Every finding on record at The Meadows

Based on observation, staff interview, and facility policy review, the facility failed to prevent the possible contamination of ice, as evidenced by a buildup of a black substance on the inside door and the interior ledge of the ice machine that was used for all residents for one (1) of three (3) kitchen tours.Findings Include: Record review of the facility policy titled Ice Machine Cleaning Policy with an effective date of 5/3/2021 revealed, .The kitchen staff will be responsible for weekly cleanings of ice machines in the kitchen .During the initial kitchen tour on 6/1/2026 at 10:24 AM, observation of the ice machine revealed two areas of black substance, each approximately two to three inches in diameter, on the underside of the ice maker lid. Black substance was also observed along the interior ledge of the ice machine. The interior ledge was covered with small, circular spots of the black substance that extended across the entire ledge surface.During an interview on 6/1/2026 at 10:25 AM, the Dietary Manager (DM) confirmed the presence of the black substance observed on the underside of the ice maker lid and on the interior ledge of the ice machine. The DM stated that dietary staff clean the ice machine weekly and that the underside of the lid and the interior ledge should have been cleaned during the routine cleaning process. The DM acknowledged that the black substance should not have been present and that its presence showed the ice machine had not been cleaned properly. The DM also stated that the black substance could potentially cause illness in residents and staff.

Based on record review, staff interview, and facility policy review, the facility failed to ensure the designated Infection Preventionist implemented and monitored the facility's Infection Prevention and Control Program by failing to conduct infection surveillance, track and trend infections, analyze infection data and identify infection control concerns. This deficient practice had the potential to affect all 118 residents residing in the facility.Findings Include:Record review of the facility policy titled Compliant Infection Preventionist (IP) Job Description revealed under, Position Summary: The Infection Preventionist (IP) is responsible for the development, implementation, oversight, and evaluation of the facility's Infection Prevention and Control Program (IPCP). The IP works collaboratively with nursing, medical staff, department managers, residents, families, and community agencies to prevent, identify, investigate, monitor, and control infections and communicable diseases throughout the facility .Record review of the facility's Urinary Tracking Infection Logs from February 2026 through April 2026 identified 54 urinary tract infection (UTI) episodes, excluding residents admitted with infections and duplicate entries for the same active infection. Multiple residents experienced recurrent UTIs. The infection tracking logs included resident names, organisms identified, antibiotic treatment, treatment completion dates, and follow-up culture results. However, there was no documentation demonstrating the infections were analyzed for trends, contributing factors, recurring organisms, or opportunities for intervention.Record review revealed the May 2026 infection control log had not been completed as of 6/2/26.Record review of Resident #118's physician orders revealed an order dated 6/2/26 for Contact Precautions for ESBL (Extended-Spectrum Beta-Lactamase) in urine every shift.On 6/3/26 at 2:30 PM, during an interview with the Infection Preventionist (IP), she stated she had not completed the May 2026 infection control log and usually remained approximately one month behind in infection control documentation. The IP stated she was unaware a resident was currently on contact precautions for an infection and could not identify the type of infection. She stated floor nurses were responsible for implementing precautions and ensuring the required equipment was available in the resident's room.On 6/3/26 at 10:00 AM, during an interview with the IP, she stated she had served in the role since 2018 and dedicated approximately three days per week to infection prevention activities. The IP stated she was unsure what infection criteria were used to identify infections and would need to review the facility policy. The IP stated she did not review resident symptoms when monitoring infections. The IP stated she only reviewed physician orders for antibiotics and entered the information into the monthly infection tracking log. The IP confirmed she did not track or trend infections, evaluate recurring infection patterns, or analyze infection data. The IP stated UTIs had been a recurring concern within the facility. The IP further confirmed she had not provided staff education regarding perineal care, catheter care, hydration, or other interventions to address the recurring infections.On 6/3/26 at 10:38 AM, during an interview with the Administrator after reviewing the infection tracking logs, confirmed the infection tracking process was lacking.Record review of the facility's Urinary Tracking Infection Logs from February 2026 through April 2026 identified a recurring pattern of urinary tract infections caused by Escherichia coli (E. coli). Despite the recurring trend, there was no evidence the facility conducted surveillance activities to identify contributing factors, determine the source, or implement corrective interventions.An interview on 6/3/26 at 3:45 PM, with the Assistant Director of Nursing (ADON) revealed the IP should identify infection sources, track infection patterns, and ensure interventions were implemented to address identified concerns. The ADON confirmed there was no tracking or trending of infection data. After reviewing the infection logs, the ADON identified a recurring concern involving E. coli in urine cultures and stated staff education regarding perineal care, catheter care, hydration, and other prevention measures should have been conducted. The ADON stated the recurring infections should have been analyzed to identify the cause and implement corrective actions.

Based on staff interview, record review, and facility policy review, the facility failed to implement an effective antibiotic stewardship program, failed to ensure urinary tract infections (UTIs) were reviewed using established infection criteria before antibiotic treatment, failed to track and trend infection data, and failed to identify and implement interventions to reduce infections for numerous UTI episodes identified on the facility's infection tracking logs from February 2026 through April 2026.This was for three (3) of four (4) months reviewed.Findings include:Review of the facility policy titled Antibiotic Stewardship Policy revealed, It is the policy of this facility to minimize inappropriate and unnecessary antibiotic use and improve patient outcomes. This facility will follow the antibiotic stewardship program. Review of the facility's Urinary Tracking Infection Logs from February 2026 through April 2026 identified 54 UTI episodes, excluding residents admitted with infections and duplicate entries for the same active infection. Multiple residents experienced recurrent UTIs. The infection tracking logs included resident names, organisms identified, antibiotic treatment, treatment completion dates, and follow-up culture results. However, there was no documentation showing the facility reviewed symptoms or infection criteria to determine whether a UTI was present, analyzed antibiotic utilization, identified infection trends, evaluated recurring organisms, or implemented interventions to reduce infections.Record review revealed the May 2026 infection control log had not been completed as of 6/2/26.Record review of Resident #118's physician orders revealed an order dated 6/2/26 for Contact Precautions for ESBL (Extended-Spectrum Beta-Lactamase) in urine every shift.During an interview on 6/3/26 at 2:30 PM, the Infection Preventionist (IP) stated she had not completed the May 2026 infection control log and usually remained approximately one month behind in her infection control documentation. The IP stated she was unaware a resident was currently on contact precautions for an infection and could not identify the type of infection. She stated floor nurses were responsible for implementing precautions and ensuring the required equipment was available in the resident's room.During an interview on 6/3/26 at 10:00 AM, the IP stated she had served in the role since 2018 and dedicated approximately three days per week to infection prevention activities. The IP stated she was unsure what infection criteria were used to determine whether residents met the requirements for a UTI diagnosis and would need to review the facility policy. The IP stated she did not review resident symptoms when tracking infections. When asked how she determined whether infection criteria were met before antibiotics were prescribed, she stated she only reviewed physician orders for antibiotics and entered the information into the monthly infection tracking log. The IP confirmed she did not track or trend infections, evaluate recurring infection patterns, or analyze antibiotic utilization. The IP stated UTIs had been a recurring concern in the facility. She further confirmed she had not provided staff education regarding perineal care, catheter care, hydration, or other interventions to reduce UTI occurrence.During an interview on 6/3/26 at 10:38 AM, the Administrator stated nurses reported resident symptoms to the Nurse Practitioner, who then determined whether testing and treatment orders would be issued. The Administrator reviewed the infection tracking log and confirmed the tracking process was lacking.Record review of the facility's Urinary Tracking Infection Logs from February 2026 through April 2026 identified a recurring pattern of urinary tract infections cause by Escherichia coli (E.coli). Despite the recurring trend, there was no evidence the facility conducted surveillance activities to analyze contributing factors, identify the source, or implement interventions. During an interview on 6/3/26 at 3:45 PM, the Assistant Director of Nursing (ADON) stated the IP should know the infection criteria used to determine whether antibiotic treatment was appropriate. The ADON stated the IP should evaluate whether residents were being treated for a true infection, identify the source of infections, track infection patterns, and ensure interventions were implemented to address identified concerns. The ADON confirmed there was no tracking or trending of infection data. After reviewing the infection logs, the ADON identified a recurring concern involving E. coli in urine cultures and stated staff education regarding perineal care, catheter care, hydration, and other prevention measures should have been conducted. The ADON stated the recurring infections should have been analyzed to identify the cause and implement corrective actions.

Based on observations, staff and resident interviews, record review, and facility policy review, the facility failed to ensure comprehensive Activities of Daily Living (ADL) care plans were implemented for two (2) of 25 residents sampled. Specifically, the facility failed to implement established ADL care plan interventions related to facial hair for Residents #59 and #67. Findings include: Review of facility policy titled Total Care Plan Policy revised 5/19/2015, revealed, .Identify problems that affect the residents and his/her care needs .Identify the interventions related to the specific problems .Be maintained on the extent practicable . Resident #67 Review of Resident #67's ADL care plan dated 11/6/25, revealed, .Place personal hygiene items within reach and allow to perform per self. Assist to complete tasks as needed. On 6/1/2026 at 11:35 AM, an observation revealed Resident #67 had several long, curly facial hairs on her chin. On 6/3/2026 at 10:00 AM, during an interview Registered Nurse (RN) #2 confirmed the presence of the chin hairs, and she further confirmed that Certified Nursing Assistants (CNAs) should be shaving residents as needed during bath/shower time. During an interview on 6/4/2026 at 8:34 AM, the Minimum Data Set (MDS) Nurse confirmed Resident #67's ADL care plan was developed to include personal hygiene, it was just not implemented by the staff. She verbalized that the purpose of the care plan is to guide the staff on how to provide care for Resident #67. Record review of the Record of admission indicated Resident #67 was admitted to the facility on [DATE]. Record review of the Client Diagnosis Report indicated Resident #67's diagnoses included Unspecified fracture of upper end of right tibia, subsequent encounter for closed fracture with routine healing; weakness; vascular dementia, unspecified severity, with other behavioral disturbance. Record review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/17/2026, revealed under Section C a Brief Interview for Mental Status (BIMS) score of 4, indicating Resident #67 had severe cognitive impairment. Under Section GG revealed that she required supervision or touching assistance with her personal hygiene. Resident #59 Record review of Resident #59's Care Plan revealed that she had limitations in functional abilities/self-care deficit related to generalized weakness with a goal that all Activities of Daily Living (ADL) needs will be met with staff assistance as required. On 06/01/2026 at 1:35 PM and on 06/03/26 at 9:50 AM, observations and interviews revealed Resident #59 with scattered chin hairs that were approximately one-half to three-fourths of an inch in length. Resident #59 revealed that she could not recall staff asking her if she would like them shaved and stated, It would be good if they had a time and place to get it done. Resident revealed that it bothered her to have facial hair and stated, It makes me feel like an odd ball. On 06/03/26 at 9:55 AM, during an interview and observation with Certified Nursing Assistant (CNA) #1, she confirmed that Resident #59 had facial hair to her chin. CNA #1 revealed that Resident #59's scheduled shower days were Mondays, Wednesdays, and Fridays and confirmed that her facial hair should have been taken care of. An interview on 06/03/26 at 10:05 AM with Assistant Director of Nursing (ADON), revealed that she wanted the residents to look nice, look presentable, and to feel good about themselves. ADON revealed that they expected their CNAs to assess for facial hair on male and female residents during their shower time. She confirmed that Activities of Daily Living (ADL) Care was including on the Care Plan and should have been completed. She also revealed that leaving female residents with unwanted facial hair was a dignity issue and was not acceptable. Record review of Resident #59's Record of admission form revealed an admission date of 01/20/25 and that she had diagnoses that included Unspecified Dementia, Weakness, and Hypertensive Heart and Chronic Kidney Disease without Heart Failure. Record review of Resident #59's Brief Interview for Mental Status (BIMS) Assessment completed on 03/20/26 revealed a score of 08 which indicated that she had moderate cognitive deficits. Record review of Resident #59's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 04/12/26 under Section GG revealed that she required substantial/maximal assistance with her personal hygiene.

