Every finding on record at Treviso Transitional Care

Based on interview and record review, the facility failed to notify the Office of the State Long-Term Care Ombudsman of the transfer or discharge and the reasons for the transfer or discharge in writing at least 30 days before the resident is transferred or discharged or as soon as practicable before transfer or discharge 1 of 2 resident (Residents #1) reviewed for transfer and discharge. The facility failed to provide notice to the Office of the State Long-Term Care Ombudsman of the transfer of Resident #1 on 05/11/2026 with a written discharge/transfer notice. This failure could place residents at risk of improper discharge planning and diminished quality of life.Findings included: Record review of Resident #1's face sheet dated 06/11/2026 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of chronic obstructive pulmonary disease (difficulty breathing), congestive heart failure (the heart does not pump efficiently), chronic kidney disease, lack of coordination. Record review of Resident #1's Discharge MDS assessment dated [DATE] indicated Resident #1 was always understood by others, was able to understand others, had a BIMS of 12 which indicated Resident #1 was moderately cognitively impaired. The MDS also indicated Resident #1 required extensive assistance for dressing and personal hygiene, bed mobility and physical help to transfer with bathing. Record review of Resident #1's electronic medical record indicated a Discharge summary dated [DATE] had been completed. Record review of Resident #1's order summary report dated as of 06/11/2026 indicated she had an order to discharge from the facility on 05/11/2026. Record review of Resident #1's nursing progress note dated 05/11/2026 indicated she was transferred to another long-term facility with Resident #1's medication given to family. During an interview on 06/10/2026 at 11:38 AM, the Ombudsman said the facility had not contacted her that Resident #1 had transferred to another facility. The Ombudsman said she still had not received any type of written or verbal communication from the facility regarding Resident #1's discharge. The Ombudsman said she learned Resident #1 had been discharged from the facility after she had seen Resident #1 at another facility while visiting. The Ombudsman said she was not aware of why Resident #1 was discharged but assumed it was regarding her behaviors. The Ombudsman said it was important for her to be notified in a timely manner of any transfer/discharges in case she needed to be an advocate for the resident, assist the resident with any information and help them navigate through the discharge/transfer process. During an interview on 06/10/2026 at 12:01 PM, Resident 1's Representative stated they had received a call from the DON at the facility approximately a month ago to schedule a meeting for Resident #1. Resident #1's Representative said the meeting was a very intense discussion regarding Resident #1's rude behaviors to staff and her expectations from staff. The Resident's Representative said after the heated and intense discussion Resident #1 finally said she needed a fresh start. The Resident's Representative stated they had all agreed upon the decision to look at other facilities for Resident #1 to transfer into. Resident #1's Representative stated they were able to relocate Resident #1 prior to the 30-day notice period that the facility had given them. Resident #1's Representative was unable to provide a copy or the exact date of the facility 30 day notice she had received from the facility. An attempted telephone interview on 06/10/2026 at 12:20 PM with Resident #1. Left a message and requested a call back. During an interview on 06/10/2026 at 01:06 PM, the DON said on 04/04/2026 a meeting was held with Resident #1 and her representatives to check-in and see how things were going with Resident #1. The DON said during the meeting Resident #1 stated she needed a fresh start. The DON said since Resident #1 initiated the transfer/discharge plan a 30-day discharge notice was not required and therefore one was not issued. The DON said she had attempted to contact the Ombudsman on 04/06/2026 via phone to notify her of Resident #1's plan to discharge but was unsuccessful. The DON said she did not leave the Ombudsman a message and did not receive a call back. The DON said the Ombudsman was in and out of the facility often and she might have mentioned Resident #1's transfer/discharge in passing. The DON said it was important to keep the Ombudsman informed regarding discharges/transfers to allow the resident and resident representative to be fully informed of their rights and to assist and or support with any resident needs. During an interview on 06/10/2026 at 01:30 PM, the Social Worker said she had attended the meeting with Resident #1 and Resident #1's representatives on 4/4/2026. The Social Worker said that during the meeting, Resident #1 had verbalized she wanted to make a fresh start at another facility. The Social Worker said a discharge notice was not completed to her knowledge. The Social Worker said she was responsible for notifying the Ombudsman of discharges and transfers. The Social Worker said she would send a list of discharges/transfers to the Ombudsman office via fax at the end of each month when a 30-day notice was not required. The Social Worker stated she could not provide any proof of notifying the Ombudsman office from January of 2026 through 06/10/2026. The Social Worker stated that she had reached out at a conference to figure out how to notify the Ombudsman of discharges and transfers that did not require the 30-day notice but had never received any feedback and did not know the correct procedure to follow. The Social Worker said she was responsible for discharge planning and the assisting the Business Office Manager with the 30-day discharge notices. The Social Worker stated Resident #1 would not have required a discharge notice to the Ombudsman because Resident #1 was self-initiated to leave the facility. The Social Worker stated it was important to include the Ombudsman with resident discharges and transfers to ensure the residents' needs and rights were met. During an interview on 06/10/2026, at 02:45 PM, the Administrator said the Business Office Manager and himself were responsible for 30-day discharge notices. The Administrator said the Social Worker was responsible for notification to the Ombudsman for discharges and transfers. The Administrator said Resident #1 had initiated the transfer at her own will during a meeting therefore a 30-day written notice was not required to be given to the Ombudsman. The Administrator said he was not familiar with the proper procedure on notification to the Ombudsman but felt what the facility was currently doing was too lackadaisical and he had made a call to the Ombudsman's office to find out the requirement. The Administrator said he had the Social Worker send via fax to the Ombudsman office all the discharges/transfers for the last 6 months since there was no documentation showing any written notifications of transfers/discharges had been completed since January 2026. The Administrator said it was important for the Ombudsman to be notified timely and in writing of all transfers/discharges. Record review of facility's Transfer or Discharge Policy dated 03/2027 indicated, Our facility shall provide a resident and or the resident's representative with a 30-day written notice of an impending transfer or discharge or when insurance provides notice of non-coverage. 2. Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge: .4. A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman.

Based on observation, interview, and record review, the facility has failed to ensure that the resident environment remains as free of accident hazards as possible and provide supervision to prevent avoidable accidents for 1 of 5 residents reviewed for accidents. (Resident #1)The facility failed to notify nursing staff when CNA B and CNA C found Resident #1 on the floor after an unwitnessed fall.The facility failed to complete an assessment on Resident #1's unreported fall.This failure could place residents at risk for injury or delayed treatment.Findings included:Record review of Resident #1's face sheet dated 03/24/26 indicated Resident #1 was an [AGE] year old female and was admitted on [DATE] with diagnoses including Unsteadiness on Feet (caused by malfunctioning sensory signals from the eyes, ears, or body, leading to a wobbly or lightheaded sensation), Malaise (faintness), Lack of Coordination (poor muscle control that causes clumsy, jerky, or uncoordinated movements, often resulting from damage to the cerebellum in the brain). Record review of the MDS dated [DATE] indicated Resident #1 was understood and understood others. The MDS indicated a BIMS score of 13 indicating Resident #1 was cognitively intact. The MDS revealed that Resident #1 was not able to transfer from the toilet due to medical condition or safety concern. Resident #1 required partial or moderate assistance for transfers. Resident #1 was coded as frequently incontinent of bowel and bladder.Record review of a care plan revised on 04/17/26 indicated Resident #1 had an actual fall on 4/17/2026 related to transferring from toilet to wheelchair without assist and wheelchair not locked. Stated she missed the seat related to unsteady gait. Diagnosis of acute/subacute Lumbar 1 compression fracture (compressed spine) with mild anterior predominant height loss. Chronic appearing compression deformity of Lumbar 3, and multilevel degenerative changes. Care plan further indicated that Resident #1 required a one person assist for transfers and to use the toilet. Care plan indicated that Resident #1 was at moderate risk for falls due to debility and generalized weakness. Staff were to anticipate resident's needs. Resident #1's care plan indicated that Resident #1 had an activities of daily living self care performance deficit related to impaired balance and pain.Record review of hospital records for Resident #1 dated 4/17/2026. Shows that Resident #1 presented to the hospital with mild pain to the left lower quadrant. Acute/subacute compression fracture of L 1 with mild anterior predominant height loss. New since previous scan. Chronic appearing anterior compression deformity of L3.During an interview on 5/12/26 at 8:30 a.m. with Resident #1's Family Member she said that on 4/14/26 at around 6:00 p.m. Resident #1 had a fall from her wheelchair in the bathroom. She said that she did not actually witness the incident, but Resident #1 told her on 4/17/26 after she said she was starting to feel some pain. She said that Resident #1 told her that CNA C took her to the toilet and left her there for about 5 minutes. She said that Resident #1 told her that when she finished using the restroom she transferred herself from the toilet to her wheelchair whose wheels were not locked. She said that Resident #1 told her that she fell on the floor and a few minutes later CNA C came into the room to help her get up into her chair. She said that Resident #1 told her that CNA C and CNA B helped Resident #1 into her chair and then into bed. She said that Resident #1 told her that she did not report it because she was afraid that everyone would be mad at her for falling and she didn't want anyone to get into trouble.During an interview on 5/12/26 at 9:41 a.m. with the Director of Nurses she said that she was made aware of the incident with Resident #1 when the Family Member of Resident #1 told her what happened. She said that she questioned CNA B and CNA C. She said that CNA C admitted that she was the CNA that first found Resident #1 on the floor and she did not report it to anyone what had occurred. She said that CNA B also admitted that she helped CNA C to move Resident #1 to her wheelchair and bed. She said that the nurse on duty had no idea that the incident occurred. She said that she spoke to Resident #1 and she told her that she transferred herself to the bathroom and neither CNA B or CNA C helped her to transfer to the toilet. She said that Resident #1 said she did not want her to know she tried to transfer herself and was afraid she would get into trouble and that was why she did not tell anyone. She said that CNA B and CNA C should have reported to a nurse that Resident #1 had a suspected fall so Resident #1 could be assessed. She said that Resident #1 was placed at risk for further injury by not allowing a nurse to properly assess her after she fell. She said that it was facility policy that a resident was assessed after a fall and by not reporting the fall it prevented a nurse from completing an assessment. Resident #1 has had a history of falling per her family at home prior to admission. She said that per her family Resident #1 also has had back injuries.During an interview on 5/12/26 at 10:16 a.m. LVN A said that she was working on 4/14/26 the day Resident #1 fell. She said that she was not made aware of the fall that occurred because CNA B and CNA C did not report to her. She said that CNAs should report falls as she would need to assess the resident for injury. She said that Resident #1 has tried to transfer herself without asking for help. She said that she has tried going to the bathroom herself without asking for help.During an interview on 5/12/26 at 10:37 a.m. with Family Member of Resident #1 he said Resident #1 told him on 4/17/26 that she fell while trying to get back into her wheelchair. He said that Resident #1 told him CNA C placed her onto the toilet and left for about 5 minutes. He said that the Director of Nurses said that she questioned CNA B and CNA C and they both said they never transferred Resident #1. He said that Resident #1 did not appear in any pain on 417/26 when she told him what happened. He said that getting accurate information from Resident #1 was difficult. He said that previously to admitting to the facility Resident #1 fractured her back at home from multiple different falls.During an interview on 5/12/26 at 10:55 a.m. CNA B said that she was working on 4/14/26 during the time that Resident #1 fell. She said that Resident #1 took herself to the bathroom without any assistance. She said that she had told Resident #1 many times to ask for help before going to the bathroom. She said that it was CNA C that found Resident #1 on the floor and CNA C called her for help. She said that when she entered the bathroom Resident #1 was sitting on the floor. She said that her and CNA C helped Resident #1 into her chair and then put her into her bed. She said that Resident #1 did not complain about pain and was not grimacing. She said that neither her or CNA C notified a nurse about what happened. She said that when a resident has an unwitnessed fall like this she was trained to notify a nurse. She said that she was so busy that day she forgot to notify the nurse what happened.During an interview on 5/12/26 at 11:00 a.m. CNA C said that she was working the day Resident #1 slid from her chair in the bathroom. She said that she was not assigned to Resident #1 but she walked by and saw her call light on so she entered and that was when she saw Resident #1 on the floor. She said that Resident #1 told her she slid onto the floor and she did not fall. She said she called for CNA B and they helped her into her chair and then back into her bed. She said that they did not report the incident because they did not know it qualified as a fall and she wasn't showing any pain. She said that she was trained on the facility fall policy, but she made a mistake in determining whether a fall happened or not. She said that Resident #1 has a history of transferring herself without asking for help. She said that Resident #1 was told many times that not to transfer by herself.During an interview on 5/12/26 at 12:50 p.m. with Resident #1 she said that she remembers the incident where she fell at the other facility she lived at. She said she cannot remember the exact day but recently she slipped