interview was conducted with the DON. The DON stated that it was best practice, when medications were administered, to document the medication administration immediately after the medication was given to the resident.

Based on interview and record review the facility did not ensure that 1 of 31 sample residents received adequate supervision to prevent accidents. Specifically, a resident experienced multiple falls without significant intervention until after the resident injured herself. Resident identifier: 26. Findings include: Resident 26 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 26's medical record was reviewed on 6/26/13. Upon admission to the facility, a physician's orders [REDACTED]. Resident 26's "Fall Risk Assessment" was reviewed. On 6/1/13 resident 26 was assessed as being "high risk" for falls due to her intermittent confusion, history of falls, problems with balance, use of multiple medications with potential side effects, and predisposing diseases. Resident 26 had been assessed as high risk for falls on 6/21/12 as well. Incident reports and fall investigation worksheets for resident 26 were reviewed. The incident reports and fall investigation worksheets revealed the following: a) 12/11/12: Resident 26 was found on the floor in her room. The call light was not in reach at the time of the fall. No documentation was listed on either of the reports to indicate what actions were taken to prevent further falls. b) 12/13/12: Resident 26 was found on the floor in her room. The call light was listed as not functioning at the time of the fall. No documentation was listed on either of the reports to indicate what actions were taken to prevent further falls. c) 12/21/12: Resident 26 was found on the floor in her room. She stated she was trying to get herself ready for bed and slid out of her wheelchair. The call light was listed as not functioning at the time of the fall. No documentation was listed on either of the reports to indicate what actions were taken to prevent further falls. d) 1/8/13: Resident 26 was found on the floor in her room. The call light was listed as not functioning at the time of the fall. No documentation was listed on either of the reports to indicate what actions were taken to prevent further falls. e) 1/23/13: Resident 26 was found on the floor in her room. The call light was listed as not functioning at the time of the fall. The intervention in place after this fall was to "please ask us for help next time". f) 1/28/13: Resident 26 was found on the floor in her room. The call light was listed as not functioning at the time of the fall. The intervention in place after this fall was to "please use her call light next time". g) 2/6/13: Resident 26 was found on the floor in her room. The intervention in place after this fall was to remind resident "to use call light before transfers. . . Bed alarm on and functioning when in bed". h) 3/1/13: Resident 26 was found on the floor in her room. The call light was not in reach at the time of the fall. No documentation was listed on either of the reports to indicate what actions were taken to prevent further falls. i) 3/9/13: Resident 26 was found on the floor in her room. The intervention in place after this fall was "educated to use call light". j) 3/13/13: Resident 26 was found on the floor in her room. No documentation was listed on either of the reports to indicate what actions were taken to prevent further falls. k) 4/5/13: Resident 26 was found on the floor in her room. The intervention in place after this fall was "Encourage resident to use call light when needing help". l) 4/15/13: Resident 26 was found on the floor in her room. No documentation was listed on either of the reports to indicate what actions were taken to prevent further falls. m) 5/13/13: Resident 26 was found on the floor in the dining room. The family response to the fall was "She is stubborn and forgets she can't do the things she used to do". The intervention in place after this fall was "Reminded pt (patient) to let staff help her walk, et (and) transfer. Engaged brakes on wc (wheelchair)." n) 5/19/13: Resident 26 was found on the floor in her room. No documentation was listed on either of the reports to indicate what actions were taken to prevent further falls. o) 6/1/13: Resident 26 was found on the floor in her room "with her head in a puddle of blood from her nose . . . she complains of pain in her left side. She has an abrasion on the bridge of her nose and under her left eye and a goose egg above her eye. She is not sure what happened." The fall investigation worksheet indicated that on 6/2/13 the resident "complains of severe pain in bilat (bilateral) hips. (Increased) pressure in head when laying down and neck pain. (Physician) authorized us to send her out for dx (diagnosis) (and) trt (treatment)." The intervention listed after the fall was "reminded that she needs to use her call light and wait for help to transfer". Resident 26's nurses notes revealed the following: a) 6/1/13 at 11:13 PM: Resident 26 "fell at about 2245 (10:45 PM) this