Based on observation, resident and staff interview, record review and facility policy review the facility failed to provide necessary Activities of Daily Living (ADL) services for two (2) of 25 sampled residents who were dependent on staff assistance to maintain their personal hygiene and grooming needs. Resident #59 and Resident #67. Findings include: Review of facility policy titled Dressing and Grooming Policy revised 11/20/2017, revealed, It is the policy of this facility that dressing, and grooming will be done as follows: Grooming includes: .shaving, removal of facial hair . Resident #67 During an observation on 6/1/2026 at 11:35 AM, revealed Resident #67 had several long, curly facial hairs on her chin. During an observation an interview with Resident #67 on 6/3/2026 at 9:56 AM, revealed Resident #67 still had multiple long, curly chin hairs. She stated, while feeling her chin, I didn't know those were there. She verbalized she would like someone to shave those off. During an interview on 6/3/2026 at 10:00 AM, Registered Nurse (RN) #2 confirmed the presence of the chin hairs, and she further confirmed that Certified Nursing Assistants (CNAs) should be shaving residents as needed during bath/shower time. Additionally, she stated that when female residents have unwanted facial hair, it is considered a dignity concern. During an interview on 6/3/2026 at 10:05 AM, the Assistant Director of Nursing (ADON) confirmed that it was the responsibility and expectation for the CNA to shave residents as needed on shower days or as needed. She stated it was a dignity issue for female residents to have unwanted facial hair. Record review of the Record of admission indicated Resident #67 was admitted to the facility on [DATE]. Record review of the Client Diagnosis Report indicated Resident #67's diagnoses included weakness and vascular dementia, unspecified severity, with other behavioral disturbance. Record review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/17/2026, revealed under Section C a Brief Interview for Mental Status (BIMS) score of 4, indicating Resident #67 had severe cognitive impairment. Section GG revealed that she required supervision or touching assistance with her personal hygiene. Resident #59 Observations and interviews on 06/01/2026 at 1:35 PM and 06/03/26 at 9:50 AM revealed Resident #59 with scattered chin hairs that were approximately one-half to three-fourths of an inch in length. Resident #59 revealed that she could not recall staff asking her if she would like them shaved and stated, It would be good if they had a time and place to get it done. Resident revealed that it bothered her to have facial hair and stated, It makes me feel like an odd ball. She also revealed that she did not want her facial hair plucked out, but she would like it to be shaved. During an observation and interview on 06/03/26 at 9:55 AM with Certified Nursing Assistant (CNA) #1, she confirmed that Resident #59 had facial hair to her chin. CNA #1 revealed that Resident #59's scheduled shower days were Mondays, Wednesdays, and Fridays and confirmed that removal of facial hair was the CNAs responsibility to take care of during that time. She stated, I don't like to have body hair myself and revealed she would take care of it. During an observation and interview on 06/03/26 at 10:00 AM with Licensed Practical Nurse (LPN) #2, she confirmed that Resident #59 had facial hair to her chin. She stated, I wouldn't like to have facial hair, it would bother me too. She also revealed that facial hair should be addressed during resident showers. An interview on 06/03/26 at 10:05 AM with Assistant Director of Nursing (ADON), revealed that she wanted the residents to look nice, look presentable, and to feel good about themselves. ADON revealed that they expected their CNAs to assess for facial hair on male and female residents during their shower time. She also confirmed that leaving female residents with unwanted facial hair was a dignity issue and was not acceptable. Record review of Resident #59's Record of admission form revealed an admission date of 01/20/25 and that she had diagnoses that included Unspecified Dementia, Weakness, and Hypertensive Heart and Chronic Kidney Disease without Heart Failure. Record review of Resident #59's Brief Interview for Mental Status (BIMS) Assessment completed on 03/20/26 revealed a score of 08 which indicated that she had moderate cognitive deficits. Record review of Resident #59's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 04/12/26 under Section GG revealed that she required substantial/maximal assistance with her personal hygiene.

Based on observation, staff interview, record review and facility policy review, the facility failed to implement and maintain an effective infection prevention and control program by failing to follow Enhanced Barrier Precautions (EBP) (Resident #91) and by failing to provide an appropriate biohazard (red barrel) container for a resident under transmission-based precautions. (Resident #118) for two (2) of 25 sampled residents. Findings Include: Review of the facility policy titled, Infection Control-Contact Isolation/Transmission Based/Enhanced Barrier Policy with a revision date of August 2024 revealed, 2. Contact Isolation.Red/Yellow bagged barrels will be utilized . Record review of physician orders revealed Resident #118 had an order dated 6/2/2026 for contact isolation precautions related to ESBL (Extended-Spectrum Beta-Lactamase) in urine every shift. An observation on 6/01/2026 at 2:53 PM revealed Resident #118 was on transmission-based precautions related to ESBL. A red bag/ biohazard barrel was not present in the resident's room for disposal of contaminated waste and personal protective equipment (PPE). Gowns, gloves, masks were discarded in a regular trash can in the bathroom. During an observation and interview with Registered Nurse (RN) #1 on 6/01/2026 at 3:05 PM, she stated there should have been a barrel in the room. During an interview on 6/02/2026 at 2:30 PM, the Infection Preventionist (IP) stated, According to the policy, there should have been a red barrel in the room. She also stated, I didn't even know that Resident #118 was on contact precautions, I'm not sure what type of infection she has. She stated, It's the first of June and the report is one month behind. During an interview on 6/04/2026 at 8:37 AM with Assistant Director of Nursing (ADON), she confirmed infection control practices should be used to prevent the spread of an infection and stated, It is the expectation of the facility to have biohazard trash bags in the room of a resident on contact isolation. Record review of the Record of admission revealed Resident #118 was admitted to the facility on [DATE] with medical diagnoses that included Cerebral Infarction. Record review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/13/2026 revealed under Section C that a Brief Interview for Mental Status (BIMS) score was 8, indicating moderate cognitive impairment. Resident #91 Review of the facility policy titled Infection Control-Contact Isolation/Transmission Based/Enhanced Barrier Policy, with a revision date of August 2024, revealed .Enhanced Barrier Precautions refer to the use of gown and gloves for use during high contact resident care activities for residents known to be colonized or infected with a MDRO (Multi-Drug Resistant Organism), as well as those at increased risk of MDRO acquisition (e.g. residents with wounds or indwelling medical devices) During an observation and interview on 6/02/2026 at 1:57 PM, signage indicating Enhanced Barrier Precautions was observed posted outside Resident #91's room. Licensed Practical Nurse (LPN) #1 escorted Resident #91 in his wheelchair from the hallway into his room and proceeded to provide Percutaneous Endoscopic Gastrostomy (PEG) tube site care. LPN #1 failed to perform hand hygiene and failed to don the required gown prior to initiating care. During the treatment, LPN #1 cleansed the PEG site and discarded a soiled gauze pad onto the bedside table. LPN #1 immediately stated, Oh, I shouldn't have done that, however, the soiled gauze remained on the bedside table. Upon completion of the treatment, LPN #1 bagged the trash and exited the resident's room to dispose of it while continuing to wear the same soiled gloves. During an interview on 6/02/2026 at 2:10 PM, LPN #1 confirmed Resident #91 was on Enhanced Barrier Precautions and stated, We usually just use gloves when we do his PEG site care. I think we wear gowns and gloves when they have a wound. After reading the Enhanced Barrier Precautions signage posted outside the resident's room, LPN #1 stated, I guess I screwed up. According to the sign, we are supposed to wear a gown since he has a PEG tube. LPN #1 further acknowledged that wearing the same soiled gloves from the resident's room into the hallway was an infection-control concern and that the gloves should have been removed and discarded before exiting the room. During an interview on 6/02/2026 at 2:40 PM, the Infection Preventionist confirmed that Enhanced Barrier Precautions are required when providing PEG site care and explained that these precautions are intended to reduce the risk of transmission of infectious organisms. During an interview on 6/03/2026 at 4:05 PM, the Assistant Director of Nursing (ADON) revealed it is the facility's expectation that infection control practices are consistently followed to prevent the spread of infection. The ADON confirmed staff are trained to wear the appropriate personal protective equipment (PPE), including both a gown and gloves, when providing care to residents on Enhanced Barrier Precautions. The ADON further stated that proper hand hygiene and removal and disposal of soiled gloves before leaving the resident's room are expected infection control practices. Record review of the Record of Admission revealed Resident #91 was admitted to the facility on [DATE] Record review of the Client Diagnosis Report revealed Resident #91 has diagnoses which include Dysphagia following cerebral infarction, and Encounter for attention to gastrostomy. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/3/26 revealed under Section K. that Resident #91 had a Feeding tube.