out of her wheelchair and hit her butt on the floor. She said that CNA C helped her to get onto the toilet, left her on the toilet alone, and then when she finished using the restroom she got herself up and sat down into her wheelchair. She said she was sitting on the toilet for about 5 minutes. She said that she decided to get up without assistance because she was ready to go back to bed. She said that when she turned around to sit down she slipped out of her chair and slid down to her butt on the floor. She said that a few minutes later CNA C came back into the room and saw her on the floor and CNA B also came and they helped her back up and into bed. She said she did not report that she hurt her back because she was afraid her would get mad at her. She said it wasn't until her came that she told him about what happened.During an interview on 5/12/26 at 1:26 p.m. with the Administrator he said that it was the policy of the facility that if a resident had a fall or was suspected to have fallen the resident would be assessed by a nurse. He said that CNAs were required to report to a nurse if a resident had a fall or if the CNA suspected that a fall occurred. He said that a resident could be placed at further risk of injury if a CNA failed to report a fall that occurred.Record review of a facility policy titled, Falls - Clinical Protocol revised September 2012 revealed that, As part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling.Staff will ask the resident and the caregiver or family about a history of falling.The staff and physician should document in the medical record a history of one or more recent falls (for example, within 90 days).While many falls are isolated individual incidents, a significant proportion occur among a few residents/patients. Those individuals may have a treatable medical disorder or functional disturbance as the underlying cause.In addition, the nurse shall assess and document/report the following:Vital signs;Recent injury, especially fracture or head injury;Musculoskeletal function, observing for change in normal range of motion, weight bearingChange in cognition or level of consciousness;Neurological status;Pain;Frequency and number of falls since last physician visit;Precipitating factors, details on how fall occurred;All current medications, especially those associated with dizziness or lethargy; andAll active diagnose.The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment and clean bed linens for 4 of 6 residents (Resident #'s 12, 30, 34, and 39) reviewed for a homelike environment. The facility failed to ensure Resident #12's floor was free of debris, dust, shreds of papers, and five thick white hardened puddles of a substance on the floor beside and under the bed.The facility failed to ensure Resident # 30, Resident #34, and Resident #39 's bed linens were changed. These failures could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life.Findings included:1. Record review of a face sheet dated 08/27/2025 indicated, Resident #12 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included dysphagia following other (difficulty swallowing) cerebrovascular disease (affects the blood vessels of the brain and circulation) hypertension (high blood pressure), hyperlipidemia (high levels of fat particles in the blood), neuromuscular (the nerves and muscles that control bladder are impaired) dysfunction of the bladder, gastrostomy (surgical opening in the abdominal wall for food intake) and dementia (a group of thinking and social symptoms that interferes with daily functioning).Record review of the Quarterly MDS assessment dated [DATE] indicated, Resident #12 was usually understood by others and usually understood others. The MDS indicated Resident #12 had a BIMS of 00 and was severely cognitively impaired. The MDS indicated Resident #12 was dependent on staff for toileting, dressing, and bathing. Record review of the care plan revised on 6/19/2025 indicated Resident #12 required assistance with ADL self-care due to a deficit related to dementia with the following interventions: required assistance of two staff for toilet use, transfers, and bed mobility. During an observation on 08/24/2025 at 12:30 PM, Resident #12 was lying in his bed asleep. Resident #12's floor around and under the dresser, chair and bedside table was covered in a layer of dust and dirt, giving a grimy appearance. Resident #12's floor beside and underneath the bed had a total of five thick white hardened puddles of a substance. There was visible debris such as white paper scattered across the floors and the floor mat surface. During an observation on 08/25/2025 at 08:00 AM, Resident #12 was lying in his bed but unable to interview due to his cognitive status. Resident #12's floor around and under the dresser, chair and bedside table were covered in a layer of dust and dirt, giving a grimy appearance. Resident #12's floor beside and underneath the bed had five thick white hardened puddles of a substance. There was visible debris such as white paper scattered across the floors and the floor mat surface. During an interview on 08/25/2025 at 02:00 PM, Housekeeper W said she had already cleaned Resident #12's room and had noticed there was some dust behind and under the furniture earlier. Housekeeper W said she was not always assigned to Resident #12's room but she cleaned her room assignments once a day and started from the floors, dusting all the surfaces and wiping down the bathrooms. Housekeeper W stated she does a walk through later during the day before her shift ended just to pick up the floors and bathrooms. Housekeeper W stated she had attempted to clean the white substance off the floor, but it was real sticky, and she had not been successful. Housekeeper W said she had reported the white sticky stains to her supervisor today. Housekeeper W said it was important for the residents' rooms to be clean and fresh because it was their home. Housekeeper W said her supervisor was able to remove the sticky substance once it had been sprayed down.During an interview on 08/26/2025 at 09:15 AM, the Environmental Services Supervisor stated the housekeepers have a 5 step cleaning process that is followed daily which included to empty and remove the trash, wipe receptacle, replace liner, high dust wipe flat surfaces with cloth and disinfectant, spot clean walls, wipe with cloth and disinfectant, dust mop gather debris with mop and pickup with dust pan, damp mop, mop floor with disinfectant from the back corner to the door. The Environmental Services Supervisor said the importance of a clean room was to decrease the chances of spreading germs that caused infections and to create a homey space for the residents. The Environmental Services Supervisor stated she was able to remove the sticky, white, hardened substance easily from Resident #12's floor once she was notified of the situation. The Environmental Services Supervisor stated she expected the rooms to be cleaned properly daily. During an interview on 08/26/2025 at 11:30 AM., the DON said the residents' rooms should be repaired and cleanly maintained to decrease infection. The DON said residents' rooms were theirs, and they should be nice and homelike.During an interview on 08/26/2025 at 4:45 PM., the Administrator said he expected the residents' rooms to remain clean to prevent the spread of infection and create a home like environment. The Administrator said the residents' rooms were monitored daily during rounds. The Administrator said they have had some cleaning issues in the past and addressed them by making staff changes. 2. Record review of the face sheet dated 08/27/2025 indicated, Resident #30 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included dementia (a group of thinking and social symptoms that interferes with daily functioning), arthritis, unsteady gait, and the need for assistance with personal care.Record review of the quarterly MDS dated [DATE] indicated, Resident #30 was understood by others and understood others. The MDS indicated Resident #30 had a BIMS of 15 and was cognitively intact. The MDS indicated Resident #30 required supervision and touching assistance for showering, toileting and dressing. The MDS indicated Resident #30 required maximal assistance for all transfers.Record review of the care plan revised on 08/24/2025 indicated Resident #30 had an ADL self-care deficit due to balance problems with the following interventions: able to turn and reposition self in the bed, participate in care, sponge bath when resident cannot tolerate full bath or shower. During an observation and interview on 08/24/2025 at 10:26 AM, Resident #30 was sitting in her bed with a fitted sheet across the middle section of the bed. Resident #30 stated the linens on her bed had not been changed after her shower. Resident #30 stated she showered yesterday. Resident #30 stated she had an incontinent episode prior to showering. Resident #30 stated the aide had laid the change of bedding on the chair yesterday but had not changed the bedding. Resident #30 stated the aide said she was coming back but had never returned to change the bedding. Resident #30 stated after she showered, she had used the call light and requested the aide come and change the linens. Resident #30 stated the aide had come to the room and told her that she was busy, and she would be back later. Resident #30 stated she laid the fitted sheet horizontally across the bed to cover the incontinent episode after she had showered because she was tired of waiting for the aide to return. During an observation on 08/25/2025 at 8:15 AM, Resident #30 was in her bed with the fitted sheet across the middle section of the bed. Resident #30 stated no one had changed the soiled bedding[VT1] . Record review of the face sheet dated 08/27/2025 indicated, Resident #34 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included dementia (a group of thinking and social symptoms that interferes with daily functioning, cerebrovascular disease (affects the blood vessels of the brain and circulation) hypertension (high blood pressure).Record review of the Quarterly MDS assessment dated [DATE] indicated, Resident #34 was understood by others and understood others. The MDS indicated Resident #34 had a BIMS of 11 and was moderately cognitively impaired. The MDS indicated Resident #34 required touch and minimum assistance with toileting, dressing, and bathing. Record review of the care plan revised on 6/19/2025 indicated Resident #34 required ADL self-care due to deficit relate to dementia with the following interventions: requires minimum assistance of one staff for toilet use, bathing and personal hygiene. During an observation and interview on 08/24/2025 at 10:36 AM, Resident # 34 stated she had got a shower yesterday by herself. Resident #34 stated the aide did not have time to change the bed linens. Resident #34 stated she was embarrassed because the linens were dirty. Resident #34 pulled back the comforter and the bottom fitted sheet revealed several light, brown-tinged circular stains. During an observation and interview on 08/25/2025 at 8:10 AM, Resident #34 stated no one had changed the linens. Resident #34 pulled back the comforter and the bottom fitted sheet revealed several light, brown-tinged circular stains.Record review of the face sheet dated 08/27/2025 indicated, Resident #39 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included angina pectoris (chest pain), chronic kidney disease, lack of coordination, insomnia, heart failure, asthma (difficulty breathing) dysphagia following other (difficulty swallowing) hypertension (high blood pressure), hyperlipidemia (high levels of fat particles in the blood).Record review of the quarterly MDS dated [DATE] indicated, Resident #39 was usually understood by others and usually understood others. The MDS indicated Resident #39 had a BIMS of 11 and was moderately cognitively impaired. The MDS indicated Resident #39 required maximum assistance with toileting, dressing, and bathing. Record review of the care plan revised on 06/11/2025 indicated Resident #39 required ADL self-care due to deficit related to disease processes with the following interventions: required assistance of one staff for toilet use, bathing and personal hygiene. During an observation on 08/24/2025 at 10:46 AM, Resident #39 was in bed resting with eyes closed, the top sheet had a dirty yellow and orange stains on them, the pillowcase edges was brownish tinged. There were two large dark brown stains on the bottom half of the top blanket. There was a strong musty odor in the room. During an observation on 08/25/2025 at 08:30 AM, Resident #39 was in bed resting with eyes closed, the top sheet had a dirty yellow and orange stains on them. There were two large dark brown stains on the bottom half of the top blanket that was partial on the floor. There was a strong musty odor in the room. During an interview on 08/25/2025 at 2:02 PM, CNA V said the CNAs were responsible for giving the residents their showers and linen changes. CNA V said it was important for linens to be changed to prevent infections for the resident's dignity. During an interview on 08/25/2025 at 3:14 PM, LVN F said the CNA should report when a resident was not showered/bathed to the charge nurse. LVN F said she expected the residents to receive their scheduled showers as well as linen changes to prevent infections, maintain skin integrity, and maintain hygiene. LVN F said no staff reported a refusal of showering/bathing as well as linen changes to her. LVN F said ultimately if shower/ bathing and linen changes were un-resolved, she notified the ADON or DON. During an interview on 08/26/2025 at 4:24 PM, the DON said it was the CNAs responsibility to give the residents their showers and change the linens. The DON said there was a shower list that identified what resident received a shower on which day and shift. The DON said the CNAs performed showers on the residents, but any of the nursing staff could and should perform showers when needed. During an interview on the DON said she expected the CNAs to communicate with the charge nurses daily to ensure residents' needs were met. The DON said she expected the charge nurses to verify the showers were given and the linens were changed by the CNAs. The DON said if a resident refused, she expected staff to try again a couple times or send a different staff member to ask the resident. The DON said if a resident continued to refuse, she expected staff to report the refusal to the family and document the refusal. The DON said she was responsible to ensure the oversight of residents' baths/showers and linens changed appropriately according to the residents' plan of care. The DON said the importance of the residents receiving their scheduled showers and linens changed was to maintain dignity, hygiene, skin integrity, skin inspections and prevent skin infections. During an interview 08/26/2025 at 04:42 PM, the Administrator said he expected baths/showers as scheduled or as requested by the resident. The Administrator said clinical staff are responsible for making sure the baths/showers and linen changes were provided for the residents. The Administrator said if the residents refused ADL care or linen changes, the staff educated the residents. The Administrator said if a resident refused, he expected staff to try again a couple times or send a different staff member to ask the resident. The DON said if a resident continued to refuse, she expected staff to report the refusal to the family and document the refusal. The Administrator said it was important for the residents to receive baths/showers/linen changes for hygiene purposes and to make the residents feel good, infection control and dignity. Record review of facility policy and procedure titled, Homelike Environment - Quality of Life implemented 11/28/2017, indicated . Residents are provided with a safe, clean, comfortable and homelike environment .a. cleanliness and order . f. clean bed and bath lines that are in good condition.