evening. She was found laying on the floor by her doorway with blood on her face and a puddle of blood on the floor. She was laying on her left side with her head part way in the bathroom. Her nose was bleeding, she has an abrasion on the bridge of her nose and one below her L (left) eye where her glasses pressed into her face, they were not broken. . . She has been very confused this evening, not sure where her room is, surprised to discover that she is here long term, believes that she just switched facilities, etc." b) 6/2/13 at 3:56 AM: "Resident requested pain medication for pain in her nose, Lortab given as ordered. Resident has 2 small cuts on her nose, 1 small cut on her chin and a bruise below right eye. . . " c) 6/2/13 at 7:37 AM: Resident "is complaining this AM (morning) of sharp pains in her R (right) hop, so an X-ray has been ordered." d) 6/2/13 at 1:24 PM: "She has complained of a lot of pain today, and has bruises under both of her eyes and across her nose. She is complaining especially of a headache." e) 6/2/13 at 2:25 PM: Resident "has been complaining of a headache today. She states that it is getting worse. She also has neck pain. With her history of neck surgery and skull fracture, (physician) authorized us to send her to the hospital." f) 6/2/13 at 10:45 PM: "Returned from hospital 2215 (10:15 PM) . . .CT (computed tomography) scan shows fx (fractured) nose . . . " On 6/27/13 at 2:30 PM, an interview was conducted with the facility Director of Nursing (DON). The DON stated that resident 26 was confused, and often times thought she was a nurse that worked at the facility. The DON further stated that resident 26 had repeatedly destroyed the pressure alarms, so the only interventions put into place to prevent further falls were increased monitoring and a cane at the resident's bedside. (Cross refer to F157)

Based on observation, interview and record review it was determined that the facility did not ensure that a resident who entered the facility without a pressure sore did not develop a pressure sore unless the individual's clinical condition demonstrated that it was unavoidable. Specifically, the facility did not provide care and services to promote the prevention of pressure ulcer development for 2 of 31 sample residents resulting in a resident developing a stage 2 pressure ulcer on the coccyx. Resident identifiers: 24 and 60. Findings include: 1. Resident 60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 60's medical record was reviewed on 6/26/13. On 4/28/13 the facility staff completed an admission Minimum Data Set (MDS) Assessment for resident 60. On the admission MDS the facility staff assessed resident 60 as not being at risk for pressure ulcers. The admission MDS revealed that resident 60 required extensive assistance with bed mobility, including moving to and from the lying position, turning side to side, and positioning the body while in bed. The admission MDS also revealed that resident 60 did not have any pressure ulcers at stage 1 or higher. The admission MDS assessment revealed that resident 60 was not on a turning/repositioning program and did not have a pressure reducing device for the chair or bed. The admission MDS assessment also revealed that resident 60 was not receiving nutrition or hydration interventions to manage skin problems. On the Care Area Assessment (CAA) Summary of the admission MDS, the care area of pressure ulcers was triggered, indicating the need for the development of a pressure ulcer care plan. A Resident Care Plan was located in resident 60's medical record. The Resident Care Plan did not contain a date. The Resident Care Plan revealed that resident 60 did not have a pressure ulcer or any pressure areas. There were no skin goals or interventions noted on the Resident Care Plan. There were also no preventative measures noted on the care plan. (Note: On 6/26/13 at 1:15 PM the Director of Nursing (DON) was interviewed. The DON stated that the Resident Care Plan, which did not contain a date, was a care plan used for residents upon admission to the facility. The DON confirmed that there were no skin goals, interventions or preventative measures noted on the Resident Care Plan for resident 60.) On 4/22/13 the facility staff completed an Admission Skin Assessment for resident 60. The Admission Skin Assessment revealed that resident 60 did not have any pressure ulcers upon admission. On 4/22/13 the facility staff completed a Weekly Skin Integrity Review for resident 60. The Weekly Skin Integrity Review showed that resident 60 had dry skin, dark pigmentation, and a rash to the right abdomen. The Weekly Skin Integrity Review also showed that resident 60 had bruising to the right elbow, left forearm and hand. The Weekly Skin Integrity Review dated 4/22/13 did not show anything related to pressure ulcers. On 4/22/13 the facility staff completed a Braden Scale for resident 60. Resident 60 scored 17 on the Braden Scale indicating that the resident was at moderate risk for pressure ulcers. (Note: The facility staff documented on the Braden Scale on 4/22/13 