Based on staff interview, record review, and review of facility-provided documentation, the facility failed to notify the medical provider prior to administering a medication that required pulse rate monitoring for one (1) of three (3) residents reviewed for medication monitoring (Resident #1). This failure resulted in a medication being administered multiple times when the resident's pulse rate was below the facility-required threshold of sixty (60), without provider notification or guidance.Findings include:Review of a statement on facility letterhead provided by the Administrator revealed, All medications requiring pulse monitoring should be monitored before the medication is given by radial pulse for one full minute. If the pulse is below 60, contact the physician for guidance prior to giving the medication.Review of Resident #1's November 2025 medication record revealed a physician's order for Sotalol 120 mg tablet every twelve hours for atrial fibrillation. Continued review revealed the resident's pulse rate dropped below sixty on three occasions on 11/8/25 through 11/9/25. On 11/8/25 at 8:00 AM, the pulse rate was fifty, and the medication was held. On 11/8/25 at 20:00 (9:00 PM), the pulse rate was fifty-six, and the medication was signed as administered without physician notification. On 11/9/25 at 8:00 AM, the pulse rate was fifty-five, and the Sotalol was signed off as administered without physician notification.An interview with the Director of Nursing (DON) on 11/18/25 at 11:50 AM revealed she confirmed the Sotalol for Resident #1 should not have been administered when her pulse was below sixty, and because it is a beta blocker it can lower the pulse even more and cause weakness and circulatory concerns. She further stated that after reviewing the resident's records she was unable to find any documentation that the provider was notified of the resident's low pulse rate.An interview with the Administrator on 11/18/25 at 12:00 PM revealed she confirmed that the nursing staff should have notified the provider of the pulse rate dropping below sixty for further instruction.Review of the Record of admission revealed the facility admitted Resident #1 on 11/4/25 with a diagnosis of atrial fibrillation.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure the safety of a resident during a mechanical lift transfer and a resident sustained a forehead laceration requiring sutures for one (1) of four (4) residents sampled. Resident #1Findings include:Record review of facility policy titled, Total Lift Policy with revision date of 2/2/17 revealed, It is the policy of the facility that a total lift will be utilized as follows: by a licensed nurse or CNA (Certified Nursing Assistant) . It requires two employees when lift is used .A phone interview with CNA #1 on 11/3/25 at 10:40 AM, revealed she was the CNA caring for Resident #1 when the lift incident occurred. She admitted that she transferred the resident without assistance and did not position the lift legs properly which caused the lift to tilt and the bar hit the resident on the forehead. She revealed I tried to do it by myself, and it didn't go well. She acknowledged that some of the staff were in an in-service, but there were others available to assist, but she did not ask for help to move the resident. She acknowledged she had been in-serviced multiple times on lift safety and the requirement for two staff members to be present when a lift was used and she failed to follow this policy. She stated she had not done this before, and she knew she made a big mistake and a bad judgement call and was remorseful that because of her bad decision a resident was harmed and required stitches to her head. An observation on 11/3/25 at 11:30 AM revealed Resident #1 sitting in her geriatric chair in the day room. The laceration on her forehead was healed with an L-shaped scar visible that was approximately two inches long on vertical part and approximately one and one-half inch long on the horizonal part. During an interview on 11/3/25 at 3:10 PM, Registered Nurse (RN) #1 revealed she was the nurse supervisor when the incident occurred. CNA #1 came to her office and told her the resident's head was bleeding. When she arrived in the room, Resident #1 was in the geriatric chair still attached to the lift and her forehead was bleeding, so she held pressure to the wound. There were no other staff member in the room, so she asked CNA #1 if she used the lift by herself and she admitted she did. She stated she told CNA #1, You know better than that. We always use two people. She revealed she notified the Nurse Practitioner (NP) who evaluated the resident and gave orders to send the resident to the emergency room (ER). On 11/3/25 at 4:00 PM, an interview with the Director of Nursing (DON) revealed CNA #1 had been in-serviced multiple times on lift safety which included the requirement to always use two (2) people and CNA #1 did not follow that procedure. Due to this, Resident #1 had a forehead laceration injury that required sutures. She acknowledged that it was her expectation for all staff to follow the policies of the facility to ensure residents' safety. She confirmed the facility failed to ensure the resident was free from injury by a staff member not following facility's policy related to lift use.During an interview on 11/3/25 at 4:05 PM, the Administrator revealed that it was her expectation that each staff member follow policies to safely meet the needs of each resident and CNA #1 failed to do that when she chose to use a lift for Resident #1 without assistance. This led to a forehead laceration that required sutures. She confirmed the facility failed to prevent an accidental injury to a resident by not properly using a lift for a resident's transfer.Record review of Interdisciplinary Progress Notes dated 10/9/25 at 10:09 AM, revealed. This nurse was approached by CNA needing assistance in patient room due to head bleeding. When this nurse entered room resident noted sitting in Geri chair with Hoyer lift still attached to sling. A large laceration was noted to resident's right forehead. This nurse applied pressure to stop the bleeding and called for (proper name removed), DNP (Doctor of Nursing Practice) to come assess, treat. It appears resident head was struck on Hoyer lift during transfer. This note was signed by RN #1Record review of Nurse Practitioner's Interdisciplinary Progress Notes dated 10/9/25 at 10:37 AM revealed, .(proper name for Resident #1 removed) complains of pain to head and I have asked nursing staff to administer Tylenol. Orders given to transfer to (name of local hospital removed) ER for evaluation and management of the laceration. She will need Computed Tomography (CT) to determine any further injury .Record review of Interdisciplinary Progress Notes dated 10/9/25 at 10:50 AM, revealed, .Resident transferred to (proper name of hospital removed) via EMS (Emergency Medical Service) Ambulance Service.Record review of Interdisciplinary Progress Notes dated 10/9/25 at 3:40 PM, revealed, Resident returned from (proper name of hospital removed) via ambulance. On assessment, resident noted to have dressing to forehead. Dressing removed and noted to have 11 stitches to laceration and dressing replaced .Record review of Physician Orders revealed an order dated 8/6/25 for Tylenol 325 milligrams tablet two tablets every four hours as needed for pain.Record review of Electronic Medication Record revealed Tylenol was administered on 10/9/25 at 10:38 AM with reason of grimacing d/t (due to) laceration on right forehead. Review revealed the resident received the Tylenol on 10/9/25 at 4:02 PM with reason of grimacing with discomfort to right forehead r/t laceration.Record review of Physician Orders revealed an order dated 8/6/25 for Hydrocodone Bitartrate Acetaminophen 325-5 milligram tablet one tablet every four hours as needed for pain.Record review of Electronic Medication Record revealed Hydrocodone was administered on 10/10/25 at 8:39 PM due to head pain. Review revealed Hydrocodone was administered on 10/11/25 with reason of head pain.Record review of Physician Orders revealed an order dated 10/9/25 to send to hospital per ambulance for evaluation of laceration/contusion to right forehead.Record review of Inservice Sign in Sheet titled In-service on New Slings for Total Lifts dated 4/4/25 revealed CNA #1's signature.Record review of In-Service Sign in Sheet for Lift check offs CNAs revealed CNA #1's signature dated 5/15/25.Record review of Inservice Sign in Sheet titled Lift Education Training for CNAs dated 8/6/25 revealed CNA #1's signature for attending. Record review of .Electric Patient Lift User Manual revealed, Safety Precautions . Perform patient transfers with at least two caregivers present for added safety .Record review of Record of Admission revealed the facility admitted Resident #1 on 8/6/25 with diagnosis listed as Alzheimer's Disease.Record review of Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 8/12/25 revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident had severe cognitive impairment.

Based on observation, staff interviews, record review, and facility policy review, the facility failed to promote dignity by not ensuring the use of a privacy cover for the urinary catheter bag for one (1) of five (5) residents reviewed with a catheter. (Resident #2) Findings Include: Review of the facility policy titled Catheter Placement Policy, with a revision date of August 14, 2017, revealed catheter bags should be placed inside a privacy bag. Review of the facility policy titled Dignity Policy, with a revision date of September 6, 2010, revealed care should be provided in a manner and in an environment that maintains or enhances each resident's dignity with respect in full recognition of his or her individuality. On 5/27/25 at 9:40 AM, observation of Resident #2 revealed the resident lying in bed with a urinary catheter bag hanging at the bedside, uncovered and lacking a privacy cover. Record review of the physician orders revealed Resident #2 had an order for a suprapubic catheter. During an interview with Licensed Practical Nurse (LPN)# 1 at Resident 2's bedside on 5/28/25 at 9:42 AM, she confirmed that the resident should have a privacy cover on his catheter bag and stated, It can be embarrassing for the resident, and it's a dignity issue. During an interview with Director of Nursing (DON) on 5/28/25 at 11:47 AM, she stated, All staff know that they should have a privacy bag over the catheter bag for dignity. We have enough catheter bag covers for the wheelchair and bed. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/14/2025, revealed in Section C a Brief Interview for Mental Status (BIMS) score was an 8, indicating the resident's cognitive status was moderately impaired. Item H0100: Appliances revealed, A. Indwelling catheter. Record review of the Record of admission revealed the facility admitted Resident #2 on 8/19/2017, with medical diagnoses including Urinary Retention.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to involve a bed-bound resident for a scheduled care plan meeting for one (1) of 21 sampled residents. Resident #80 Findings Include: Review of the Care Plan Invitation Policy unrevised revealed, It is the policy of this facility that invitations to care plan conferences will be handled in the following manner: The resident and/or the responsible party will be invited to attend the care planning conference by one week prior to the scheduled date . A formal interdisciplinary care planning conference will be held weekly on Thursday. All members present are to provide input and sign the care plan verifying attendance . Review of the Resident Rights Policy with a revision date of 12/06/10 revealed under, Exercise Rights: Each resident will be able to exercise his/her rights as a resident in this facility and as a citizen of the United States. 11. To participate in his/her total care plan preparation and implementation . An observation and interview with Resident #80 on 5/27/25 at 10:06 AM revealed she was lying in bed and stated she was bed bound and did not attend her care plan meetings because she did not leave her room. The resident explained she had never been invited to a meeting, and the facility had not mentioned anything about having one and confirmed that her family was not involved with her care. An interview with Social Services (SS) #1 on 5/27/25 at 2:12 PM revealed the facility has care plan meetings every Thursday. She explained that she notifies the residents of their upcoming care plan meeting when she goes into their rooms to do their Brief Interview for Mental Status (BIMS) and mood assessment. She stated the resident's son-in-law came to the first couple of care plan meetings but has not come in quite a while. SS #1 stated the resident prefers not to come out of her room and confirmed the team did not accommodate for the resident by holding the meeting in her room. She acknowledged the resident should be involved and make decisions regarding her care. An interview with the Director of Nursing (DON) on 5/29/25 at 8:12 AM confirmed the staff should involve Resident #80 in care plan meetings and explained the resident should have a direct voice regarding how her care was managed. Record review of the Record of Admission revealed the facility admitted Resident #80 on 10/31/23 with medical diagnoses that included Seizures and Unspecified Sequelae of Nontraumatic Subarachnoid Hemorrhage. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/24/25 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident #80 was cognitively intact.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to allow a resident the opportunity to make important care-related decisions for one (1) of 21 sampled residents. Resident #87 Findings Include: Review of the Resident Rights Policy with a revision date of 9/06/10 revealed under, Exercise Rights: Each resident will be able to exercise his/her rights as a resident in this facility and as a citizen of the United States. An observation and interview with Resident #87 on 5/27/25 at 10:56 AM revealed she was sitting in her wheelchair in her room and stated that she did not sleep well last night and explained that they made her get up early this morning. She revealed, I told them I would rather not get up, and I wanted to sleep in. The resident stated that they made her get up anyway. An interview with Resident #87 on 5/28/25 at 9:50 AM revealed she was [AGE] years old, and depending on how she felt, she might not want to get up early every morning. The resident stated she would like to make those care decisions for herself. An interview with Licensed Practical Nurse (LPN) #2 on 5/28/25 at 10:02 AM revealed Resident #87 was on the get-up list for the 11-7 shift to get her up. She explained that the night shift started getting the residents up around 5:30 AM and confirmed the resident did voice at times she did not want to get up early, but the daughter wanted her up for all meals. LPN #2 acknowledged it was the residents' right to make care choices, and the facility should honor that request. An interview with the Director of Nursing on 5/29/25 at 8:12 AM confirmed Resident #87 should be able to make decisions regarding her care that were important to her, such as sleeping in late if she wanted to. Record review of the Record of Admission revealed the facility admitted Resident #87 on 5/03/24 with a medical diagnosis that included Mixed Anxiety Disorder. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/04/25 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 10, which indicated Resident #87 was moderately cognitively impaired.