Based on observation, interview, and record review the facility failed to promptly resolve grievances for 1 of 6 residents (Resident #54) reviewed for grievances.The facility did not ensure Residents #54 grievances related to meals being served late was resolved.The facility did not ensure the grievance received during Resident Council related to meals being served late on 03/07/2025, 04/04/2025, 06/02/2025, and 07/03/2025 were resolved.These failures could place residents at risk for grievances not being addressed and resolved promptly, hunger, frustration and low blood sugars. Findings included: Record review of a face sheet dated 08/27/2025 revealed Resident #54 was [AGE] year-old male admitted on [DATE] with diagnoses including type 2 diabetes (adult onset of too much sugar in the blood), personal history of a trauma fracture, pain, unsteadiness on feet, and an elevated white blood count. Record review of the quarterly MDS dated [DATE] revealed Resident #54 was understood and understood others. The MDS revealed Resident #54 had highly impaired hearing, clear speech, and adequate vision with corrective lenses. The MDS revealed Resident #54 had a BIMS of 06 which indicated severe cognitive impairment and required extensive assistance for bed mobility, dressing, toilet use, personal hygiene, transfer and bathing. Record review of Resident #54's care plan with revised date of 07/17/2025 revealed the potential for hypo/hyperglycemia (blood sugar levels) related to diabetes mellitus with the intervention of Accu-Chek (blood sugar check by pricking the skin) with sliding scale per orders. Record review of grievance log dated 03/07/2025 revealed the resident council had expressed concerns with food not served timely. The grievance log stated residents reported that dinner was served at 7PM. The grievance log stated the resolution was in-service training for all dietary staff on the topic of meals are to be served at a timely manner to maintain a structured daily routine for residents.Record review of grievance log dated 04/04/2025 revealed the resident council had expressed concerns with food not served timely. The grievance log stated residents reported that dinner was served at 9PM 0n 04/03/2025. The grievance log stated the resolution was in-service training for all dietary staff on the topic of meals are to be served at a timely manner and there was an issue with the tray system and missing meal tickets. Record review of grievance log dated 06/02/2025 revealed the resident council expressed concerns with food not served timely. The grievance log stated residents reported that dinner was served late and cold. The grievance log stated the residents had concerns due to potential low blood sugars. The grievance log stated the resolution was in-service training for all dietary staff on the topic of meals are to be served at a timely manner to maintain a structured daily routine for residents.Record review of grievance log dated 07/03/2025, revealed the resident council expressed concerns with food not served timely. The grievance log stated residents reported that dinner was served at late. The grievance log stated the resolution was in-service training for all dietary staff on the topic of meals are to be served at a timely manner to maintain a structured daily routine for residents. Dietary staff were to notify the nursing staff if meals were late so the residents would be informed. During an interview on 08/24/2025 at 11:32 AM, Resident #54's family member stated the meals were always late when Resident #54 was eating in his room on hall 400. Resident #54's family member stated it would be after 2:00 PM when trays were served. Resident #54's family member stated she was concerned for Resident #54 during those late mealtimes because of a potential for a low blood sugar. Resident #54's family member stated she was glad Resident #54 was moved to the 100 hall and the DON had suggested Resident #54 eat in the dining hall to ensure his meals were served on time. Resident #54's family member stated she was concerned for other residents who could not advocate for themselves and was receiving the late meals. During an observation on 08/24/2025 at 12:48 PM, the lunch trays arrived on hall 400 to be served. The sign on hall 400 indicated lunch served at 12:00 PM.During an observation on 08/24/2025 at 1:14 PM, the lunch trays arrived on hall 500 to be served. The sign on hall 500 indicated lunch served at 12:00 PM. During an interview on 08/26/2025 at 04:10 PM, the DON said dietary services had been an ongoing complaint/grievance for lateness of meals. The DON said it was better than it had been in the past. The DON said mealtimes were important for a variety of reasons such as health needs like preventing weight loss, dignity, maintain appropriate blood sugar levels. The DON stated dietary services continued to be educated on routine scheduled mealtime deliver.During an interview on 08/26/2025 at 04:45 PM, the Administrator said he was primarily responsible for keeping up with the grievance log, following up and resolving grievances. The Administrator said when a resident filed a grievance a resolution was developed and completed within 2-3 days at the very longest. He said if a resolution could not be completed in that time frame of 2-3 days a written update was provided. The Administrator said the grievances regarding the meals served late had been an ongoing issue in the facility. The Administrator stated although the situation was better - the facility still had meal delivery time issues. The Administrator said the dietary services were contracted out from the facility. The Administrator said the contracted help was difficult to regulate. The Administrator said that come October the facility would undergo dietary services change. The Administrator said grievances should be addressed in a timely manner, so the residents feel like they are being heard. He said grievances not being addressed timely could cause residents to have unresolved complaints.Record review of a facility Grievance Policy dated 02/16/23 revealed .our facility assists residents, their representatives, other interested family members or resident advocate in filing grievances or complaints when such request are made.the administration has delegated the responsibility of grievance and/or complaint investigation to its Grievance officials.ADM and Social Worker.upon receipt of a written grievance, oral.the grievance officers will investigate the allegations with appropriate management staff and other staff and submit a written report of such findings to the administrator within 72 hours.the administrator will review the findings with the person investigating the complaint to determine what corrective actions need to be taken and to respond to the complaint.the administrator and grievance officers will record and track all grievances on a log sheet.the resident filing the grievance and/or complaint on behalf of the resident will be informed of the findings of the investigation and the actions taken to correct.such report will be made orally by grievance official.within 72 hours of filing the

Based on observation, interview, and record review the facility failed to develop, and implement a comprehensive care plan to meet the medical, nursing, mental and psychosocial needs for 5 of 22 residents reviewed for care plans (Resident #3, Resident # 5, Resident # 8, Resident # 75, Resident #97)The facility failed to ensure Resident #3's diagnosis of diabetes was coded on the quarterly MDS on 6/5/2025 and care planned. The facility failed to ensure Resident #5's bathing type/preference was care planned on 5/22/2025. The facility failed to ensure Resident #8's seatbelt restraint on wheelchair was care planned with interventions on how to monitor. The facility failed to ensure Resident #75's swallowing difficulties, coded on his 8/9/25 admission MDS assessment was care planned.The facility failed to ensure Resident #75's active discharge planning was care planned. The facility failed to ensure Resident #97's swallowing difficulties, coded on his 8/7/25 admission MDS assessment was care planned.The facility failed to ensure Resident #97's active discharge planning was care planned.The facility failed to ensure Resident #97's care plan intervention of no water pitcher at the bedside was implemented on 8/25/25. These failures could place residents in the facility at an increased risk of a decline in physical or functional well-being, of not receiving necessary care or services, and having personalized plans developed/implemented to address their needs. Findings included: 1. Record review of the face sheet dated 04/16/24 indicated Resident #3 was [AGE] year-old female who was readmitted [DATE] with diagnoses including fracture of lower end of left tibia (a break in the shinbone which is the larger bone in the lower leg), neuromuscular dysfunction of bladder (refers to a condition where the bladder's ability to store and release urine is impaired due to problems with nervous system), malignant neoplasm of uterus (a cancerous tumors that develop when cells in the lining of the uterus) and Diabetes (a group of diseases that affect how the body uses blood sugar). Record review of the most recent MDS dated [DATE] indicated Resident #3 was understood and understood others. Resident #3 had a BIMS score of 14 indicating she was cognitively intact. The MDS did not indicate Resident #3 was a Diabetic. In section N0350 of the MDS indicated Resident #3 was receiving Insulin injections in the last 7 days and was not marked to receiving hypoglycemic (including insulin) in section N0415. Record review of Resident #3's care plan revised on 7/15/2025 did not indicate Resident #3 was a Diabetic. Record review of Resident #3's MAR dated 8/1/2025-8/31/2025 indicated Resident #3 was administered Insulin Glargine (a long-acting modified form of medical insulin used to manage Type I and Type II Diabetes) subcutaneously (under the skin) at bedtime and Lispro per sliding scale (a treatment approach that adjust insulin doses based on current blood sugar reading) before meals for diabetes. Record review of Resident #3's order summary report dated 8/25/2025 indicated was ordered Insulin Glargine (a long-acting modified form of medical insulin used to manage Type I and Type II Diabetes) subcutaneously (under the skin) at bedtime and Lispro per sliding scale (a treatment approach that adjust insulin doses based on current blood sugar reading) before meals for diabetes. During an interview on 8/26/2025 at 11:06 AM, LVN U said the nurse was responsible updating the diagnosis into the computer. LVN U said she completes a head-to-toe assessment and the MDS nurse reviews the nursing assessments, hospital records to enter the MDS in the computer. LVN U said the care plan was identified through the MDS and the DON. LVN U said Diabetes and insulin should be care planned. She said if a resident had medical issues the nurse knows to check and look for signs and symptoms. LVN U said a resident could have signs and symptoms, potentially not be treated or go into a diabetic coma. LVN U said she looks at the orders and does not have access to the care plan. LVN U said the care plan was for the resident, the department heads, MDS and the families. LVN U said Resident # 3 did have an order for insulin for her diabetes and Resident #3's blood glucose was checked 3 times daily. During an interview on 8/26/2025 at 11:53AM, MDS Coordinator B said the last quarterly MDS does not indicate Resident #3 had Diabetes. She said the MDS indicated Resident #3 was checked to be on insulin. MDS Coordinator B said there was not a care plan indicating Resident #3 was a diabetic. She said anyone on staff can access the care plan. MDS Coordinator B said it would be important for Diabetes to be on the care plan. She said there would need to be interventions for her Diabetes on the care plan. MDS Coordinator B said the resident was on insulin and had orders for insulin. MDS Coordinator B said it was not on her diagnosis list. MDS Coordinator B said if Diabetes was not on the care plan, it would not be ensuring all the needs resident's needs were being met. During an interview on 8/26/2025 at 12:52 PM, ADON N said she was not the MDS nurse, but she thought diabetes would need to be on the care plan. ADON N she has done care plans. She said the facility would care plan infection and behaviors on the care plan. ADON N said she expected the MDS nurses to document and code the MDS with accuracy. She said the MDS drives the care plan. ADON N said MDS was a minimal data assessment that go off the orders. ADON N said diabetes should be on the care plan. During an interview on 8/26/2025 at 3:43 PM, the DON said she expected the nurse to code diabetes and expected it to be on the care plan. The DON said the facility updated the care plan when there was a change in condition, quarterly, annually, and as needed in team meeting. The DON said the MDS Coordinator and herself were responsible for updating the care plan. The DON said it could cause a negative outcome but did not elaborate. During an interview on 8/26/2025 at 4:12 PM, the ADM said the MDS nurse was responsible for ensuring the diagnoses were coded on MDS. He said the care plan and MDS were completed upon admission, quarterly and annually. He said he expected the diagnoses to be care planned and was important for the provision of care. The ADM said it could negatively result in improper care of the resident. 