that the staff were to "Turn and reposition frequently, in bed and chair, utilizing proper positioning techniques and equipment.") On 4/23/13 the facility staff completed a Nutrition Risk Review for resident 60. The Nutrition Risk Review showed that resident 60's skin was intact. The Nutrition Risk Review also revealed that there were no pressure ulcers and that resident 60 was at moderate risk for pressure ulcers. On 4/29/13 the facility staff completed a Nursing Comprehensive Assessment for resident 60. The Nursing Comprehensive Assessment showed that resident 60 did not have a pressure ulcer present, or a pressure ulcer which had resolved in the 90 days prior to the assessment. On 5/6/13 the facility staff completed a Weekly Skin Integrity Review for resident 60. The Weekly Skin Integrity Review showed that resident 60 had an open area to the coccyx. On 5/13/13 the facility staff completed a wound/skin update. The wound/skin update showed that resident 60 had a red area measuring 4 by (x) 4 centimeters (cm), as well as a 1 x 1 cm open red sore to the coccyx. The wound/skin update revealed that the start date of the wound was 5/3/13 and was not present on admit. The wound/skin update did not show that a pressure mattress was being used at the time. Resident 60's wound/skin updates revealed the following measurements: a) On 5/13/13 a red area to the coccyx measuring 4 x 4 cm and a 1 x 1 cm open red sore. The start date was documented as 5/3/13 and not present on admit. b) On 5/21/13 a 1 x 1 cm stage 2 on the coccyx. The start date was documented as 5/3/13 and not present on admit. c) On 5/26/13 a 0.75 x 0.5 cm stage 2 to the coccyx and not present on admit. d) On 6/2/13 a a 1 x 1 cm stage 2 to the coccyx. The physician's orders [REDACTED]. The physician's orders [REDACTED]. a) On 4/29/13 an order of "Spray [MEDICATION NAME] to breakdown on lower coccyx, q (every) shift, until healed." b) On 5/9/13 an order for [REDACTED]. c) On 5/21/13 an order for [REDACTED]." d) On 5/24/13 an order for [REDACTED].) On 5/21/13 the facility staff developed a Pressure Ulcer Interdisciplinary Care Plan for resident 60. The Pressure Ulcer Care Plan revealed that resident 60 had a stage 2 pressure ulcer to the coccyx related to: immobility, incontinence and nutritional status. The approaches on the care plan included providing a pressure relieving or reduction device and a turning and repositioning program to turn every 2 hours. (Note: Resident 60 was admitted to the facility on [DATE] and developed a pressure ulcer on 5/3/13. There was not a care plan related to skin integrity or pressure ulcer prevention prior to 5/21/13 located in resident 60's medical record.) On 6/27/13 the turning logs for resident 60 were reviewed. A turn and rotate form was found with a dates of 5/2/13, 5/3/13, 5/4/13 and 5/5/13. The forms were blank and contained no documentation that the resident was turned and repositioned. A turn and rotate form dated 5/6/13 revealed that resident 60 was turned and repositioned every 2 hours on 5/6/13 (15 days after the resident was admitted and 3 days after the resident had developed a pressure ulcer). There was no documentation located which indicated that resident 60 was turned or repositioned prior to 5/6/13. (Note: Resident 60 was admitted on [DATE] and developed a pressure ulcer on 5/3/13.) On 6/27/13 at 9:05 AM, Certified Nursing Assistant (CNA) 3 was interviewed. CNA 3 stated that resident 60 was "really hard to move". CNA 3 stated that resident 60 required assistance with repositioning in bed. On 6/27/13 at 9:35 AM, Licensed Practical Nurse (LPN) 2 was interviewed. LPN 2 stated that resident 60 was "pretty much" an extensive assist with cares. LPN 2 stated that resident 60 was on a turning schedule and they were doing turning logs on the resident. LPN 2 stated that the CNAs were to turn the resident every 2 hours and document it on the turning log. (Note: Turning logs before 5/6/13 could not be located in resident 60's medical record.) On 6/27/13 at 9:35 AM, LPN 1 was interviewed. LPN 1 stated that resident 60 required extensive assistance, including assistance with repositioning in bed and feeding assistance. On 6/27/13 at 9:50 AM, CNA 4 was interviewed. CNA 4 stated that resident 60 required total assistance with transfers and repositioning. On 6/27/13 at 10:30 AM, the DON was interviewed. The DON stated that when a resident was at moderate risk for pressure ulcers then the resident was to be placed on a turn and reposition program and a skin care plan was to be developed. The DON confirmed that resident 60 was at a moderate risk for pressure ulcers on admit as indicated by a Braden Score of 17. The DON stated that the facility had a turn and reposition program for residents who were at risk for pressure ulcers, immobile, in bed a lot during the day or had any skin impairments. A "Turn and Rotate Every 2 Hours" log was placed in a folder in resident's room when they were on the turn and reposition program. Staff were to initial the log every two hours when a resident was turned and repositioned. On 