Based on staff interviews, record review, and facility policy review, the facility failed to accurately complete Section K of the Minimum Data Set (MDS) for a resident with significant weight loss for one (1) of 21 sampled residents. Resident #48 Findings Include: Review of the facility policy titled Resident Assessment Instrument Policy (RAI) with a revision date of 5/19/15 revealed, It is the policy of this facility that the RAI will be done as follows: According to the guideline specified by CMS (Centers for Medicare and Medicaid Services) . Record review of the Weights Detail Report for Resident #48 revealed the following recorded weights: 3/27/25 237.1 4/29/25 230.3 Record review of the readmission Assessment for Resident #48 dated 5/07/25 revealed a weight of 206.6, which was a significant weight loss of 10.29% (percent) from the last documented weight on 4/29/25. Record review of the Admit 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/13/25 revealed under section K0300, a weight loss of 5% or more in the last month was not marked. An interview with the Minimum Data Set (MDS) Nurse on 5/29/25 at 8:56 AM confirmed Resident #48 had weight loss that should have been captured on the 5-day MDS assessment. She stated, It just got missed. She revealed the information submitted in the assessment must be accurate to develop the resident's care that is needed. An interview with the Director of Nursing (DON) on 5/29/25 at 9:09 AM revealed her expectations were for the MDS staff to accurately reflect the resident's status at the time the assessment was completed. Record review of the Record of Admission revealed the facility admitted Resident #48 on 8/12/24 with a medical diagnoses that included Chronic Kidney Disease, stage 3, and Chronic Systolic Congestive Heart Failure. Record review of the MDS with an Assessment Reference Date (ARD) of 5/23/25 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 3, which indicated Resident #48 was severely cognitively impaired.

Based on staff interviews, record review and facility policy review the facility failed to ensure that one (1) of 24 sampled residents was protected from verbal abuse. Resident #268 Findings Include: Record review of the Facility's Abuse, Neglect, or Exploitation Policy with revised date of November 21, 2017, documented, It is the policy of this facility that all residents will be free from abuse, neglect, and exploitation following the guidelines in the Vulnerable Adult Act . On 11/28/23 at 12:40 PM, an interview with Director of Nursing (DON), revealed that on 10/30/23, it was reported to her that Certified Nursing Assistant (CNA) #1 had spoken inappropriately to a resident. She revealed that it was told to her that CNA #1 and CNA #2 were in Resident #268's room helping her pack up her personal items for resident to be moved into a different room, due to resident testing positive for covid. The DON revealed that while conducting the investigation, it was revealed to her that while the two CNAs were packing up resident's personal items, the resident had asked for a pillow and CNA #1 responded with Shut the F*** (explicit language) up. DON revealed that upon interview with CNA #2, she revealed that she knew this should be reported and went to the supervisor immediately after she finished taking care of the resident. The DON revealed that Resident #268 called the Director of Rehabilitation (DOR), and immediately reported the incident. The DON revealed that the DOR went straight to the Registered Nurse (RN) Supervisor, reported it and by the time CNA #2 finished up with the resident and made it to administration, the RN Supervisor was already in the room interviewing with resident. The DON revealed that she and the Administrator (ADM) interviewed CNA #2 to get her account of the incident and she confirmed that CNA #1 had in fact said what resident reported she said. The DON revealed that CNA #1 was called in for questioning and denied the accusation; but, due to being heard and reported by Resident #268 and witnessed by CNA #2, CNA #1 was terminated, and she left the building immediately. DON revealed that she reported the incident to the State Agency and to the Attorney General's Office. On 11/28/23 at 2:50 PM, an interview with Director of Rehabilitation (DOR), revealed that she had known Resident #268 for years prior to resident coming to the facility and she (resident) felt comfortable talking to her. DOR revealed that on 10/30/23, Resident #268 was being moved from one room to another due to testing positive for Covid and that she (DOR) was called by this resident to come to her room. The DOR revealed that the resident reported to her (DOR) that a CNA had told her to shut the 'F***' (explicit language) up and that the resident said it back to her. DOR revealed that the resident had told her that CNA #1 was at the head of the bed and CNA #2 was towards the foot of the bed to the side and they were moving bed and all into the other room. DOR revealed that she went straight to the RN Supervisor, reported it, and she (DOR) stated, We don't tolerate that. DOR revealed that they immediately started investigating, interviewing and that CNA #1 was terminated that same day. On 11/29/23 at 9:00 AM, an interview with CNA #2, revealed that on 10/30/23, she (CNA #2) and CNA #1 were getting Resident #268's personal things together to get her moved into another room because she had tested positive for COVID. CNA #2 revealed that Resident #268 had hip issues, was lying in her bed and they were moving bed and all to the other room. She revealed that Resident #268 had asked for her pillow which was near CNA #1, and she told her no. CNA #2 revealed that Resident #268 asked repeatedly for her pillow and then CNA #1 said to resident, Just shut the f**** (explicit language) up! She revealed that the resident heard what she had said and repeated back to her with, you shut the f*** up and CNA #1 still didn't get the pillow resident had asked for. CNA #2 revealed that the resident seemed mad, and the way CNA #1 had talked to her was disrespectful and rude and stated, I was shocked that she said it. CNA #2 revealed that CNA #1 could come across as rude sometimes, but she had never witnessed anything like this with her. CNA #2 revealed that CNA #1 left the room after this, and she continued to provide care to the resident making sure she was comfortable in bed and that she had what she needed. CNA #2 revealed that when she left Resident #268's room, she went to report the incident. CNA #2 revealed that Resident #268 had called the DOR to her room and told her what happened immediately after she left her and before she was able to find her supervisor. On 11/29/23 at 9:30 AM, an interview with the RN Supervisor revealed that he was working on 10/30/23 when the alleged verbal abuse by CNA #1 to Resident #268 occurred. He revealed that Resident #268 called the Director of Rehabilitation, reported that CNA #1 had cursed her and that she had cursed her (CNA #1) back. RN Supervisor revealed that he spoke with CNA #1, and she denied the allegation. RN Supervisor revealed that he went with CNA #1 into Resident #268's room, and she denied saying it yet again. RN Supervisor revealed that he then spoke with CNA #2 who was a witness to the incident, and she confirmed that CNA #1 had cursed the resident. RN Supervisor revealed that he had never seen this kind of behavior with CNA #1 and that she no longer worked here. On 11/30/23 at 9:45 AM, an interview with Director of Nursing (DON) revealed that CNA #1 was terminated due to verbal abuse towards Resident #268. She revealed that verbal abuse included talking down to residents, raising voices to others, and cursing residents. She revealed that CNA #1 denied the allegation; but, DON stated, It was witnessed by the resident and another CNA. The DON revealed that she knew that they were responsible for everyone working under them and knew that it was their job to make sure these residents were taken care of. Record review of the facility investigation completed by the DON documented that on 10/30/23 at 12:00 PM, that CNA #1 and CNA #2 were in Resident #268's room helping pack up her personal items for resident to be moved into a different room due to resident testing positive for covid. Upon interviews during investigation process, while the CNAs were packing personal items, Resident #268 asked for a pillow and CNA #1 responded to resident with Shut the 'F' (explicit language) up. Interview with CNA #2 revealed that she knew this was a reportable incident and had intentions of coming out to meet with supervisor after she completed care for resident; but, due to the flow and quick time frame of awareness made to administration, supervisor was already in room interviewing with resident by this time. Resident #268 called DOR to her room and reported a statement made to her by CNA #1 and DOR reported said statement to RN Supervisor. Upon interview with CNA #1 with Resident #268 present and resident representative, CNA #1 denied telling Resident #268 to shut the 'F' (explicit language) up. RN Supervisor reported the incident to Administrator and DON, who called CNA #2 into the office to get her account of the incident. CNA #2 confirmed that CNA #1 did say what Resident #268 reported she said. DON then called in CNA #1, and she denied saying said statement to Resident #268. DON told CNA #1 that Resident #268 reported it, CNA #2 confirmed witnessing her saying what was reported by resident, so her employment would be terminated. DON reviewed the policy and expectations of how to care for and treat residents and made CNA #1 aware of the severity of what she had done and how she could have handled things differently. DON reported this incident to the State Agency on 10/30/23 around 1:10 PM and online report was sent to Attorney General's (AG) office at 1:57 PM. Record review of statement written and signed by DOR, documented that she was called to Resident #268's room and was told that the CNA #1 told her to shut the f*** up. DOR revealed that she went and told the RN Supervisor, they (DOR and RN Supervisor) interviewed CNA #1, and she denied the accusation. CNA #2, who witnessed the incident, was then interviewed and she said that CNA #1 told patient to shut the f up and that she had witnessed her telling the patient those exact words. Record review of the written statement completed and signed by CNA #2 on 10/30/23 documented that CNA #2 and CNA #1 went into Resident #268's room to move the patient to room [ROOM NUMBER]. During the move, the patient was asking for a pillow, CNA #1 told the patient No we have to wait until we get to your room. The patient asked nicely twice if she could have her pillow and CNA #1 got frustrated and told her to shut the F up. The patient heard CNA #1 and replied saying 'no you shut the f*** up.' After that the conversation was over and they continued to move the patient to room [ROOM NUMBER] and then left. Record review of the written statement completed and signed by RN Supervisor on 10/30/23 documented that he was notified about Resident #268 complaint that a CNA told her to shut the 'F***' (explicit language) up. RN Supervisor spoke with resident who verified which CNA spoke to her in that manner. CNA #1 was brought into the room with Resident #268, was questioned, and she denied saying those words. RN Supervisor revealed that CNA #2 was present and had witnessed the incident and during interview with her, she verified that CNA #1 did use those exact words in which Resident #268 indicated she said. He revealed that the DON called CNA #1 into her office in which appropriate disciplinary action was taken. Record review of Resident #268's Record of Admission revealed an admitted [DATE]. Record review of Resident #268's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/19/23 under Section C was documented a Brief Interview for Mental Status (BIMS) Score of 14 which indicated that resident was cognitively intact. Record review of Resident #268's History and Physical (H&P) completed by the Nurse Practitioner documented that resident had the following diagnoses to include: Fracture of Unspecified part of Left Femur, History of falling, Difficulty in Walking, Presence of Left Artificial hip joint, Parkinson's Disease, Chronic Kidney Disease, and Weakness.