2. Record review of a face sheet printed on 8/24/2025 indicated Resident #5 was a [AGE] year-old, male and was readmitted on [DATE] with diagnoses including acute osteomyelitis, heart failure (occurs when the heart muscle is unable to pump blood effectively, which can result from various conditions that damage the heart) , hypertension (occurs when the pressure in your blood vessels is consistently too high) and peripheral vascular disease (a slow and progressive disorder of the blood vessels causing narrowing, blockage, or spasms in a blood vessels). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #5 was understood and understood others. The MDS indicated Resident #5 had a BIMS score of 7 which indicated he was severely cognitively impaired. The MDS indicated Resident #5 had no functional impairment in his upper extremities and was impaired to both lower extremities requiring the use of mobile device of wheelchair in the last 7 days of the assessment period. The MDS indicated Resident #5 required substantial assistance with personal care such as showering/bathing and dressing upper/lower body. Record review of a care plan last revised on 7/25/2025, indicated Resident #5 had self-care deficits related to disease process with interventions for assistance of 1 staff to participate with bathing and 2 persons to assist with transfers. During an interview on 8/24/2025 at 10:05 AM, Resident #5 said he was not receiving showers and there was not enough staff to get him up out of bed. Resident #5 said hospice could not get him up. During an interview on 8/25/2025 at 8:40 AM, Resident #5 said he only received bed baths 5 days a week. He said hospice does not get him up because they cannot use the mechanical lift with one person. He said he feels sticky after a bed bath and wishes he could take a shower. During an interview and observation on 8/25/2025 at 3:15 PM, Resident #5 said he asked the charge nurse about 2 weeks ago for a shower, but he could not recall the nurse's name. He said she told him that he would get a shower, but he did not want to take away from his roommate's shower time. He said he never received a shower. Resident #5 said getting a bed bath and washing his hair with dry shampoo was drying out his scalp. Resident #5 was observed to have large white patch to right side of head. During an interview on 8/26/2025 at 9:35 AM, CNA R said Resident #5 was on hospice and they provided him with a bed bath. CNA R said Resident #5 occasionally received a shower and said she had given him a shower. CNA R said she thought he should be able to get a shower if he wanted one. CNA R said she would fit him in to get a shower. She said he had voiced he did not feel clean, and she said he had dryness on his scalp. CNA R said if a resident were not getting his preference in bathing, it could upset him, and he may feel dirty. CNA R said she was not sure if the nurses were aware of his dry scalp, and she said she would have to let the nurse staff know. CNA R said she would check with the nursing staff to see if they were aware of his dry scalp. During an interview on 8/26/2025 at 10:30 AM, LVN U said Resident #5 was on hospice and the Hospice aides were responsible for bathing him. She said he received a bed bath from hospice, but she had just received a request for showers. She said he had hypotensive episodes and gets dizzy. She said she had informed the unit manager Resident #5 was wanting showers today. LVN U said she was not aware prior to today that he wanted a shower. She said he had not made a request before. During an interview on 8/26/2025 at 11:53AM, the MDS Coordinator B said the staff would write down the preferences and communicate to other staff. MDS Coordinator B said she the facility had morning meetings, and they do discuss acute care plans. During an interview on 8/26/25 at 12:30 PM, the Activity Director said the facility completes an assessment upon admission and annually we ask what they like to do. She said she would read it out and input the information in the system. The Activity Director said dietary puts in their assessment. She said she does ask questions about bathing. She said the nurses were the ones who identify which type of bath was ordered. During an interview on 8/26/2025 at 12:52 PM, ADON N said the facility staff discuss in the clinical meetings in the morning and discuss resident's preferences. ADON N said anyone could update the care plan. She said she was there when Resident # 5 received his bed bath last week and he did not mention he wanted a shower. ADON N said Resident #5 had dandruff since he had been at the facility. ADON N said the hospice aides soaps him up like he was in a bathtub. ADON N said she expects the aides to clean and rinse him well, so he does not feel sticky. During an interview on 8/26/2025 at 3:43 PM, the DON said she thought the communication should be between hospice and the facility staff to make it happen. The DON said when Resident #5 got to the facility, he was weak, and it was not safe for him to shower. She said he had mentioned wanting a shower in the past, but he was not strong enough. The DON said Resident #5 was in his right mind and did speak his mind. The DON said she was not aware of the white patches on the right side of his scalp. The DON said she wants to get him what he asks for so that he is comfortable. During an interview on 8/26/2025 at 4:12 PM, the ADM said he would expect Resident #5's shower/bath preferences to be care planned. He said he would expect the nurses or staff to update or report any new preferences. The ADM said not receiving the proper bath could cause skin breakdown. The ADM said the charge nurse was responsible for ensuring Resident #5 received his bath or choice. 3. Record review of a face sheet printed on 8/24/2025 indicated Resident #8 was an [AGE] year-old, female and was readmitted on [DATE] with diagnoses including Chronic pain syndrome (a long-term condition characterized by persistent pain that last for months or years, significantly affecting daily life), hemiplegia affecting left nondominant side (partial or total paralysis on one side of the body), hypertension (occurs when the pressure in your blood vessels is consistently too high), age-related osteoporosis (occurs when the body loses bone mass) and neuromuscular dysfunction of bladder (occurs when there is a problem with the brain, nerves, or spinal cord that affects bladder control). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #8 was understood and understood others. The MDS indicated Resident #8 had a BIMS score of 14 which indicated she was cognitively intact. The MDS indicated Resident #8 had no functional impairment in her upper extremities and was impaired to both lower extremities requiring the use of mobile device of wheelchair in the last 7 days of the assessment period. The MDS indicated Resident #8 required substantial assistance with personal care such as toileting, showering/bathing, and dressing upper/lower body. The MDS indicated physical restraints were not used for Resident #8. Record review of a care plan last revised on 6/20/2025, indicated Resident #8 was at moderate risk for falls related to gait and balance problems. The care plan interventions included to anticipate and meet the resident's needs, keep call light within reach and encourage resident to use it for assistance as needed, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. During an observation and interview on 8/25/2025 at 8:47 Am, Resident #8 was observed sitting up in her power wheelchair in the main area near the nurse's station. Resident #8 was observed to have a black safety belt securing her in the powerchair. Resident #8 observed to have limited grasp in her upper extremities, and she said she was unable to remove independently. Resident #8 said she wanted the safety belt on because she slides out of her wheelchair. During an observation and interview on 8/25/2025 at 1:21 PM, Resident #8 sitting in her wheelchair with the safety belt across her chest just below her breast. Resident said she wanted the safety belt on to help keep her in her seat. During an interview on 8/26/2025 at 9:35 AM, CNA R said Resident #8 was unable to transfer herself. She said Resident #8 could navigate the environment in her motorized wheelchair. CNA R said resident was contracted in her upper hands and sometimes had difficulty turning on her powerchair. CNA R said technically, she had restraints because she had a seatbelt on her wheelchair, so she does not flip out. CNA R said Resident #8 had the seatbelt on since she had worked at the facility which was 3 months. CNA R said the LVN or RN maybe responsible for the assessment of residents with restraints. CNA R said it maybe care planned. CNA R said when Resident #8 returns to bed, she would unlock the seatbelt. CNA R said the seatbelt was like a baby seatbelt. CNA R said she makes sure the seatbelt is not suffocating her. CNA R said Resident #8 could not unlock her own seatbelt. CNA R said she would consider the seatbelt a restraint. CNA R said she could not think of how the restraint could negatively impact Resident #8. She said Resident #8 was in her right mind and would come to staff for assistance or if something hurt her. During an interview on 8/26/2025 at 10:30 AM, LVN U said a restraint was anything that was preventing a Resident from moving freely. LVN U said there was no residents on Hall 200 that currently had restraints. She said if a resident had restraints, the Nurse Practitioner would have to put in an order for seatbelt or a restraint. LVN U said she considered a seatbelt on a wheelchair a restraint. LVN U said Resident #8 did not have a restraint on her wheelchair. LVN U said the nurses were responsible to assessing a resident with a restraint. LVN U said she did not know Resident #8 used the strap on her wheelchair and said it could be the mechanical lift sling strap. LVN U said Resident #8 would not be able to unlock a seatbelt. LVN U said Resident #8 could have respiratory issues from the strap or if the strap were too tight, it could cause sores. LVN U said Resident #8 did not have any issues. She said the policy for the nursing home would be the guide to determine if a resident required a restraint. LVN U said there would be an order and care planned. LVN U said the DON and MDS nurse were responsible for updating the care plan. During an interview and observation on 8/26/2025 at 11:06 AM, observed Resident #8 in her wheelchair. LVN U was present and said there was a seatbelt, and she was unaware. LVN U said the seatbelt was part of the wheelchair and not the mechanical lift sling. During an interview on 8/26/2025 at 11:53 AM, MDS Coordinator B said Resident #8 did not have a care plan for restraints. MDS Coordinator B said the nurse would be responsible for putting in the care plan for restraints. MDS Coordinator B said she was unsure if Resident #8 could unlock the seatbelt by herself. She said the nurses would be responsible for ensuring a resident was able to unlock themselves from a seatbelt. MDS Coordinator B said it could cause harm due to discomfort. MDS Coordinator B said Resident #8 had an evaluation in her chart for physical restraints, but the documentation had “NA” (Not applicable) for restraints. MDS Coordinator B said the care plans were updated quarterly, and the staff have morning meetings where they discuss things that need to be updated. MDS Coordinator B said both MDS nurses were responsible for updating quarterly care plans. During an interview on 8/26/2025 a 12:40 PM, the Director of Therapy T said wheelchairs normally come with seatbelts. She said the therapist must reposition Resident #8 frequently and position her every day. Director of Therapy T said she did not think Resident #8 could unlock the seatbelt. She said the therapist had worked with her on gripping a spoon and fork. Director of Therapy T said the facility was a “restraint free” facility and she was not aware of the seatbelt. She said she did not know who was putting the seatbelt on Resident #8. She said she was shocked to see it on her. Director of Therapy T was told by Resident #8 after hearing about the seatbelt that she felt safer with it on. Director of Therapy T said another therapist was trying to figure out a way to keep her safe in her wheelchair and the foam cushion instead of the pillow. During an interview on 8/26/2025 at 12:52 PM, the ADON said the facility does not use restraints. The ADON said a seatbelt is not considered a restraint if the resident could unhook it. The ADON said she had not observed Resident #8 with a seatbelt on. The ADON said it was possible that Resident #8 could unlock the seatbelt. The ADON said typically, the facility staff work with therapy to determine if Resident #8 was able to unlock her seatbelt if in use. The ADON said it would need to be care planned and a restraint assessment would need to be completed by the nurses. The ADON said a resident could get a skin injury or cut themselves. The ADON said she had never seen a seatbelt on Resident #8. During an interview on 8/26/2025 at 3:31 PM, the DON said she had a conversation with Resident #8 and was told by Resident #8 she had told the aide she wanted to use the seatbelt. The DON said she spoke with CNA R, and she told her she did not ask the nurse whether Resident #8 was supposed to wear the seatbelt. The DON said CNA R was going by what Resident #8 wanted and felt comfortable. She said the CNA did not know to go to the nurse. The DON said therapy had not seen a seatbelt on Resident #8. The DON said she educated CNA R to go to the nurse and educated on restraints, orders, assessment, and care plans. The DON said therapy was getting involved to work with Resident #8. The DON said CNA R was new CNA and had gone through the classes and orientation. The DON said she expected the CNA to go to the nurse to ask before placing a seatbelt on any resident. The DON said she expected the residents to be assessed for restraints and expected there to be an order. The DON said the nurses were responsible for ensuring the residents are restraint free. The DON said a restraint could have a negative outcome if not addressed. She said it could cause skin injury. During an interview on 8/26/2025 at 4:12 PM, the ADM said he considered a seatbelt a restraint if the resident was unable to unlock the seatbelt without assistance. He said he expected the staff and CNA to ask nurses about orders, assessments prior to using a restraint. He said using a restraint could affect the resident's dignity and psychologically. The ADM said he expected an order in place with return demonstration. The ADM said the nurses were responsible for ensuring orders, assessments were in place with the use of any restraints. The ADM said it would also need to be care planned. 