6/27/13 at 12:15 PM, a second interview was conducted with the DON. The DON stated that resident 60 was on the turn and reposition program. The DON provided turn and rotate logs for resident 60. The earliest documentation on the turn and rotate logs for resident 60 was on 5/6/13. (Note: Resident 60 was admitted on [DATE] and developed a pressure sore on 5/3/13.) The DON was unable to provide any documentation that resident 60 was turned and repositioned prior to 5/6/13. The DON stated that the alternating air mattress was ordered on [DATE]. (Note: Resident 60 was admitted on [DATE] and developed a pressure ulcer on 5/3/13.) The DON was unable to provide further documentation that an alternating air mattress was placed prior to 5/24/13. When asked if resident 60 had a cushion on the wheelchair for preventing pressure ulcers the DON stated that resident 60 was in bed most of the time. This surveyor asked for further documentation or information related to interventions that were in place to prevent pressure ulcers or any further information regarding risk factors that resident 60 may have had. No further documentation was provided regarding risk factors or preventative measures for resident 60. 2. Resident 24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 24's medical record was reviewed on 7/1/13. On 6/21/13, the facility staff completed a Braden Scale for resident 24. The Braden Scale revealed that resident 24 was bedfast, had very limited mobility, very limited sensory perception, occasionally moist skin and probably inadequate nutrition. Resident 24 had a Braden Score of 12 indicating the resident was at high risk for pressure ulcers. On the Braden Scale the staff documented that the staff was to "Turn and reposition frequently, in bed and chair, utilizing proper positioning techniques and equipment." On 6/21/13, the facility staff completed a Nursing Comprehensive Assessment for resident 24. The Nursing Comprehensive Assessment revealed that resident 24 required extensive assistance with dressing and was bedfast all/most of the time. The Nursing Comprehensive Assessment also revealed that resident 24 was frequently incontinent of the bowel and bladder and had fragile skin. On 6/27/13, observations were made of resident 24. A continuous observation of resident 24 was started at 8:20 AM. At 8:20 AM resident 24 was observed lying in bed in the supine position. Continuous observations of resident 24 were made until 11:00 AM. It was observed that resident 24 was not turned or repositioned during the time of the continuous observation from 8:20 AM to 11:00 AM. Resident 24 was still lying in bed in the supine position at 11:00 AM. It was observed that resident 24 was not turned or repositioned between the times of 8:20 AM and 11:00 AM. (Note: The facility staff documented on the Braden Scale on 6/21/13 that the staff were to "Turn and reposition frequently, in bed and chair, utilizing proper positioning techniques and equipment.") On 7/1/13, observations were made of resident 24. A continuous observation of resident 24 was started at 7:30 AM. At 7:30 AM resident 24 was observed lying in bed in the supine position. Continuous observations of resident 24 were made until 10:30 AM. It was observed that resident 24 was not turned or repositioned during the time of the continuous observation from 7:30 AM to 10:30 AM. Resident 24 was still lying in bed in the supine position at 10:30 AM. It was observed that resident 24 was not turned or repositioned between the times of 7:30 AM and 10:30 AM. (Note: The facility staff documented on the Braden Scale on 6/21/13 that the staff were to "Turn and reposition frequently, in bed and chair, utilizing proper positioning techniques and equipment.") On 7/1/13 at 11:20 AM, CNA 5 was interviewed. CNA 5 confirmed that she was assigned to resident 24. CNA 5 stated that resident 24 usually just stayed in bed and required assistance with turning and repositioning. CNA 5 stated that resident 24 had not been repositioned yet during that shift. CNA 5 stated that if the staff were documenting when resident 24 was repositioned then CNA 5 did not know where it was. CNA 5 stated that some residents had a folder with forms in their room where the staff could document when a resident was turned and repositioned. CNA 5 stated that she did not think resident 24 had a form in the room. On 7/1/13 at 12:45 PM, CNA 6 was interviewed. CNA 6 stated that resident 24 required total assistance with positioning and transferring. CNA 6 stated that staff were supposed to turn and reposition residents every 2 hours. CNA 6 stated that the staff documented turning and repositioning on a paper in every room. CNA 6 stated he was not sure if resident 24 had a turning form in the room. Resident 24's medical record and bedroom were reviewed for a turning log on 7/1/13. A turning log was not located in the medical record or in resident 24's room. On 7/1/13 at 1:30 PM, Registered Nurse (RN) 2 was interviewed. RN 2 stated that resident 24 required a lot of assistance, including assistance with turning and