Based on staff interview, record review and facility policy review the facility failed to accurately complete a Pre-Admission Screening (PAS) for a resident with a mental disorder for one (1) of two (2) resident PASSARs (Pre-Admission Screening and Resident Review) reviewed. Resident #35 Findings Include: Review of the facility policy titled, Resident Assessment-Coordination with PASARR Program with an implementation date of 07/10/23 revealed under the Policy: This facility coordinates assessments with pre-admission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs . Record review of Resident #35's Record of Admission revealed the resident was admitted to the facility on [DATE]. Record review of Resident #35's History and Physical (Proper name of Health Services) dated 3/6/23 revealed the resident had a medical diagnoses history on admission of Bipolar Disorder. Record review of Resident #35's Pre-Admission Screening that was completed on 3/21/23 indicated the resident did not have any history of a mental illness. An interview on 11/29/23 at 2:00PM with Case Manager Nurse revealed that residents are discussed in their morning meetings regarding behaviors or new diagnoses. She stated that Resident #35 had a diagnosis of Bipolar Disorder when the Pre-Admission Screening was completed and the question regarding if the resident had a mental disorder should have been marked yes on the PAS that was completed on 3/21/23. She revealed that back in July of this year they had a staff meeting and discussed looking at these harder than we were, because it was a bigger deal than we thought. An interview on 11/29/23 at 2:30 PM, with the Quality Assurance Nurse (QA) confirmed that the resident had a diagnosis of Bipolar Disorder when the residents PAS was completed, and the form was not filled out correctly because it indicated the resident did not have a mental disorder. Record review of Resident #35's Minimum Data Set with an Assessment Reference Date of 09/03/23 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 15, which indicates the resident is cognitively intact and in Section I that the resident had a diagnosis of Bipolar Disorder.

Based on staff interview and record review the facility failed to have a stop date on an As Needed (PRN) psychotropic medication for one (1) of three (3) residents reviewed for the use of psychotropic medications. Resident #58 Findings Include: Review of the typed statement on facility letterhead (undated) revealed the facility did not have a policy regarding a stop date for psychotropic medications and was signed by the Administrator. Record review of Resident #58's Physician's Orders revealed the following: Order dated 7/20/23-Lorazepam oral concentrate 2mg (milligrams)/1ml (milliliter) give 1ml every 2 (two) hours as needed for anxiety oral. An interview on 11/30/23 at 10:25 AM, with the Consultant Pharmacist revealed that any psychotropic medication that is PRN should have a stop date and that he had indicated on his 8/11/23 Medication Regimen Review for Resident #58 that he had relayed to the QA (Quality Assurance) nurse to check and make sure a stop date was on the PRN Ativan order that was written on 7/20/23. An interview and record review on 11/30/23 at 10:30 AM, with Registered Nurse (RN) #1 revealed she is Resident #58's nurse and that she does have behaviors sometimes with increased anxiety. She confirmed that the resident had an order for Ativan scheduled one time per day and Ativan every 2 hours PRN. An interview on 11/30/23 at 10:47 AM, with the Director of Nurses (DON) confirmed that PRN psychotropic medications should have a stop date, because it may not be something they continue needing. She stated that if the PRN psychotropic medication was continued without a stop date, then it could cause the resident to be a fall risk. She confirmed that Resident #58's PRN Ativan order written on 7/20/23 did not have a stop date and that the Consultant Pharmacist's report from 8/2023 indicated that he had relayed to the QA nurse for her to check and make sure a stop date was put on that order. An interview on 11/20/23 at 11:00 AM with Family Nurse Practitioner (FNP) confirmed that she wrote the order for PRN Ativan on 7/20/23 and did not put a stop date on the order. She stated that she thought that with the resident being on hospice and her writing that she wanted the resident on the PRN Ativan indefinitely was ok. She revealed she understands that they need a stop date and review, and she would take care of that now. Record review of Resident #58's Record of Admission revealed the resident was admitted to the facility on [DATE]. Record review of the History and Physical for Resident #58 dated 6/15/23 revealed medical diagnoses that included Dementia .with mood disturbance, Generalized Anxiety Disorder and Major Depressive Disorder. Record review of Resident #58's Minimum Data Set with an Assessment Reference Date of 09/08/23 revealed in Section C a Brief Interview of Mental Status score of 07, which indicates the resident was severely cognitively impaired.

Based on staff interviews, record reviews, and facility policy reviews the facility failed to transmit Annual and Quarterly Minimum Data Set (MDS) Assessments accurately and timely for two (2) of two (2) residents reviewed for MDS assessments. Resident #76 and Resident #101 Findings include: Review of the facility policy titled, CH 5: Submission and Correction of the MDS Assessments dated October 2023 revealed, When the transmission file is received by iQIES (Internet Quality Improvement and Evaluation System), the system performs a series of validation edits to evaluate whether or not the data submitted meet the required standards .All error and warning messages are detailed and explained in the Error Messages guide .5.2 Timeliness Criteria .Encoding Data: .For a comprehensive assessment ( .Annual ., encoding must occur within 7 days after the Care Plan Completion Date (V0200C2 + 7 days). For a Quarterly, Significant Correction to prior Quarterly, Discharge, or PPS assessment, encoding must occur within 7 days after the MDS Completion Date (Z0500B + 7 days) . A record review of the MDS 3.0 NH Final Validation Report for Resident #76 with a target date of 10/10/2023 revealed that the annual assessment had been rejected due to invalid skip patterns. The dates rejected were 10-24-2023, 10/30/2023, and 11/01/2023. A record review of the MDS 3.0 NH Final Validation Report for Resident #101 with a target date of 10/20/2023 revealed that the quarterly assessment had been rejected due to invalid skip patterns for dates of 10/30/2023 and 11/01/2023. An interview on 11/30/23 at 09:06 AM, the MDS nurse revealed that the annual MDS assessment for Resident #76 had an Assessment reference date (ARD) of 10/10/23 and was submitted on 10/24/23. She revealed the annual assessment was rejected because of Section D inaccuracy and the annual assessment was unlocked and fixed and re-submitted on 10/30/23 the assessment was rejected again because of Section D inaccuracy. She revealed on 11/1/23 the annual was once again unlocked and fixed and at that time it was rejected because of Section O. She revealed at this time it is still rejected and she has not fixed and re-submitted. The MDS nurse revealed Resident #101's quarterly assessment was rejected because the residents Social Security number was put in inaccurately. She revealed it was a typo but now we are making sure we slow down when adding information to prevent that from happening again. She revealed a modification was submitted on 11/1/23 but was rejected due to inaccuracy again. She confirmed it is still not corrected and both Resident #76 and Resident #101 are on her to-do list for Monday. She revealed when an MDS is rejected she or the other MDS nurses look at the validation report. She confirmed the validation report identified the errors that were made on each submission. She confirmed they were not submitted accurately. She revealed the purpose of the MDS assessment is for reimbursement to the facility and to determine the development of clinical care plans based on interdisciplinary team assessments. A record review of the facility Record of Admission for Resident #76 revealed she was admitted to the facility on [DATE]. A record review of the facility Record of Admission for Resident #101 revealed she was admitted to the facility on [DATE].