4. Record review of Resident #75's face sheet dated 8/25/25 indicated Resident #75 was an [AGE] year-old male admitted to the facility on [DATE]. Resident #75 had diagnoses including congestive heart failure (is a condition where the heart muscle is weakened and cannot pump blood effectively), type 2 diabetes (is a chronic condition that happens when you have persistently high blood sugar levels), and hemiplegia (is paralysis that affects only one side of your body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction affecting left non-dominant side(occurs when blood flow to the brain is interrupted, leading to tissue damage). Record review of Resident #75's admission MDS assessment dated [DATE] indicated Resident #75 was understood and had the ability to understand others. Resident #75's BIMS score was 12 which indicated moderate cognitive impairment. Resident #75 required setup for eating. Resident #75 had signs and symptoms of possible swallowing disorder due to holding food in mouth/cheeks or residual food in mouth after meals. Resident #75 had a mechanically altered and therapeutic diet. Resident #75 overall goal was discharge to the community. The source of discharge goal was the family. Resident #75's MDS assessment indicated there was an active discharge plan occurring for the resident to return to the community. Resident #75's MDS Assessment, Care Area Assessment Summary, indicated nutritional status care area was triggered. Record review of Resident #75's care plan dated 8/24/25 indicated Resident #75 had an ADL self-care performance deficit related to hemiplegia and impaired balance. Intervention included Resident #75 required times one staff participation to eat. Resident #75's care plan did not reflect swallowing difficulties and active discharge planning. During an observation and interview on 8/24/25 at 10:51 a.m., Resident #75 was lying in bed watching television. Resident #75 was hard of hearing. Resident #75 said he did therapy every day. He said his family member worked out of the country and their spouse worked full time. He said he was getting stronger to go live with his family members. 5. Record review of Resident #97's face sheet dated 8/25/25 indicated Resident #97 was a [AGE] year-old male admitted to the facility on [DATE]. Resident #97 had diagnoses including myocardial infarction (occurs when blood flow decreases or stops in one of the coronary arteries of the heart), congestive heart failure (is a condition where the heart muscle is weakened and cannot pump blood effectively), chronic obstructive pulmonary disease (is a chronic lung disease that causes inflammation and narrowing of the airways, leading to airflow obstruction), and acute and chronic respiratory failure (is a condition where there's not enough oxygen or too much carbon dioxide in your body). Record review of Resident #97's admission MDS assessment dated [DATE] indicated Resident #97 was understood and had the ability to understand others. Resident #97 had a BIMS score of 15 which indicated an intact cognition. Resident #97 required setup for eating. Resident #97 had signs and symptoms of possible swallowing disorder due to holding food in mouth/cheeks or residual food in mouth after meals. Resident #97 overall goal was discharge to the community. The source of discharge goal was the family. Resident #97's MDS assessment indicated there was an active discharge plan occurring for the resident to return to the community. Resident #97's MDS Assessment, Care Area Assessment Summary, indicated nutritional status care area was triggered. Record review of Resident #97's care plan dated 8/15/25 indicated Resident #97 had a diagnosis of history of fluid overload secondary to congestive heart failure. Resident #97 is on a 1500 milliliters fluid restriction per day. Intervention included no water pitchers at bedside. Record review of Resident #97's care plan dated 8/17/25 indicated Resident #97 had an ADL self-care performance deficit related to impaired balance. Intervention included Resident #97 required times one staff participation to eat. Resident #97's care plan did not reflect swallowing difficulties and active discharge planning. During an observation on 8/25/25 at 9:47 a.m., Resident #97 was out of the facility. On Resident #97's bedside table was a water pitcher with clear liquid in it. During an interview and observation on 8/25/25 at 3:04 p.m., LVN K and the surveyor walked into Resident #97's room together. On Resident #97's bedside table was a water pitcher. LVN K said the nurses were responsible for ensuring Resident #97 did not have a water pitcher at the bedside. She said she knew Resident #97 was not supposed to have a water pitcher at the bedside. She said she was not sure why Resident #97 was on a fluid restriction. She said Resident #97 could have the order for no water pitcher at the bedside because of a heart issue or fluid retention. During an interview on 8/25/25 at 3:23 p.m., CNA E said she did not normally work the hall Resident #97 resided on. She said she asked the nurses about each resident before the start of her shifts. She said that was how she knew which residents were on fluid restrictions. She said she did not give Resident #97 a water pitcher this morning. She said she only made Resident #97's bed after he left the facility. She said it was important to follow the fluid restriction because you did not want the residents to excessively drink due to kidney issues, fluid retention, or deficiency issues. She said the excessive fluid could cause congestive heart failure or kidney failure. During an interview on 8/26/25 at 9:20 a.m., the MDS Coordinator C, with MDS Coordinator B present, said the DON started the comprehensive care plan. The MDS Coordinator C said it had to be opened by a RN. The MDS Coordinator C said the comprehensive care plan was completed by the Coordinators. The MDS Coordinator C said she used a worksheet that included the residents' diagnoses, medications, physician orders, and care area assessment summary to determine what was included on the residents' care plan. The MDS Coordinator C said she normally added the residents' swallowing difficulties to the care plan only if they had a diagnosis or documentation. The MDS Coordinator C acknowledged the swallowing difficulties could only be added to the MDS assessment, if there had been documentation in the residents' chart of swallowing difficulties. The MDS Coordinator C said if the care area assessment summary triggered for discharge planning and there were issues, like uncertain placement, then the social service was responsible for care planning. The MDS Coordinator C said discharge planning normally was not care planned unless there were issues. The MDS Coordinator C said Resident #75 and Resident #97 were rehabilitation residents with plans to discharge back to the community. The MDS Coordinator B said care areas triggered on the MDS assessment and discharge planning needed to be care planned to make sure to meet the residents' needs and know their wishes. The MDS Coordinator C said it was important to care plan those things to make sure the staff knew the residents' needs and wishes. The MDS Coordinator C said comprehensive care plan were overseen by the IDT. The MDS Coordinator C said the comprehensive care plans were reviewed in morning meetings. During an interview on 8/26/25 at 11:03 a.m., CNA A said she worked last weekend. She said she gave Resident #97 a water pitcher because he requested it over the weekend. She said Resident #97 was on fluid restriction. She said the nurses did make the CNAs aware of who was on fluid restrictions. She said she did not know there was an order and on his care plan for no water pitcher at the bedside. She said Resident #97 threw fits when he did not get what he wanted. She said sometimes the nurses were aware his was requesting more fluids. She said it was important to follow the care plan intervention because the body could get fluid overloaded. She said the resident could then need hospitalization. During an interview on 8/26/25 at 12:10 p.m., LVN H said the IDT was responsible for all the information on the comprehensive care plan. She said the MDS Coordinators were responsible for care area triggered from the MDS. She said she would want the residents' swallowing difficulties or disorder on the care plan. She said she would want it for safety, to know the specific issue and if speech therapy was involved. She said a residents' swallowing difficulties affected their eating and medication administration. She said she would also want the residents' discharge planning on the care plan. She said it was important to know who the resident was going home with and the plan on how they were getting discharged . She said it was also important so everyone was on the same page. She said Resident #97 was fluid restricted. She said everyone was responsible but especially the nursing and dietary staff, for ensuring Resident #97 fluid restriction was followed. She said everybody was responsible for ensuring Resident #97 did not have a water pitcher at his bedside. She said she could not recall if Resident #97 had a water pitcher at his bedside on 8/24/25. She said if the care plan intervention was not followed, the resident could be hospitalized for fluid overload. She said Resident #97 was alert and oriented to person, place, time, and event. She said Resident #97 could do want he wanted. She said if the resident was non-complaint with no water pitcher being at the bedside or fluid restriction, then education and documentation needed to be done. During an interview on 8/26/25 at 3:00 p.m., ADON N said everyone was responsible for ensuring Resident #97 did not have a water pitcher at the bedside. She said Resident #97 was not a “guzzler” of fluids. She said if a resident requested a water pitcher, they needed to be educated and encouraged to adhere to the recommendation. She said if a resident was non-complaint, then the nurse should document and notify the nursing management and physician. She said if the care plan intervention was not followed then it could affect the resident's lab values and general health. She said the MDS Coordinators were responsible for care planning care areas triggered on the MDS. She said the nursing management care planned acute changes of condition. She said she would expect the residents' discharge planning to be care planned. She said the IDT was responsible for care planning the residents' discharge plan. She said the IDT met on Wednesdays to discuss discharge plans. She said the residents with discharge plans were discussed every day in the skilled meeting. During an interview on 8/26/26 at