repositioning. RN 2 stated that resident 24 should be turned and repositioned every 2 hours, even if there was a pressure pad on the bed. RN 2 stated that they usually documenedt on a turn and reposition form when a resident was turned or repositioned. RN 2 stated that she was assigned to resident 24. RN 2 stated that she was not sure if resident 24 had been turned or repositioned during her shift because she had not spoken to the CNA about it yet. RN 2 stated that she was not sure if resident 24 had a turn and reposition sheet in the room or not. On 7/1/13 at 1:45 PM, the DON was interviewed. The DON stated that resident 24 was able to shift her weight a lot. The DON stated that resident 24 had an alternating pressure mattress on the bed. The DON stated that resident 24 should still have been turned and repositioned every 2 hours even with an alternating pressure mattress. The DON stated that resident 24 should have been on the turn and reposition program and that she would start a turning log on resident 24 right away.

Based on interview and record review, it was determined the facility did not provide the necessary care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being for 1 of 4 sample residents. Specifically, (1) The facility licensed nursing staff did not provide basic life support when required; (2) The facility did not obtain ordered laboratory tests; and (3) The facility did not notify the primary care physician of abnormal laboratory tests. Resident identifer: CL 1. Findings include: Resident CL 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident CL 1's medical record was reviewed on [DATE]. Review of resident CL 1's medical record revealed that resident CL 1 had not formulated an Advance Directive or a physician's orders [REDACTED]. Review of the admission Minimum Data Set (MDS) assessment completed on [DATE] revealed that resident CL 1 was assessed as having a Brief Interview of Mental Status score of 11 (scores ranged from ,[DATE]. A score of 0 meant that the resident was not alert and a score of 15 meant that the resident was alert and oriented). The facility staff documented that resident CL 1 had hallucinations (perceptual experiences in the absence of real external sensory stimuli) and [MEDICAL CONDITION] (misconceptions or beliefs that are firm held, contrary to reality). The facility staff further assessed resident CL 1 as requiring limited assistance with a one person physical assist with dressing and hygiene. The facility staff documented that resident CL 1 smoked cigarettes. A. The electronic "Interdisciplinary Progress Notes" were reviewed. On [DATE] at 11:42 PM, a facility licensed nurse documented "At approximately 1935 (7:35 PM), pt's (patient's) brother called and wanted to speak to pt. (Resident CL 1) had went to smoke with other residents, and CNA (Certified Nurse Assistant) at 1930 (7:30 PM). Staff went out to get pt, and other residents said "He just put his cigarrete (sic) out and went in. CNA looked in smokers room on her way in and found pt on floor, face very blue. CNA got this nurse and no pulse or breathing was noted. CPR (Cardiopulmonary Resuscitation) was immediately started and 911 was called. Ambulance arrived at 1945 (7:45 PM), and took over life-saving measures. Pt. was transported to (local hospital) at 2005 (8:05 PM). Called Brother (name redacted) at 2000 (8:00 PM) and let him know of situation, gave him the number to (the local hospital)." Review of emergency room report, dated [DATE], documented "...the patient arrives in critical condition and is unresponsive and initially had no pulses. HEENT (head, ears, eyes, nose and throat): Pupils are equal and round, about ,[DATE] (millimeters) bilaterally and not appear to be responsive. Oropharynx: On initial opening of his mouth has a large amount of spaghetti, emesis filling up the entire mouth. LUNGS: No obvious auscultation of any lungs sounds. HEART: Also no auscultated heart sounds. NEUROLOGIC: No spontaneous neurological movement. EMERGENCY DEPARTMENT COURSE: On arrival, the patient is being bagged by EMS (Emergency Medical Services) and has continued CPR and immediately I turned attention to his airway with first opening of his mouth. On arrival, the patient has a mouth full of spaghetti and emesis. ..." On [DATE] at 5:31 PM, Registered Nurse (RN) 1 was interviewed. RN 1 stated that she was assigned to care for resident CL 1 on [DATE]. RN 1 stated that she first realized that resident CL 1 was not immediately available while administering the evening/night medications. RN 1 stated that she could not remember if she was going to administer his evening medications or his night medications, and was unable to locate him. She stated that she did not think too much about resident CL 1's location as he was independent in his activities of daily living and frequently went outside to smoke. RN 1 stated that resident CL 1 received a phone call from his brother, so she instructed a CNA to find the resident. RN 1 stated that resident CL 1 was not found during the initial search of the facility which included