Based on observation, staff interview, facility policy review, Mississippi (MS) State Board of Nursing website review, and the Nurse Practice Act, the facility failed to ensure a Registered Nurse (RN) and/or Respiratory Therapist (RT) were scheduled for each shift to provide consistent respiratory care services, 24 hours each day to deep suction the [CONDITION(S)] ([CONDITION(S)]), if needed and /or provide other emergency care related to the [CONDITION(S)], to a resident with a [CONDITION(S)], for one (1) of 1 resident reviewed with a [CONDITION(S)], Resident #26. During a review of the facility Staffing Grid, the facility did not have RN or RT coverage for the 11-7 shift on 08/05/2022 and there was not an RN assigned on the 3-11 shift and the 11-7 shift on 08/06/2022. Resident #26 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #26 was diagnosed with an Acute Upper Respiratory Infection requiring antibiotics and nebulizer treatments on 08/04/2022. The facility's failure to provide 24 hour per day services of an RN and/or RT, for possible deep suctioning and other emergency care of the [CONDITION(S)] tube was likely to cause serious harm, serious injury, serious impairment, or death to Resident #26. The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 08/10/2022, which began on 08/05/2022, when the facility failed to ensure qualified staff, a RN and/or RT, were present 24 hours per day to perform deep suctioning of a [CONDITION(S)] and other emergency procedures if needed, for Resident #26. The SA notified the Administrator on 08/10/2022 of the IJ and SQC. The facility submitted an acceptable Removal Plan on 08/11/2022, in which the facility alleged all corrective actions were completed on 08/10/2022, and the IJ was removed as of 08/11/2022. The SA validated the Removal Plan on 08/12/2022 and determined the IJ was removed prior to exit. The scope and severity for the IJ at CFR 483.25(i) Respiratory care, including [CONDITION(S)] care and tracheal suctioning, was lowered to a D level, while the facility develops and implements a Plan of Correction (POC) and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with the regulatory requirements. Findings include: Record review of the facility policy titled, Suctioning Policy, revised May 28, 2018, revealed, It is the policy of this facility to ensure that standards of best practice are consistent when upper airway suctioning is performed to remove secretions from the oropharynx, nasopharynx, or trachea . Procedure . 10. Tracheal suctioning . d. If suctioning catheter needs to be inserted beyond the end of the tracheotomy tube (deep suctioning) this will be performed by an RN. Review of the Mississippi (MS) State Board of Nursing Laws and Rules Administrative Code Part 2830 Practice of Nursing Title 30: Professions and Occupations Chapter 2, Functions of the Licensed Practical Nurse, (LPN) revealed: Rule 2.1 LPN Supervision, The LPN gives nursing care which does not require the specialized skill, judgement, and knowledge required of an RN, Advanced Practice Registered Nurse (APRN), Licensed Physician, or Licensed Dentist. Review of the MS State Board of Nursing (BON) website revealed frequently asked questions (FAQ's). The BON's statement regarding the LPN's scope of practice with [CONDITION(S)] care revealed: It is within the scope of practice of the LPN to perform [CONDITION(S)] care and suction secretions from the [CONDITION(S)] tube. However, it is not within the scope of practice for the LPN to perform deep right main stem suctioning. If deep suctioning is required for a patient, a Registered Nurse (RN) must perform the procedure. Record review of the assessment of Resident #26, completed by the Nurse Practitioner (NP) on 08/10/22, revealed, He is currently being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . A chest x-ray was obtained on 8/4/22 due to increased congestion, fever, and cough. In addition to the mentioned antibiotics, he routinely receives [MEDICATION(S)] every six (6) hours (hr), scheduled, for congestion due to impaired respiratory function, [MEDICATION(S)] 40mg twice daily for secretions, [MEDICATION(S)] 10mg daily for secretions, Guaifenesin 100mg/5mg #20 milliliters (ml) every (q) 4hrs for secretions and Acetylcyteine 20% twice daily and as needed (PRN) for secretions. He has not required an as needed dose of Acetylcyteine since 8/4/22. He has an as needed order for [MEDICATION(S)] 20mg intramuscular (IM) and received an as needed dose on 8/4/22, 8/7/222, and 8/9/22. He receives routine [CONDITION(S)] care and suctioning every shift and as needed. He has required as needed [CONDITION(S)] suctioning 8/4/22, 8/6/22, 8/8/22, and twice on 8/9/22 this month. Nurse report that his secretions have improved from green to yellow since receiving antibiotics. He has not required deep suctioning. No reports of apnea or labored breathing. He is afebrile and is no longer coughing. On 8/9/22, review of the Staffing Grid revealed there was not a RN assigned to the 11-7 shift on 8/5/22 and there was not a RN assigned on the 3-11 shift and the 11-7 shift on 8/6/22. An observation on 08/08/2022 at 12:30 PM, of Resident #26 revealed his [CONDITION(S)] with no visible secretions, the [CONDITION(S)] gauze was clean and secured at the base of the [CONDITION(S)] inner cannula. The observation revealed Resident #26 was receiving humidified air via [CONDITION(S)] collar, from a humidified air compressor. There was a covered suction machine and nebulizer set-up in the room. No visible signs of respiratory distress were noted. There were no audible breath sounds that would possibly indicate complications of breathing, and he was easily aroused by low tones. Record review of the Record of Admission revealed Resident #26 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #26's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/18/2022, revealed Section C was not completed, due to question B0100, Comatose, of Section B of the MDS being answered, yes, indicating, persistent vegetative state/no discernible consciousness. On 08/09/2022 at 11:15 AM, a record review and an interview with the Administrator confirmed the Staffing Grid reflected there was not an RN assignment on the 11-7 shift on 08/05/2022 and there was no RN assignment on the 11-7 shift and the 3-11 shift on 08/06/2022. The Administrator revealed respiratory therapists are not employed in the nursing facility. The Administrator revealed the Nurse Practitioner (NP) was on call, as back-up RN coverage, for evenings, nights, and weekends, that she lived 5 minutes away from the nursing facility, and she could be called to come to the facility, in case of emergent [CONDITION(S)] care needs for Resident #26. The Administrator also revealed that she and the Director of Nursing (DON) were responsible for nurse scheduling. The Administrator confirmed she was aware of the need to have 24-hour a day RN coverage to ensure Resident #26 had qualified staff available, to reform deep suctioning or emergent [CONDITION(S)] care if the need should arise. An interview with the DON on 08/09/2022 at 11:30 AM, revealed she and the Administrator are responsible for nurse scheduling and that she normally had enough RNs to work every shift. She confirmed there was no RN coverage for the 11-7 shift on 08/05/2022 and on 08/06/2022. She also confirmed there was no RN coverage on the 3-11 shift on 08/06/2022. The DON also revealed the shifts were not covered on 08/05/2022 and 08/06/2022 because the assigned RN for the three (3) shifts called in on 08/05/2022 and 08/06/2022. She was unable to get the part-time RN to come to work, and could not find any other RN on staff to cover the shifts. The DON revealed she was responsible to come in and work an RN shift if she was not successful in finding other RN coverage. She did not come in to work the 3 shifts because it was an oversight on her part. The DON revealed back-up RN coverage assistance, for Resident #26, was available from the Nurse Practitioner, who was on call and could have been called from home if Resident #26 needed RN assistance for [CONDITION(S)] care on 08/05/2022 and 08/06/2022. She also stated the Assistant Director of Nursing (ADON) was used as back-up RN coverage when there was no staff RN to cover a shift. The DON revealed she had been having some scheduling conflicts, but not having 24-hour a day RN coverage was not a frequent occurrence. The DON confirmed she was aware that a resident with a [CONDITION(S)] required either an RN or an RT for deep suctioning. An interview with the ADON on 08/09/2022 at 12:45 PM, revealed she was not aware there was not 24-hour RN coverage on the nurse schedule for the 11-7 shift on 08/05/2022 and the 3-11 and the 11-7 shifts on 08/06/2022. She stated she was not available to cover the 3 shifts. The ADON confirmed she was one of the back-up RNs, if there was no staff RN available to work a scheduled evening, night, or weekend shift, but was always informed by the DON when she needed to work to ensure an RN was in the building 24-hours a day. In an interview with the DON on 08/09/2022 at 3:15 PM, she stated, I am working with the RNs to try to provide 24-hour a day coverage. Scheduling has been hard. I can't get the day shift RNs to agree to work night shift and I have already worked a lot of extra shifts. Resident #26 has not had any respiratory problems in years and had not required deep suctioning in a very long time. He is stable and if he had any problems at night, the Licensed Practical Nurses, (LPNs) could call 911 and call me for help. On 08/10/2022 at 03:00 PM, an interview and a record review of the Payroll Detail sheets, with the Administrator, which documented all clock hour for RNs from 08/01/2021 through 08/07/2022, confirmed 24-hour RN coverage was not available in the nursing facility for 52 shifts. The Administrator stated she was not aware there had not been 24-hour a day RN coverage for this time period. An interview with the NP on 08/11/2022 at 09:30 AM, confirmed she was on call, for back-up RN coverage, when there was not an RN covering a shift on the weekends. She revealed she lived 10 minutes away from the nursing facility, and would come and clock in at the facility if she was called to work a shift. NP noted she had never been contacted by the DON or ADON to come and cover a shift other than for 08/05/2022 and 08/06/2022. She stated she was out of town on those days and was not able to come to the facility. The NP revealed she was only aware of the nursing facility's increased staffing issues with 24-hour a day RN coverage for the past two weeks. She agreed to be one of the back-up coverage RNs, for Resident #26, a long while ago, but could not remember exactly when she made the agreement with the Administrator and DON. In an interview with the NP on 08/12/22 at 09:30 AM, she stated, The resident is responding well to the antibiotics and other medications ordered for his Upper Respiratory Infection. Record review of the Physician Orders for Resident #26 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] (PRN), for increased secretions, with an order dated of 4/28/2022, and an order to suction [CONDITION(S)] PRN , dated 2/25/2020. Removal Plan: The facility submitted an acceptable Removal Plan on 08/11/2022 at 10:00 AM, in which the facility alleged all corrective actions were completed 08/10/2022 and the IJ was removed on 08/11/2022. The SA validated the Removal Plan on 08/12/2022 and determined the IJ was removed on 08/12/2022, prior to exit. Review of the facility's Removal Plan revealed the facility took the following corrective actions to remove the IJ prior to exit: The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), on 08/10/22, when the facility failed to ensure qualified staff were present 24 hours per day to perform deep suctioning of a [CONDITION(S)] and other emergency procedures if needed, for Resident #26. The facility Executive Director, the Administrator, the Director of Nursing, and the Assistant Director of Nursing were notified 8/10/2022 at 05:00 PM of Immediate Jeopardy (IJ)and Substandard Quality of Care (SQC) due to the facility failure to have a Registered Nurse or Respiratory Therapist available 24 hours per day, 7 days per week to provide deep suctioning in the event emergency care was needed. Resident #26 was admitted to the facility on [DATE] with a [CONDITION(S)]. This placed Resident #26 at risk for serious injury, harm, impairment, or death. He was identified as the only resident with a [CONDITION(S)]. During the period of August 2021-August 2022 the staffing schedule and timecards revealed 52 days without 24 hour Registered Nurse or Respiratory Therapist coverage for the 3 PM -11 PM and 11 PM-7 PM shifts during the time frame of August 1, 2021 through August 7, 2022. Facility Actions: Upon identification of a lack of Registered Nurse coverage on 08/10/2022 by the State Agency (SA), the Director of Nursing immediately verified Registered Nurse coverage for 08/10/2022 and going forward for each shift for [CONDITION(S)] needs for Resident #26. 1. The Administrator discussed deficient findings with the Director of Nursing on 8/9/22 at 10:00 AM and verified lapse in coverage on specific shifts. The Director of Nursing immediately verified Registered Nurse coverage for 8/10/22 and going forward for each shift for deep suctioning and emergent [CONDITION(S)] care, if needed for Resident #26. 2. The Medical Director, who is also the Attending Physician, was notified on 8/10/22 at 5:48 PM, of the Immediate Jeopardy, and the need for 24-hour coverage by a Registered Nurse or Respiratory Therapist by the Administrator. 3. Resident #26 was fully assessed by the Nurse Practitioner on 8/10/22 and documentation signed off at 7:42 PM with no acute findings or evidence of respiratory distress. 4. The comprehensive care plan and Physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. An emergency Quality Assurance (QA) Committee meeting was held on 8/10/22 at 6:00 PM, to review and revise, if needed, the facility policy for [CONDITION(S)] suctioning which states that all Licensed Nursing Personnel or per State Nurse Practice Act/Respiratory Therapist is to be followed regarding [CONDITION(S)] suctioning. Policy has been reviewed and approved as current policy states that deep suctioning must be done by Registered Nurse. No changes to current policy were made. In addition, discussion was held regarding the need for 24-hour Registered Nurse or Respiratory Therapist coverage 7 days per week. Administration reemphasized the need for admission personnel to coordinate with the Administrator and/or Director of Nursing prior to the admission of a new resident who requires care exclusively by a Registered Nurse. The Director of Nursing will be responsible for ensuring 24-hour Registered Nurse or Respiratory Therapist coverage 7 days per week. Attendees: Owner, Administrator, Medical Director (via phone call), Director of Nursing, Nurse Practitioner, Assistant Director of Nursing, Education Coordinator (via phone call), Business office manager, Director of Social Services, Rehabilitation Social Worker, Receptionist, Rehabilitation Coordinator, 3 QA nurses, Clinical Nurse, Rehabilitation Director, Admission Coordinator, Minimum Data Set Coordinator, Minimum Data Set Nurse, Wound Nurse, Dietician, Dietary Manager. 6. In-service education was initiated on 8/10/22 at 6:45 PM, by the Administrator and Nurse Practitioner, with all licensed Nursing Staff, regarding the need for a Registered Nurse or Respiratory Therapist coverage 24-hours per day 7 days per week as long as there is a [CONDITION(S)] resident in the facility. The Administrator and Director of Nursing emphasized the importance of working the full shift scheduled and not leaving early as this may cause a lapse in 24-hour coverage. The Director of Nursing is to be immediately notified of any schedule change to ensure coverage. No licensed nurse will be allowed to work until in-service education is completed to include new hires also. In-service will continue until all nursing staff has been educated on Suctioning policy and scope of practice for Licensed Practical Nurse and Registered Nurse. The facility policy for [CONDITION(S)] suctioning was reviewed as part of the in-service and education to ensure licensed staff understand the Mississippi Nurse Practice Act which requires deep suctioning to be performed only by a Registered Nurse or Respiratory Therapist. One-on-one in-service was held on 8/10/22 at 7:30 PM by the Administrator with the Director of Nursing and Assistant Director of Nursing who are responsible for scheduling all nursing personnel. The requirement for 24-hour Registered Nurse coverage for [CONDITION(S)] deep suctioning was thoroughly discussed and emphasized the importance of notifying the Administrator if there is a lapse in coverage. Validation: The SA validated the facility's Removal Plan on 08/12/2022: Facility Actions: 1. The SA validated by record review and interview, the Registered Nurse coverage on 08/09/2022, which the Director of Nursing implemented, for the Registered Nurse coverage for 08/09/2022 and going forward for each shift for [CONDITION(S)] needs for Resident #26. 2. The SA validated by record review and interview, the Medical Director was notified on 8/10/2022 at 06:00 PM of the need for 24-hour coverage by Registered Nurse or Respiratory Therapist by the Administrator. The SA validated by record review and interview, the Medical Director and Attending Physician for Resident #26 was notified of the Immediate Jeopardy and Substandard Quality of Care at 06:00 PM on 08/10/2022 by the Administrator. 3. The SA validated by record review, the comprehensive care plan for Resident #26 was reviewed and reflected the Registered Nurse will provide deep suctioning to the [CONDITION(S)] if needed per MD orders by the Director of Nursing on 08/09/2022 at 3:15 PM. 4. The SA validated by interview and record review, Resident #26 was fully assessed by the Nurse Practitioner on 08/10/2022 and documentation signed off at 7:42 PM with no acute findings or evidence of respiratory distress. 5. The SA validated by record review and interview; an emergency Quality Assurance Committee meeting was held 08/10/2022 at 06:00 PM to review the facility policy for [CONDITION(S)] suctioning which stated if suctioning catheter needs to be inserted beyond the end of the tracheotomy tube (deep suctioning) this will be performed by an RN. In addition, discussion was held regarding the need for 24 hour Registered Nurse coverage 7 days per week. The Director of Nursing will be responsible for ensuring 24 hours Registered Nurse or Respiratory Therapist coverage 7 days per week. Attendees: Owner, Administrator, Medical Director (via phone call), Director of Nursing, Nurse Practitioner, Assistant Director of Nursing, Education Coordinator (via phone call), Business office manager, Director of Social Services, Rehabilitation Social Worker, Receptionist, Rehabilitation Coordinator, 3 QA nurses, Clinical Nurse, Rehabilitation Director, Admission Coordinator, Minimum Data Set Coordinator, Minimum Data Set Nurse, Wound Nurse, Dietician, Dietary Manager. 6. The SA validated by record review and interview, in-service education was initiated on 08/10/2022 by the Nurse Practitioner with all licensed staff regarding the need for a Registered Nurse or Respiratory Therapy coverage 24 hours per day 7 days per week as long as there is a [CONDITION(S)] resident in the facility. The Director of Nursing is to be immediately notified of any schedule change to ensure coverage. No licensed nurse will be allowed to work until in-service education is completed to include new hires. The facility policy for [CONDITION(S)] suctioning was reviewed, as part of the in-service, to ensure licensed staff understood the Mississippi Nurse Practice Act which restricts deep right main stem suctioning to be performed only by a Registered Nurse or Respiratory Therapist. One-on-one in-service was held on 8/10/22 at 7:30 PM by the Administrator with the Director of Nursing and Assistant Director of Nursing who are responsible for scheduling all nursing personnel. The requirement for 24-hour Registered Nurse coverage for [CONDITION(S)] deep suctioning was thoroughly discussed and emphasized the importance of notifying the Administrator if there is a lapse in coverage. The SA validated all corrective actions were taken by the facility and the actions were completed as of 08/10/2022 and the IJ was removed on 08/11/2022, prior to exit on 08/12/22.