Based on observation, interview, and record review the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practices for 4 of 17 residents (Resident #40, Resident #13, Resident #41, Resident #97) reviewed for respiratory care.1. The facility failed to ensure Resident #40's oxygen was placed on 2 liters per minute via nasal cannula as ordered by the physician.2. The facility failed to ensure Resident #13 had a physician order for her tracheostomy (is a medical device inserted into the trachea (windpipe) to establish an airway for breathing) type, size, configuration, and inflated or deflated. On 8/24/25, Resident #13 had a Shiley (type of tracheostomy tube) 6.0 XLT (Extended-Length), deflated cuffed tracheostomy. 3. The facility failed to ensure Resident #41's oxygen was administered at the correct setting of 4 liters per minute on 8/24/25 and 8/25/25 as ordered by the physician.The facility failed to ensure on 8/25/25, Resident #41 was not on an oxygen cylinder tank (medical devices that store supplemental oxygen) that read refill which indicated the oxygen cylinder was empty. 4. The facility failed to ensure Resident #97's oxygen was administered at the correct setting of 2 liters per minute on 8/24/25 as ordered by the physician. The facility failed to ensure on 8/24/25, Resident #97's nebulizer mask (is a device used with a nebulizer machine to deliver medication as a fine mist directly into the lungs) was stored in a bag when not in use.These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care.Findings included: 1. Record review of Resident #40's face sheet, dated 6/18/25 revealed a [AGE] year old male admitted on [DATE] with diagnoses that included Emphysema (lung disease where the air sacs (alveoli) in the lungs are damaged and destroyed, leading to shortness of breath, coughing, and wheezing), Chronic Obtrusive Pulmonary Disease (lung disease that involves a group of lung conditions, including emphysema and chronic bronchitis, that block airflow and make breathing difficult), and Malignant Neoplasm of Prostate (a type of cancer that begins with abnormal cells in the prostate gland). Record review of Resident #40's significant change MDS assessment, dated 05/29/25, revealed Resident #40 had a BIMS of 13, which indicated he was cognitively intact. Order for oxygen was after the latest MDS. Record review of Resident #40's care plan dated 7/6/2025 indicated that Resident #40 had a problem related to his diagnoses of emphysema and chronic obtrusive pulmonary disease. Resident #40 was to be given oxygen therapy per physician's orders.Record review of an order for Resident #40, dated 8/1/2025, “O2: O2 at 2 l/m via nasal cannula PRN SOB ” During an observation and interview on 8/25/25 at 9:07 a.m., Resident #40's oxygen concentrator was set to 1 liter per minute. He said that he wore his nasal cannula most of the day, so he doesn't lose his breath. He said he didn't know what the concentrator should have been set at. During an observation on 8/25/25 at 2:00 p.m., Resident #40's oxygen concentrator was set to 1 liter per minute . During an interview on 8/26/25 at 1:59 p.m. LVN U said nursing staff was responsible to ensure that residents who used an oxygen concentrator for supplemental oxygen were set to the required volume. She said that if a resident required 2 liters a minute it should not be greater or less then the ordered amount. She said that residents could be placed at risk for respiratory problems, become short of breath, and have lowered oxygen saturation. During an interview on 8/26/25 at 4:19 p.m., the Director of Nurses said that resident's oxygen should be set at the level ordered by their physician. She said the volume of air could be found in the resident's orders. She said that residents could be placed at risk of having shortness of breath and lowered oxygen saturation if their orders were not followed. She said that nurses were responsible for ensuring this type of order was followed. During an interview on 8/26/25 at 4:36 p.m., the Administrator said that it was the responsibility of nursing staff to ensure that residents orders were followed which includes the rate at which they were receiving oxygen. He said that residents could be placed at risk of shortness of breath and lowered oxygen saturation levels. 2. Record review of Resident #13's face sheet, dated 8/24/25, indicated Resident #13 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #13 had diagnoses including chronic respiratory failure (is a condition where the lungs are unable to provide enough oxygen to the body over a prolonged period, leading to low oxygen levels in the blood (hypoxemia)), asthma (is a chronic respiratory condition that causes inflammation and narrowing of the airways, leading to recurring episodes of wheezing, shortness of breath, chest tightness, and coughing), stenosis of larynx (is a narrowing of the larynx (voice box) that impedes airflow, leading to symptoms like hoarseness, wheezing, and shortness of breath), and tracheostomy status. Record review of Resident #13's quarterly MDS assessment dated [DATE] indicated Resident #13 was understood and had the ability to understand others. Resident #13 had a BIMS score of 15 which indicated intact cognition. Resident #13 had oxygen therapy, tracheostomy care, and non-invasive mechanical ventilator (the delivery of oxygen into the lungs via positive pressure without the need for endotracheal intubation (is a flexible tube that is placed in the trachea (windpipe) through the mouth or nose)). Record review of Resident #13's care plan dated 7/9/24 indicated Resident #13 had tracheostomy related to chronic respiratory failure, respiratory illness, and stenosis of larynx. Intervention included trach size: Portex Bivonatis (type of tracheostomy)6, deflated bulb outer diameter, 100 liters. Date initiated 6/6/24. Record review of Resident #13's order summary dated 8/24/25 indicated: *Tracheostomy: Change humidifier container weekly and date, every shift, every Sunday. Start date 10/9/23. *Tracheostomy: Change Tracheostomy tubing and collar weekly and as needed, every day, every Sunday. Start date 10/9/23. *Tracheostomy: Cleanse site with normal saline, pat dry and apply dry dressing daily and as needed. Start date 5/21/25. *Tracheostomy: Tracheostomy: Cleanse site with normal saline, pat dry and apply dry dressing daily and as needed, every day shift. Start date 5/21/25. *Tracheostomy: Oxygen via Tracheostomy collar at 5 liters per minute at night and as needed for shortness of breath, as needed. Start date 8/1/25. *Tracheostomy: Oxygen via Tracheostomy collar at 5 liters per minute at night and as needed for shortness of breath, at bedtime for shortness of breath. Start date 8/1/25. *Tracheostomy: Suction as needed. Start date 10/9/23. *Tracheostomy: Trachea Collar day time, every shift. Start date 1/2/24. Resident #13's order summary did not reflect a physician order for a tracheostomy type, size, configuration, and inflated or deflated. Record review of Resident #13's Administration Record Report dated 8/1/25-8/31/25 indicated: *Tracheostomy: change disposable inner cannula (is a removable, disposable or reusable tube that fits inside the main tracheostomy tube) #6 daily and as needed every day shift related to tracheostomy status. Start date 6/5/25. The Medication Administration Record indicated treatment on 8/24/25. *Tracheostomy: change every 3 months with ENT, every day shift, every 15 months, starting on the 15th for 1 day. Start date 9/15/24. The Administration Record Report indicated Resident #13's tracheostomy change was not due in August 2025. Resident #13's Administration Record Report did not reflect a physician order for a tracheostomy type, size, configuration, and inflated or deflated. During an observation and interview on 8/24/25 at 2:27 p.m., Resident #13 was sitting on her bed. Resident #13 spoke very softly and occasionally the surveyor had to read her lips. Resident #13 said she had a 6.0 tracheostomy in. Resident #13 raised her chin for the surveyor to observe the tracheostomy tube outer cannula (the main body of the tube that remains in the trachea). Resident #13's tracheostomy tube had markings that stated, “Shiley XLT 6.0.” Resident #13 pilot [NAME] (a small balloon attached to the cuff that indicates when the cuff is inflated) was flat or deflated. Resident #13 said she was hoping to get her tracheostomy taken out soon. During an interview on 8/26/25 at 12:10 p.m., LVN H said whoever got the order for Resident #13's tracheostomy should have ensured it was in the resident's medical records. She said it was important to have the tracheostomy order to know exactly what the resident had. She said it would be disastrous if the wrong tracheostomy size was put in the resident. 3. Record review of Resident #41's face sheet dated 9/2/25 indicated Resident #41 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #41 had diagnoses including chronic obstructive pulmonary disease (is a chronic lung disease that causes inflammation and narrowing of the airways, leading to airflow obstruction), chronic respiratory failure (is a condition where the lungs are unable to provide enough oxygen to the body over a prolonged period, leading to low oxygen levels in the blood (hypoxemia)), and heart failure (is a condition where the heart muscle is weakened or stiffened, making it unable to pump blood effectively). Record review of Resident #41's quarterly MDS assessment dated [DATE] indicated Resident #41 was understood and had the ability to understand others. Resident #41 had a BIMS score of 4 which indicated severely impaired cognition. Resident #41 received oxygen therapy. Record review of Resident #41's care plan dated 6/5/25 indicated: *Resident #41 had altered respiratory status/difficult breathing related to chronic respiratory failure. Intervention included provide oxygen as ordered. * Resident #41 had oxygen therapy related to chronic respiratory failure. Intervention included oxygen settings: oxygen via nasal cannula/mask at 4 liters continuously. Record review of Resident #41's physician order dated 5/23/25 at 2:46 p.m., indicated Oxygen at 4 liters per minute via nasal cannula continuously, every shift, every day, 6am-6pm/6pm-6am. Record review of Resident #41's Administration Record Report dated 8/1/25-8/31/25 indicated Oxygen at 4 liters per minute via nasal cannula continuously, every shift. Start date 5/23/25. The MAR indicated LVN H administered the physician order on 8/24/25 (6am-6pm) and LVN K on 8/25/25 (6am-6pm). During an observation and interview on 8/24/25 at 11:57 a.m., Resident #41 was lying in the bed. Resident #41's nasal cannula prongs (is a device that gives you additional oxygen (supplemental oxygen or oxygen therapy) through your nose) were not in her nose. Resident #41 placed the prongs in her nose when questioned about oxygen use. Resident #41's nasal cannula tubing was connected to a flowmeter (is a medical device used for oxygen flow measurement) on the wall. Resident #41's flowmeter was on 2.5 liter per minute. During an observation on 8/25/25 at 9:44 a.m., Resident #41 was in her room sitting in a wheelchair. Resident #41's nasal cannula was connected to an oxygen cylinder with a regulator (is a device that reduces and controls the high pressure of oxygen from a tank or cylinder to a safe, low, and usable pressure for delivery to a patient). The regulator indicated Resident #41 was on 4 liters per minute. The oxygen cylinder meter was near the “refill” mark. During an observation on 8/25/25 at 11:32 a.m., Resident #41 was in her room sitting in a wheelchair. Resident #41's nasal cannula was connected to the flowmeter on the wall. The flowmeter indicated Resident #41 was on 3.5 liters per minute. During an observation on 8/25/25 at 3:29 p.m., Resident #41 was sitting in the common area, in a wheelchair. Resident #41's nasal cannula was connected to an oxygen cylinder with a regulator. The regulator indicated Resident #41 was on 3 liters per minute. The oxygen cylinder meter was on the red colored “refill” mark. Resident #41 did not appear in any respiratory distress. During an interview on 08/25/25 at 3:41 p.m., LVN K said she was assigned to Resident #41. The surveyor showed LVN K Resident #41's oxygen cylinder with a regulator. She said Resident #41 was supposed to be on 4 liters according to the doctor's order. She said she knew the amount of oxygen the resident was supposed to be on by reviewing the physician orders and MAR/TAR. She said if the resident was on the wrong liters, they could not be getting the proper amount of oxygen for the ordered saturation range. She said the nurse was responsible for the oxygen tanks. She said the nurses should ensure the residents' oxygen tank did not run out while in use. She said if the resident was using a tank that was on refill they could not be getting the proper oxygenation. She said not getting enough oxygen could cause altered level of consciousness and brain function. 