other resident's rooms, the day room, and the courtyard. She stated that a more in depth search was conducted immediately after the initial search. RN 1 stated the second search of the facility included all locked rooms and the smoking room which was located in the courtyard. RN 1 stated that a facility CNA (she was unsure of the CNA's name) called out for help which she responded to. RN 1 stated she passed another facility CNA and directed that CNA to call 911 and to get the other nurse on duty for assistance. RN 1 stated that resident CL 1 was found face down, without a pulse, and was not breathing. RN 1 stated that it "seemed like a long time" for the second CNA to return with assistance. She stated that resident CL 1 was repositioned in the smoking room after multiple failed attempts to reposition him. RN 1 stated that since the CNA had not returned with the facility emergency equipment, she left resident CL 1 to find an ambu bag (a medical device used to provide assisted ventilation to people who are either not breathing or are having trouble breathing). RN 1 stated that she ran "around the corner" to the supply room behind the nurses station. RN 1 stated that she was unable to find the facility crash cart, ambu bag, or mouth shield to provide rescue breathing. RN 1 stated that a facility CNA found a mouth shield in her car and brought the mask into the facility. RN 1 stated that when she returned to resident CL 1, that the other facility nurse and another CNA were providing CPR. RN 1 stated that she had received training in CPR and first aide. On [DATE] at 6:00 PM, RN 1 again placed a telephone call to the state surveyor. RN 1 reported that two CNA's were present in the immediate vicinity when resident CL 1 was found in the smoking room. She stated that she sent one CNA to call 911. RN 1 stated that she had started chest compressions but stopped when a CNA reported that she could not find the crash cart with the ambu bag. RN 1 stated that she instructed the CNA's to continue with CPR. RN 1 then stated that when she returned to resident CL 1, that the other facility nurse was there providing assistance to resident CL 1. RN 1 stated that she assisted the Emergency Medical Technician's with gaining entry into/out of the facility and provided them with resident CL 1's history. On [DATE] at 6:45 AM, CNA 4 was interviewed. CNA 4 stated that he was assisting the smoking residents on [DATE]. He stated that he heard a "thud" that sounded like someone hit the ground. CNA 4 stated that he found resident CL 1 laying on the ground, face up. He stated that he immediately called for assistance then assessed resident CL 1 for a pulse. CNA 4 stated that resident CL 1 did not have a pulse and that he assessed his airway by "opening his mouth." CNA 4 stated that he did not provide rescue breaths as there was not an ambu bag or a mouth shield available. CNA 4 stated that he began providing chest compressions with CNA 5 (alternating chest compressions). CNA 4 stated that he had received training in CPR and first aide. On [DATE] at 10:35 AM, RN 3 was interviewed. RN 3 stated that resident CL 1 received a phone call from his brother and that a search of the building to locate resident CL 1 was initiated. RN 3 stated that CNA 10 found resident CL 1 laying, face up, on the floor inside the smoking room. RN 3 stated resident CL 1's face was "black" and that he did not have a pulse and was not breathing. RN 3 stated that she started chest compressions while CNA 10 ran out to her car to obtain a mouth shield as the facility staff were unable to find an ambu bag. RN 3 stated that chest compressions continued until EMS personnel arrived on scene. RN 3 stated that resident CL 1's airway was not assessed as there was not an ambu bag or a mouth shield available. RN 3 stated that she had received training in CPR and first aide. On [DATE] at 12:47 PM, the facility Administrator submitted a facsimile to the state agency which included notarized statements from four facility staff related to the events that occurred on [DATE]. The notarized statements included: 1. CNA 10: "To whom it may concern: On [DATE] while working as a CNA at (facility name), sometime after dinner, the facility received a phone call for one of the residents from his brother. I asked him to please hold while I went to look for him. I checked his bedroom, the TV (television) room, and dining room but could not find him. I decided to go check outside in the smoking room, because I knew that he was a smoker and felt as if he might be out there. After opening the door to the smoking room I saw (resident CL 1) face down on the ground. Another resident, (name removed), was outside the door to the smoking room, and since he was physically able, I asked him to get the nurse quickly. So he hurried back inside and got the nurse to come out. As this was happening I started to try and get (resident CL 1) into a supine position so I could assess his airway and pulse. While I was trying to do this, the nurse, (RN 1), came out and helped me to get him into a position where we