Cross Reference F695 Based on observation, staff interview, record review, Mississippi Board of Nursing Laws and Rules and facility policy review, the facility failed to provide qualified staff, a Registered Nurse (RN) and/or Respiratory Therapist (RT), 24 hours each day for 52 shifts from 08/26/2021 through 08/06/2022 to deep suction the [CONDITION(S)] ([CONDITION(S)]), if needed and/or provide other emergency care to render respiratory care services to a resident with a [CONDITION(S)], for one (1) of 1 resident reviewed with a [CONDITION(S)], Resident #26. Findings include: Record review of the facility policy titled, Suctioning Policy, revised May 28, 2018, revealed, It is the policy of this facility to ensure that standards of best practice are consistent when upper airway suctioning is performed to remove secretions from the oropharynx, nasopharynx, or trachea . Procedure . 10. Tracheal suctioning . d. If suctioning catheter needs to be inserted beyond the end of the tracheotomy tube (deep suctioning) this will be performed by an RN. Review of the Mississippi (MS) State Board of Nursing Laws and Rules Administrative Code Part 2830 Practice of Nursing Title 30: Professions and Occupations Chapter 2, Functions of the Licensed Practical Nurse, (LPN) revealed: Rule 2.1 LPN Supervision, The LPN gives nursing care which does not require the specialized skill, judgement, and knowledge required of an RN, Advanced Practice Registered Nurse (APRN), Licensed Physician, or Licensed Dentist. Review of the MS State Board of Nursing (BON) website revealed frequently asked questions (FAQ's). The BON's statement regarding the LPN's scope of practice with [CONDITION(S)] care revealed: It is within the scope of practice of the LPN to perform [CONDITION(S)] care and suction secretions from the [CONDITION(S)] tube. However, it is not within the scope of practice for the LPN to perform deep right main stem suctioning. If deep suctioning is required for a patient, a Registered Nurse (RN) must perform the procedure. An observation on 08/08/2022 at 12:30 PM, of Resident #26 revealed the resident had a [CONDITION(S)] with no visible secretions, the [CONDITION(S)] gauze was clean and secured at the base of the [CONDITION(S)] inner cannula. Resident #26 was receiving humidified air via [CONDITION(S)] collar, from a humidified air compressor, there was a covered suction machine and nebulizer set-up in the room, there were no visible signs of respiratory distress, there were no audible breath sounds that would possibly indicate complications of breathing, and he was easily aroused by low tones. Record review of the Record of Admission revealed Resident #26 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #26's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/18/2022, revealed Section C was not completed, due to question B0100, Comatose, of Section B of the MDS being answered, yes, indicating, persistent vegetative state/no discernible consciousness. Record review of the Physician Orders for Resident #26 revealed an order to suction [CONDITION(S)] PRN (as needed), dated 2/25/2020. On 8/9/22, record review of the Staffing Grid revealed there was not an RN assigned to the 11-7 shift on 08/05/2022 and there was not an RN assigned on the 3-11 shift and the 11-7 shift on 08/06/2022. On 08/09/2022 at 11:15 AM, a review of the Staffing Grid and interview with the Administrator confirmed the Staffing Grid reflected there was not an RN assignment on the 11-7 shift on 08/05/2022 and there was no RN assignment on the 11-7 shift and the 3-11 shift on 08/06/2022. The Administrator stated that she and the Director of Nursing (DON) were responsible for nurse scheduling and there were no respiratory therapists employed by the nursing facility. The Administrator revealed the Nurse Practitioner (NP) was on call, as back-up RN coverage, for evenings, nights, and weekends, that she lived 5 minutes away from the nursing facility, and she could be called to come to the facility, in case of emergent [CONDITION(S)] care needs for Resident #26. The Administrator confirmed she was aware of the need to have 24-hour a day RN coverage, to ensure Resident #26 had qualified staff available, to perform deep suctioning or emergent [CONDITION(S)] care if the need should arise. On 08/09/2022 at 3:15 PM, in an interview with the DON she stated, I am working with the RNs to try to provide 24-hour a day coverage. Scheduling has been hard. I can't get the day shift RNs to agree to work night shift and I have already worked a lot of extra shifts. An interview on 08/11/22 at 09:30 AM with the NP revealed she was only aware of the nursing facility's increased staffing issues with 24-hour a day RN coverage for the past two weeks. NP revealed she agreed to be one of the back-up coverage RNs, for Resident #26, a long while ago, but could not remember exactly when she made the agreement with the Administrator and DON. A record review of the facility ' s Payroll Detail sheets from 08/01/2021 through 08/07/2022 confirmed RN coverage was not available in the nursing facility for 52 shifts from 08/01/2021 through 08/06/2022. An interview on 08/10/22 at 3:00 PM with the Administrator revealed she was not aware there had not been RN coverage for that many shifts in the past year.