4. Record review of Resident #97's face sheet, dated 8/25/25, indicated Resident #97 was a [AGE] year-old male admitted to the facility on [DATE]. Resident #97 had diagnoses including myocardial infarction (occurs when blood flow decreases or stops in one of the coronary arteries of the heart), congestive heart failure (is a condition where the heart muscle is weakened and cannot pump blood effectively), chronic obstructive pulmonary disease (is a chronic lung disease that causes inflammation and narrowing of the airways, leading to airflow obstruction), and acute and chronic respiratory failure (is a condition where there's not enough oxygen or too much carbon dioxide in your body). Record review of Resident #97's admission MDS assessment dated [DATE] indicated Resident #97 was understood and had the ability to understand others. Resident #97 had a BIMS score of 15 which indicated an intact cognition. Resident #97 had shortness of breath with exertion and when lying flat. Resident #97 had continuous oxygen therapy. Record review of Resident #97's care plan dated 8/17/25 indicated: *Resident #97 had oxygen therapy related to acute respiratory failure, chronic obstructive pulmonary disease, and congestive heart failure. Intervention included oxygen settings: oxygen via nasal cannula/mask at 2 liters continuously. *Resident #97 had altered respiratory status and difficulty breathing related to acute respiratory failure. Intervention included administer medication/puffers as ordered. Record review of Resident #97's physician order dated 8/3/25 at 2:39 p.m., indicated oxygen at 2 liters per minute via nasal cannula every shift related to acute and chronic respiratory failure. Record review of Resident #97's order summary dated 8/25/25 indicated: *Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML, 1 vial inhale orally every 4 hours as needed for wheezing related to chronic obstructive pulmonary disease. Start date 8/20/25. Record review of Resident #97's Administration Record Report dated 8/1/25-8/31/25 indicated: *Oxygen at 2 liters per minute via nasal cannula every shift related to acute and chronic respiratory failure. Start date 8/4/25. The MAR indicated LVN H administered the physician order on 8/24/25. *Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML, 1 vial inhale orally every 4 hours as needed for wheezing related to chronic obstructive pulmonary disease. Start date 8/20/25. The MAR indicated RN O administered the physician order on 8/25/25 at 4:16 a.m. During an observation and interview on 8/24/25 at 11:16 a.m., Resident #97 was sitting in a recliner. Resident #97's nasal cannula was connected to the flowmeter on the wall. The flowmeter indicated Resident #97 was on 3 liters per minute. Resident #97 said he had received a nebulizer treatment earlier and it had really helped his breathing. Resident #97's nebulizer mask was on the nightstand not stored in a bag. During an interview on 8/25/25 at 3:04 p.m., LVN K said the residents' nebulizer mask was supposed to be stored in bag when it was not in use. She said the nurses were supposed to make sure the mask was stored in a bag. She said the CNAs could also notify the nurses if they noticed the mask not in the bag. She said she was not sure why the nebulizer mask had to be in bag. She said it was probably because of bacteria. During an interview on 8/25/25 at 3:23 p.m., CNA E said the nurses were responsible for storing the nebulizer mask when it was not in use. She said it was important to store it in a bag to keep it away from germs and cross contamination. During an interview on 8/26/25 at 3:00 p.m., the ADON N said nursing was responsible for the residents' respiratory equipment. She said she expected the nurses to follow the physician orders related to the ordered liters. She said she expected the nurses to always check the oxygen cylinder tanks to make sure they were not empty. She said if the resident was not on the ordered number of liters or using an empty oxygen tank, they could not have an adequate supply of oxygen. She said decrease oxygen levels could cause shortness of breath and anxiety. She said the nebulizer mask should be stored in a bag when it was not in use. She said it was stored in bag to prevent the spread of infections. She said Resident #13 should have a tracheostomy order. She said the staff would not know the correct size if something happened. She said nursing management oversaw the nursing staff. She said the nursing management oversaw this process by checking orders and making rounds. During an interview on 8/26/25 at 5:44 p.m., the ADM said the charge nurses were responsible for the residents' respiratory equipment. He said the nursing administration should oversee the nurses. He said the residents should be on the ordered number of liters and a filled oxygen tank to provide adequate need of oxygen and for proper oxygen levels. He said this prevented shortness of breath. He said the nebulizer mask should be stored in bag when not in use. He said it was important to do this for infection control and dust. He said not storing the mask properly placed the resident at risk of an infection. He said Resident #13 should have a tracheostomy order. He said it was important for proper ordered care and tracheostomy care. He said without a tracheostomy order it placed the resident at risk for infection and harm. He said the DON oversaw the nursing staff. He said the process should be overseen by monitoring orders daily and rounding with assessments. During an interview on 8/26/25 at 6:13 p.m., the DON said the nurses were responsible for oxygen therapy and equipment. She said the residents should be on the ordered number of liters and a filled oxygen tank to maintain comfort. She said not doing those things placed the residents at risk for a negative outcome. She said the nursing management should oversee this process by monitoring and education. She said the nurses were responsible for obtain a physician order for Resident #13's tracheostomy. She said a physician order was important for care and knowledge. She said it also ensured accurate medical records. She said the clinical team oversaw the nurses. Record review of facility policy titled, “Oxygen Administration” dated October 2010 revealed that, “The purpose of this procedure is to provide guidelines for safe oxygen administration…. Record review of facility policy titled, “Oxygen Administration” dated October 2010 revealed that, “The purpose of this procedure is to provide guidelines for safe oxygen administration…. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review the resident's care plan to assess for any special needs of the resident. Assemble the equipment and supplies as needed. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter. The oxygen mask is a device that fits over the resident's nose and mouth. It is held in place by an elastic band placed around the resident's head. The nasal cannula is a tube that is placed approximately one-half inch into the resident's nose. It is held in place by an elastic band placed around the resident's head. The nasal catheter is a piece of tubing inserted through the resident's nostrils into the back of his/her mouth. It is held in place by a piece of skin tape attached to the resident's forehead and/or cheek. After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record the date and time that the procedure was performed. The name and title of the individual who performed the procedure. The rate of oxygen flow, route, and rationale. The frequency and duration of the treatment. The reason for as needed administration. All assessment data obtained before, during, and after the procedure. How the resident tolerated the procedure. Record review of facility policy titled, “Tracheostomy Care” dated August 2013 revealed that, “…The purpose of this procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas… Preparation and Assessment… Check physician order…”

Based on observation, interview, and record review, the facility failed to assist residents in obtaining routine dental care for 3 of 3 (Resident's #35, #100, and #37) residents reviewed for dental services. The facility failed to ensure adequate follow-ups were completed on dental referrals for Residents #35, #100, and #37. This failure could affect residents by placing them at risk for oral complications and diminished quality of life. Findings included: Record review of a face sheet dated 08/27/2025 indicated Resident #35 was a [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses including acute kidney failure, heart failure, hypertension (high blood pressure), and altered mental status. Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #35 understood others and was understood by others. The MDS indicated Resident #35 had a BIMS of 12 and was moderately cognitively impaired. The MDS indicated Resident #35 did not have any mouth or facial pain, discomfort, or difficulty swallowing. The MDS indicated Resident #35 had natural teeth. Record review of Resident #35's electronic data record indicated no dental referral had been made. During an observation and interview on 08/24/2025 at 10:26 AM, Resident #35 stated her implants broke. Resident #35 was observed with only anchorage implant wires present in her mouth. Resident #35 voiced concerns regarding a referral for dental services to be provided by the facility. Resident #35 stated no one at the facility had ever visited with her regarding the need for her implants to be repaired. Resident #35 stated she had difficulty eating most of the time unless food was soft. Resident #35 stated she would like to have her implants so that she could have a better variety of food to eat. Record review of the face sheet dated 08/27/2025 indicated, Resident #100 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included congestive heart failure, hypertension (high blood pressure), cerebrovascular disease (affects the blood vessels of the brain and circulation), hyperlipidemia (high levels of fat particles in the blood). Record review of the Quarterly MDS assessment dated [DATE] indicated, Resident #100 was understood by others and understood others. The MDS indicated Resident #100 had a BIMS of 13 and was cognitively intact. The MDS indicated Resident #100 required maximum assistance with toileting, dressing, and bathing. The MDS indicated Resident #100 did not have any mouth or facial pain, discomfort, or difficulty chewing. Record review of Resident #100's electronic data record indicated no dental referral had been made. During an interview on 08/24/2025 at 10:35 AM, Resident #100 stated she had pain in her teeth. Resident #100 stated it had been a very long time since anyone in the facility had followed up with her regarding her dental needs. Resident #100 stated she was able to eat but suffered from throbbing tooth pain at times that would eventually go away. Record review of the face sheet dated 08/27/2025 indicated, Resident #37 was an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included cerebral infarction (occurs when blood flow to brain is interrupted resulting in tissue damage), chronic obstructive pulmonary disease (breathing difficulties), hypertension (high blood pressure), cerebrovascular disease (affects the blood vessels of the brain and circulation), hyperlipidemia (high levels of fat particles in the blood). Record review of the Quarterly MDS assessment dated [DATE] indicated, Resident #37 was usually understood by others and usually understood others. The MDS indicated Resident #37 had a BIMS of 0 and could not complete the interview. The MDS indicated Resident #37 required maximum assistance with toileting, dressing, and bathing. The MDS indicated Resident #37 did not have any mouth or facial pain, discomfort, or difficulty chewing. Record review of Resident #37's electronic data record indicated no dental referral had been made. During an interview and observation on August 2408/24/2025 at 11:02 AM, Resident #37 stated he did not have any teeth and wanted dentures. Resident #37 said the facility was supposed to be letting him know something but never had. During an interview on 08/24/2025 at 12:13 PM., the Social Worker said she was responsible for dental referrals and the follow -ups. The Social Worker said the facility had made dental referrals and most every resident in the facility had been referred in May. The Social Worker was not able to provide any documentation of communication following the referral for Resident #35's dental implants, Resident #100's post dental visit status, or Resident # 37's financial update from Medicaid regarding dental services for his dentures. The Social Worker said it was important to make dental referrals and to follow-up on the referrals appropriately and timely to prevent weight loss and ensure the residents' needs were met. During an interview on 08/26/2025 at 4:00 PM, the DON said she was not aware of Resident #35's dental implant issues. The DON said she expected the Social Worker to ensure and handle those types of dental referrals appropriately and timely, so the residents do not have any type of deficits such as weight loss or pain associated with dental needs going unnoticed. Did you ask about the other residents? During an interview on 08/26/2025 at 04:30PM., the Administrator said the Social Worker was responsible for dental referrals and follow-ups. The Administrator said it was important to make dental referrals and follow-ups to prevent pain, weight loss and ensure the residents' dignity and needs were met appropriately. The Administrator said it was very important to follow up and communicate with the family/resident to ensure all avenues were covered to complete the referral processes. Record review of the facility's Dental Services policy last revised on 6/2022 indicated, It is the policy of this facility to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. Routine dental services means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease dental radiographs as needed dental cleaning, fillings (new and repair), minor partial or full denture adjustments, smoothing of broken teeth, and limited prosthodontic procedure, e.g., taking impressions for dentures and fitting dentures. Emergency dental services includes services needed to treat an episode of acute pain in teeth, gums, or palate; broken, or otherwise damaged teeth, or any other problem of the oral cavity that required immediate attention by a dentist.