could assess his airway. His face was cyanotic and we could not feel a pulse or detect any breathing. To the best of my recollection, as we were feeling for a pulse the other nurse (RN 3) came out and she was the one who initiated CPR. As she began CPR, (RN 3) asked me to go inside and find an AMBU bag behind the door in the medication room. I ran back there to look for it but could not find it so I started looking all around the medication room, the back supply room, and the nurse's station. As I recall, another CNA, (CNA 4) was helping me look for the AMBU bag. Then I called (name removed), the Director of Nursing, to ask her where the AMBU bags could be. She said that they should be behind the door in the medication room but, as stated before, they were not there. While searching for the AMBU bag, realized that I had a CPR mask in my car so I ran outside to grab it from my car but by the time I got back, the EMTs (Emergency Medical Technician's) had arrived. At this point (CNA 4) was doing chest compressions while the EMTs were beginning their care. After a couple of minutes I took over doing compressions. After another couple of minutes the EMTs told me to stop doing compressions and took (resident CL 1) in the ambulance shortly thereafter." The written statement was signed by CNA 10 and notarized on [DATE]. 2. CNA 4: "In Regards to the events of [DATE]: I was out with the smokers including (resident CL 1). He walked back towards the back door to the building when (CNA 10) came outside looking for him. She discovered him laying on his back in the smoke room and yelled for me to come look at him. When I got in the smoke room, (CNA 10) ran to get a nurse. (RN 3) came outside and assessed him while (CNA 10) ran inside to call 911 and get and (sic) ambu bag. By that point the ambulance arrived (10 min (minutes) or so). The paramedic instructed (CNA 10) and I to continue chest compressions while they established an airway and used an ambu-bag to perform rescue breathing. (RN 3) remained at the scene until the paramedic took him away. To the best of my knowledge and recollection, this is what happened." The written statement was signed by CNA 4 and notarized on [DATE]. 3. RN 1: "In regards to the events of [DATE]: After looking for (resident CL 1) for several minutes, when his brother had called to talk to him, I was at the nurses' station, when a different resident came around the corner from the smoke room area and yelled, 'We need a nurse here'. I ran to the smoke room. I found (resident CL 1) face down inside the smoke room with a CNA at his side. Another CNA had come with me outside also. I told the second CNA to go call 911, and then to get (RN 3) and the crash cart. Upon seeing (resident CL 1), I could tell he was cyanotic. The skin that was showing was blue, and he was cold to the touch. We tried shouting his name, to see if he was responsive. He was not. The first CNA and I tried to turn him over, to be able to assess more. For several minutes we tried, but without any success, due to his size and the limited space in the room. Finally, after trying several different positions we were able to turn him over. We felt for a pulse and I was not able to feel any pulse in his neck. I listened and felt, and look for any air entering his lungs. Listened and felt over his mouth and nose, and watched his chest for any movement. There was no movement, and no breath sounds. The CNA, who found (resident CL 1) and I were getting into positions to start CPR, when the second CNA, whom I had sent to call 911, came back. He said paramedics were on their way, and that he couldn't find the crash cart, or any equipment, and he couldn't find (RN 3). He asked if the crash cart might be in the Med (Medication) room, which only the nurses have the key to. I told him and the first CNA to start CPR on (resident CL 1), and I ran to get the equipment and (RN 3). Turning the corner, I found (RN 3) and told her (resident CL 1) was unconscious in the smoke room. She took off to the smoke room, and I continued to the med room to look for the crash cart, or anything to help. At this time, a couple different CNAs joined me, in looking for a crash cart, AMBU-bag, or anything. We couldn't find anything. I sent one of CNA's who were with me, to go ask (RN 3) where the equipment was, specifically. I continued looking. A few seconds later, The (sic) CNA came back and said, 'behind the door'. We looked, but couldn't find anything. At this time, I ran back to the smoke room. Upon turning the corner, I told (RN 3) I couldn't find anything. She told me it should be back there, but to also bring (resident CL 1's) chart back with me to her. For the few seconds I saw (resident CL 1) at that time, I saw that compressions were being done. I ran back to the back room, looked again for any equipment, and then grabbed (resident CL 1's) chart. I ran back to the smoke room, and opened the chart, looking for pertinent information about (resident CL 1). At this time, the paramedics arrived on scene. I helped to hold the door open for the stretcher to