S/S D Based on observation, staff interview and facility policy review and record review, the facility failed to prevent the likelihood of the spread of the coronavirus- COVID-19, as evidenced by lack of social distancing during staff meal time for one (1) of one (1) dining room tour observed. Review of the facility policy,with an effective date of 3/23/20, titled, COVID-19 Prevention Protocol revealed the facility will follow guidelines set forth by the CDC and the Mississippi State Department of Health for prevention of COVID-19 and the spread of COVID-19. Review of the Infection Prevention and Control Program, undated, revealed this program will be utilized to prevent, identify, report, investigate, and control infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services. Findings include: During an observation of the dining room and patio, in the presence of the Administrator (ADM), on 10/6/20 at 12:30 PM, revealed the Maintenance Director and Maintenance staff #3 sitting at a table with masks off eating lunch and talking. They were not socially distanced. The Activities Staff #1 and the Activity Staff #2 were sitting at a dining room table together, not socially distanced. Outside on the patio, Licensed Practical Nurse (LPN) #1 and another staff person were sitting at a table talking and eating lunch. Housekeeping staff #2 and another staff were sitting at a table talking and eating lunch. They were not socially distanced while unmasked for mealtime. During an interview, on 10/6/20 at 12:32 PM with Licensed Practical Nurse (LPN)#1, she stated that they should not be as close to each other as they are because it could spread [MEDICAL CONDITION]. An interview, on 10/6/20 at 12:35 PM, with the ADM, revealed they would correct this. She stated that employees should sit one at each table. An interview, on 10/6/20 at 1:06 PM, with Maintenance staff #1, revealed he had attended in-service education on wearing masks, social distancing, hand sanitizing, and gloves. He stated social distancing means being six (6) feet apart. The Maintenance Staff #1 stated that, as far as he could remember, they were instructed that they could sit two to a table. He stated that the CDC requires social distancing to prevent the spread of [MEDICAL CONDITION]. An interview, on 10/6/20 at 1:15 PM with Activity Staff #1 stated that she had been in-serviced on social distancing and masks. She stated that they had been instructed that could sit two (2) to a table and no more than 10 in the room. She stated that she felt like she was socially distanced but realized they were not six (6) feet apart. She stated that at one time they were to be three (3) feet apart and they just took it for granted and continued with two people at a table. An interview on 10/6/20 at 1:25 PM with Housekeeping Staff #2, revealed that social distancing means being six (6) feet apart. She stated that they had been told they could sit two (2) to a table to eat, talk, and visit without masks. Housekeeping staff #2 stated that in her mind she thought they may have been six (6) feet apart but, didn't really know. An observation on 10/6/20, at 1:30 PM with the Maintenance Staff #1 revealed, during actual measurement, the diameter of the dining room tables was 47.5 inches and the patio tables were 48 inches. He confirmed the staff would not be socially distanced sitting two (2) to a table. An interview, with the ADM on 10/6/20 at 2:20 PM, confirmed the staff had initially been instructed on three (3) feet for social distancing but it had been increased to six (6) feet. She stated that they didn't change policy/procedure. She stated that this could cause an increased risk for exposure, especially if someone is asymptomatic. Record review revealed a mandatory staff in-service was presented on August 6 and August 13,2020 which covered helping to prevent the spread of respiratory diseases like COVID -19. The in-service information included to stay six (6) feet (about 2 arms length) from other people. In-service sign in sheets revealed LPN #1, Housekeeping and Maintenance staff #1, #2, #3, and #4, and Activities staff #1 and #2 attended this in-service.

Based on observation, staff interview, and facility policy review, the facility failed to prevent the possible spread of infection during Resident #4's tracheostomy care as evidenced by Licensed Practical Nurse (LPN) #1 contaminated her sterile gloves by touching the bottles of peroxide and sterile water, and then picked up the suction catheter with the same contaminated glove to suction the tracheostomy, this was for one of seven (1 of 7) care observations observed. Findings include: Review of the facility's policy titled, Infection Control Policy, undated, revealed the policy is designed to provide a safe, sanitary, comfortable environment, and to help prevent the development and transmission of disease and infection. Review of the facility's policy titled, Tracheostomy Care Policy, revised [DATE], revealed under Procedure: 6. Open sterile container using sterile technique. 7. Pour peroxide and sterile water or ordered solution into sterile basin. 8. Don sterile gloves. Observation on [DATE] at 8:50 AM, revealed Certified License Practical Nurse (LPN) #1 opened sterile suction and trach care kits, donned sterile gloves, and picked up an unsterile bottle of peroxide and water which contaminated her gloves, and poured the solutions into sterile basins. LPN #1 also touched the suction catheter with the contaminated, unsterile gloves during the suctioning procedure. When the tracheostomy care procedure was completed, LPN #1 tidied the resident by removing a towel drape, lowering the bed, and adjusted the tracheostomy mask with the same gloves worn during the procedure. Interview with LPN #1 on [DATE] at 1:30 PM, revealed she stated, I was so nervous, I know I got my sterile hand dirty when I suctioned. She also confirmed she put her sterile gloves on before she poured the peroxide and water into the basins, and did not remove her gloves before lowering the bed, and adjusting the tracheostomy mask. LPN #1 revealed this could cause a respiratory infection due to the resident being compromised. Interview on [DATE] at 2:00 PM, with the Director of Education, revealed Infection Control In-services are done at least four times a year, and handwashing and changing gloves are included. Interview on [DATE] at 10:00 AM, with the Director of Nursing (DON), revealed she thought LPN #1 messed up because she was so nervous. The DON stated LPN #1 knew that you can only touch sterile things with sterile gloves, and when she picked up the peroxide and water she contaminated her gloves. Review of in-service education held on [DATE] and [DATE], titled Back to Basics, revealed hand hygiene and standard precautions for gloves and sterile techniques were covered. Review of attendance records revealed LPN #1 attended the in-service. Review of the facility's Admission Record revealed the facility admitted Resident #4 on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed Resident #4's cognitive status was severely impaired. Further reveiw of the MDS revealed Resident #4's Special Treatments included suctioning, and tracheostomy care.

Based on observation, record review and interview the facility failed to provide preventative measures to prevent the development, prevent the worsening of and promote healing of a facility acquired pressure ulcers for one (1) of five (5) sampled residents with pressure ulcers (Resident #7). Resident #7 went from having no pressure sores on 4/19/12, to a blister on 4/22/12, and to a Stage III pressure sore on 7/24/12. Findings include: Resident #7 Record review revealed that Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status score of 3, which indicated that Resident #7's cognitive status was severely impaired. This MDS coded that Resident #7 required extensive assistance with activities of daily living, and was at risk for pressure ulcer with no pressure ulcers identified. Review of the most Minimum Data Set (MDS), dated [DATE], revealed Resident #7 had a Stage III Pressure Ulcer that measured 3.5 cm (centimeters) x (by) 3.4 cm x 0 cm and required extensive assistance with all activities of daily living. Review of April 2012, May 2012, June 2012, July 2012, August 2012 and October 2012 physician's orders [REDACTED]. On 4/22/12 Resident #7 was identified as having a newly developed area (blister) to the right lateral heel that was not open. physician's orders [REDACTED]. Bunny Boots in Bed. 2. Clean (R) right heel with NS (normal Saline), apply Vaseline, protective dsg (dressing) QOD (every other day) on even days..." On 5/30/12 the physician's orders [REDACTED]. D/C (discontinue) current tx (treatment) to (R) heel. 2. Clean (R) heel with NS, apply Xyloform, wet dressing QOD ..." On 6/18/12 physician's orders [REDACTED]. D/C (discontinue) Tx (treatment) to (R) heel. 2. Clean (R) {right} heel wound with NS, apply [MEDICATION NAME] dsg (dressing) daily. 3. May use mechanical debridement as needed by PT (physical therapy)." On 6/26/12 physician's orders [REDACTED]." On 7/16/12 physician's orders [REDACTED]." On 7/24/12 physician's orders [REDACTED]. D/C (discontinue) Tx (treatment) for mechanical debridement per PT (Physical Therapy). 2. D/C Tx for [MEDICATION NAME] dsg (dresing) to (R) (right) heel ..." On 7/24/12 the Pressure ulcer had progressed to a Stage III that measured 3.4 x 3.5 x 0, with new physician orders [REDACTED]...1. Turn (L) {left} and back with no (R) {right} prop while in bed Q shift. 2. PT (Physical Therapy) to tx (treat) wound care to (R) lateral heel...Air mattress to bed for pressure relief. PT to tx 5 times per week x 8 weeks for sharp/dull debridement, santyl to wound bed, dressing change, Megisorb AG, wraps to secure bandage..." On 7/25/12 treatment orders changed to "1. Clean (R) heel wound with NS, apply santyl ointment, meglisorb ag and secure with wrap on Sat (Saturday) and Sun (Sunday), PT (Physical Therapy) to treat Mon (Monday) - Fri (Friday)... 2. Clean (R) heel wound with NS (normal saline), apply Xeroform and dressing and wrap dly (daily.)" On 8/15/12 the treatment orders were changed to "DC (discontinue) santyl to R (right) heel wound." Physician orders [REDACTED]. Clean denuded blister to RLE (right lower extremity) with NS, apply Xeroform and Tefla dressing daily" On 10/3/12 the right heel was identified as healed. Physician orders [REDACTED]." Review of the Physical Therapy notes, dated 7/24/12, noted: "Physical Therapy Initial Plan of Care" for Resident #7 documented, "...Start of Care: 7/24/12 discharged : 10/02/12... Pressure Ulcer, heel; Aftercare, FX (fracture) hip; Joint disorder unspecified lower leg...Doctor's order: PT to treat 5 times per week x 8 weeks for sharp/dull debridement, santyl to wound bed, dressing change, [MEDICATION NAME] AG to wound bed, wraps to secure dressing....wound size: 3.5 cm by 3.4 cm, wound bed color: pink and yellow and white..." A "Physical Therapy Progress Report" documented, "...Period From 9/19/12 to 9/25/12 ... Wound size: wound size 1.6 cm x 2.0 cm with area of scabbing no longer present. Goal: Wound size decreased from 3.5 cm by 3.4 cm to 0.0..." A "Physical Therapy Discharge Summary" documented, "...Document Date: 10/02/12...Reason for referrals: pt with high flexor tone with external rotation to R (right) LE (lower extremuity). He now has a pressure wound to lateral heel. Nursing referred due to difficulty healing... Prior level: wound size 2.0 cm (centimeters) x 1.5 cm. Current Level: 1/0 cm x 1.4 cm..." Interviews were conducted and revealed findings as follows: On 10/16/12 at 10:30 a.m. Resident #7's right heel was observed for treatment. There were no open areas to the heel and the skin was intact. The treatment nurse revealed that Resident #7 was admitted to rehab initially for a broken hip. Interview on 10/17/12 at 9:23 a.m. with the Physical Therapist regarding the pressure ulcer to Resident #7's right heel revealed that Resident #7 had been admitted to the therapy hall and was not mobile due to a right [MEDICAL CONDITION] on his hemiparegic side. Resident #7 was weight bearing as tolerated but was unable to bear weight. Resident #7 had no pressure ulcers at the time of admission on 4/19/12. The Physical Therapist revealed that he had been referred back to therapy for wound treatment on 7/24/12 and they determine he had been crossing his right foot over the left foot (indicating it was causing pressure to the right lateral heel). Therapy started putting measure into place to promote healing. The Physical Therapist stated to her knowledge the resident did not have any pressure ulcer prevention measures in place except the use of bunny boots while in bed from 4/19/12 until 7/24/12 when physician's orders [REDACTED]. Interview on 10/18/12 at 9:10 a.m. with the Nurse Practitioner regarding Resident #7's pressure area revealed his heel was not opened initially but he had protective boots in place but they had a hard time keeping them on him.