get outside to the smoke room. The Paramedics took over the CPR and (RN 3) stepped out of the smoke room, and grabbed the chart, looking for anything to tell the paramedics to help. At this time, the paramedics were doing CPR and other care (sic) for (resident CL 1). (RN 3) asked me to help open doors for any paramedics, and to keep residents and other CNAs out of the way of the paramedics. I had to go with any paramedic who was returning for something on the ambulance, to enter the code, to let them out of the facility. For several minutes the paramedics worked on (resident CL 1). While (RN 3) and I assisted where possible, opening doors, answering questions about (resident CL 1), clearing other residents away. Eventually they took him to the ambulance and left to the hospital. We continued with our other responsibilities to other residents, until the end of our shift. To the best of my knowledge and recollection, this is what happened." The written statement was signed by RN 1 and notarized on [DATE]. 4. RN 3: "In Regards to The Events of [DATE]: At approx (approximately) 19:35 (7:35 PM), (resident CL 1's) brother (name removed) called and wanted to speak to him. I asked Certified Nursing Assistant (name removed) to go get him outside because the resident smoke time was at 1930 (7:30 PM). I was speaking to brother on the phone at the nurses' desk; while they went to get (resident CL 1). (CNA 10) came in and said "(RN 3) come quick, (resident CL 1) is dead in the smoke room'. At this point I told the brother that I would call him right back and hung up. I entered the smoke room and pt (patient) was lying on his back, I told (CNA 10) to go get an Ambu bag and have other nurse call 911. I knelt next to pt. and adjusted his head and pulled chin down, however I did not do a breath, as I did not have an Ambu bag yet. I immediately started chest compressions after about 5 minutes (CNA 4) came in and asked if I wanted him to do compressions. I continued for a few minutes and then (CNA 4) took over. Paramedics arrived at approx 1945 (7:45 PM) and took over CPR. I stood outside of smoke room and spoke to paramedic, and answered his questions about what had happened. At this point paramedics, were doing CPR and was using Ambu bag; at no time did I leave the scene. When paramedic got (resident CL 1) on stretcher and went into building I followed them in and call (sic) brother approx 2000 (8:00 PM). Told him we had found his brother deceased and that Paramedics were leaving at that time. Gave brother phone number to (hospital). To the best of my knowledge and recollections, this is what happened." The written statement was signed by RN 3 and notarized on [DATE]. Cross-reference: F-518 related to the facility's response to a medical emergency. B. On [DATE] resident CL 1's primary care physician ordered for the facility to check a "CBC (complete blood count), CMP (complete metabolic profile), A1C (hemoglobin A1C), Lipids, (and) [MEDICATION NAME] level..." On [DATE], the CBC, CMP, A1C, Lipids and [MEDICATION NAME] levels were checked. The laboratory values were as follows: a. CMP: Sodium low at 126 millimoles per liter. The laboratory documented a normal value was ,[DATE]; b. CBC: White blood cell count high at 12.0. The laboratory documented a normal value was 3.6 - 10.61 K/uL (thousand per cubic milliliter). On [DATE] at 3:14 PM, a facility Registered Nurse (RN) documented "Lab results have been received. The doctor will review the results when he gets in." On [DATE], CL 1's primary care physician ordered "H20 (water) restriction: 1 gallon a day. BMP 1 week, UA (urinalysis) (with) C&S (culture and sensitivity) (and) chest x-ray now. CBC in 1 wk (week)." There was no documentation available for review which indicated that a urinalysis with culture and sensitivity was obtained as ordered by resident CL 1's primary care physician. On [DATE] at 2:45 PM, resident CL 1's primary care physician was interviewed. The primary care physician stated that a urinalysis was ordered for resident CL 1 because of the high white blood cell count that was obtained on [DATE]. On [DATE] at approximately 3:15 PM, the facility Director of Nursing (DON) was interviewed. The DON stated the urinalysis with culture and sensitivity was not obtained as ordered on [DATE]. Cross-reference: F-502 for failure to obtain ordered laboratory services. C. On [DATE] at 2:45 PM, resident CL 1's primary care physician was interviewed. The primary care physician stated that he was not notified of the abnormal laboratory results as above until [DATE]. The primary care physician stated that the abnormal laboratory results should have been reported to him on [DATE] per the "On-Call Manual." The "On-Call" instruction manual revealed that the licensed nursing staff should have notified the physician for: "...Critical lab abnormalities including...WBC (white blood cell count) (greater than) 11,000 (K/uL)...or any other lab value that is designated by the lab to be "critical." Cross-reference: F-505 for not notifying the physician of abnormal laboratory test results.