Based on observations, interviews, and record review the facility failed to ensure each resident receives and the facility provides food that accommodates residents' food preferences for 4 of 22 residents (Resident#13, Resident #41, Resident #75, and Resident #97) reviewed for the accommodation of resident's meal choices.The facility failed to ensure Resident#13, Resident #41, Resident #75, and Resident #97 meal choices were honored.This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss. Findings included: 1. Record review of Resident #13's face sheet, dated 8/24/25, indicated Resident #13 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #13 had diagnoses including Type 2 diabetes (is a chronic condition that happens when you have persistently high blood sugar levels) and chronic respiratory failure (is a condition where the lungs are unable to provide enough oxygen to the body over a prolonged period, leading to low oxygen levels in the blood (hypoxemia)). Record review of Resident #13's quarterly MDS assessment dated [DATE] indicated Resident #13 was understood and had the ability to understand others. Resident #13 had a BIMS score of 15 which indicated intact cognition. Resident #13 required supervision for eating. Resident #13 was on a therapeutic diet. Record review of Resident #13's care plan dated 6/16/23 indicated Resident #13 was at risk for weight fluctuations due to obesity, changes in appetite, difficulty adjusting to new environment, and recent hospitalization. Intervention included provide prescribed diet and observe closely during mealtimes. During an observation and interview on 8/24/25 at 2:27 p.m., Resident #13 was sitting on the bed. Resident #13 had an uneaten salad on her bedside table. Resident #13 said she had not received what she had asked for. She said she eventually settled on a salad. 2. Record review of Resident #41's face sheet dated 9/2/25 indicated Resident #41 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #41 had diagnoses including chronic obstructive pulmonary disease (is a chronic lung disease that causes inflammation and narrowing of the airways, leading to airflow obstruction), chronic respiratory failure (is a condition where the lungs are unable to provide enough oxygen to the body over a prolonged period, leading to low oxygen levels in the blood (hypoxemia)), heart failure (is a condition where the heart muscle is weakened or stiffened, making it unable to pump blood effectively), and nutritional anemia (is a lack of healthy red blood cells caused by lower than usual amounts of vitamin B-12 and folate). Record review of Resident #41's quarterly MDS assessment dated [DATE] indicated Resident #41 was understood and had the ability to understand others. Resident #41 had a BIMS score of 4 which indicated severely impaired cognition. Resident #4 required supervision for eating. Resident #41 was on a therapeutic diet. Record review of Resident #41's care plan dated 9/29/24 indicated Resident #41 had an ADL self-care performance deficit related to disease process. Intervention included eating: Resident #41 required times 1 staff participation to eat. During an interview on 8/24/25 at 11:57 a.m., Resident #41 said she received the food she ordered 50% of time. She said the food was what you would expect in a nursing home. 3. Record review of Resident #75's face sheet dated 8/25/25 indicated Resident #75 was an [AGE] year-old male admitted to the facility on [DATE]. Resident #75 had diagnoses including congestive heart failure (is a condition where the heart muscle is weakened and cannot pump blood effectively), type 2 diabetes (is a chronic condition that happens when you have persistently high blood sugar levels), and hemiplegia (is paralysis that affects only one side of your body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction affecting left non-dominant side(occurs when blood flow to the brain is interrupted, leading to tissue damage). Record review of Resident #75's admission MDS assessment dated [DATE] indicated Resident #75 was understood and had the ability to understand others. Resident #75's BIMS score was 12 which indicated moderate cognitive impairment. Resident #75 required setup for eating. Resident #75 had signs and symptoms of possible swallowing disorder due to holding food in mouth/cheeks or residual food in mouth after meals. Resident #75 had a mechanically altered and therapeutic diet.Record review of Resident #75's care plan dated 8/24/25 indicated Resident #75 had an ADL self-care performance deficit related to hemiplegia and impaired balance. Intervention included Resident #75 required times one staff participation to eat.During an observation and interview on 8/24/25 at 10:51 a.m., Resident #75 was lying in bed watching television. Resident #75 was hard of hearing. He said it did no good filling out the lunch form. He said he would fill the lunch form out but would not get what he ordered. 4. Record review of Resident #97's face sheet dated 8/25/25 indicated Resident #97 was a [AGE] year-old male admitted to the facility on [DATE]. Resident #97 had diagnoses including myocardial infarction (occurs when blood flow decreases or stops in one of the coronary arteries of the heart), congestive heart failure (is a condition where the heart muscle is weakened and cannot pump blood effectively), chronic obstructive pulmonary disease (is a chronic lung disease that causes inflammation and narrowing of the airways, leading to airflow obstruction), and acute and chronic respiratory failure (is a condition where there's not enough oxygen or too much carbon dioxide in your body).Record review of Resident #97's admission MDS assessment dated [DATE] indicated Resident #97 was understood and had the ability to understand others. Resident #97 had a BIMS score of 15 which indicated an intact cognition. Resident #97 required setup for eating. Resident #97 had signs and symptoms of possible swallowing disorder due to holding food in mouth/cheeks or residual food in mouth after meals.Record review of Resident #97's care plan dated 8/17/25 indicated Resident #97 was at risk for weight fluctuations due to changes in appetite, difficulty adjusting to new environment, and recent hospitalization. Intervention included provide prescribed diet and observe closely during mealtimes. During an interview on 8/24/25 at 11:16 a.m., Resident #97 said he had a loss of appetite since admission. He said he went through stages of appetite changes. He said there was a 50/50 chance he would get what he ordered for meals. During an interview on 8/26/25 at 11:03 a.m., CNA A said the CNAs asked the residents in the morning what they wanted for lunch and dinner. She said Resident #75 was very particular about his meal choices. She said Resident #97 was also picky about his food. She said Resident #13 could be picky sometimes. She said the residents sometimes complained about not getting what they ordered. She said most of the time, the residents did not get the meal according to their meal ticket. She said then the CNAs had to go back to the kitchen and get what the residents ordered. She said the residents got very mad and wanted to get the correct food choices. She said the residents not getting the meal choices could cause weight loss and not eating. She said the resident could also refuse to eat the rest of the day or cause depression. During an interview on 8/26/25 at 12:10 p.m., LVN H said the CNAs were responsible for getting the residents meal choice. She said in the morning, the CNAs got the residents meal choices for lunch, dinner, and the next day's breakfast. She said she had not received a lot of complaints from the residents about not getting their meal choices. She said the Cooks with DM overseeing them should make sure the residents were being served their meal choices. She said then it was the responsibility of the nursing staff. She said the dietary staff was usually accommodating. She said she did not know about Resident #13 not getting what she wanted for lunch last Sunday (8/24/25). She said she did notice Resident #13 eating a salad last Sunday (8/24/25). She said when the residents did not get their meal choices, it could cause weight loss leading to skin breakdown. She said the residents could feel angry not receiving want they ordered. During an interview on 8/26/25 at 1:47 p.m., [NAME] M said she was responsible for reading the residents' meal tickets and plating the food. She said it was important to serve the residents' meal choices because it was what they wanted and to follow the ordered diet. She said the residents could feel unhappy when they were served the wrong meal choices. She said the kitchen tried to fix any problems brought to their attention. She said if the residents were served the wrong meal choices, they could experience weight loss. She said the kitchen had alternative meals options and the always available menu. She said it was important for the residents to have their meal choices because it was their right. During an interview on 8/26/25 at 1:55 p.m., the Dietary Manager said the [NAME] Aides were responsible for writing on the residents' meal tickets. She said the Cooks were responsible for plating the food. She said the residents should receive their meal choices because it was their choice and right. She said it probably did not make the residents feel too good when they did not receive their meal choices. She said if the residents did not receive what they wanted then she sent a [NAME] Aide to talk to the residents. She said the residents could experience weight loss when they did not receive their meal choices. She said she was responsible for the whole system. During an interview on 8/26/25 at 3:00 p.m., the ADON N said Resident #75 complained once to her about his meal. She said something had gotten substituted. She said the nursing staff sent the meal choices to the kitchen. She said the kitchen should send out the residents correct meal choices. She said the nurses checked the meal ticket for accuracy before giving it to the CNAs. She said if the residents received something they did not want, they tried to get them something else. She said the residents not receiving their meal choices could upset them. She said it could cause weight fluctuation. She said the Dietary Manager oversaw the dietary staff. She said the nurses oversaw the CNAs. She said the nursing administration and IDT discussed dietary concerns in the morning meetings. She said most of the complaints about the food was not like home cooked meals. During an interview on 8/26/25 at 5:16 p.m., CNA P said she remembered last Sunday (8/24/25) that Resident #13 wanted chicken tenders for lunch. She said Resident #13 ended up getting a salad instead. During an interview on 8/26/25 at 5:44 p.m., the ADM said the CNAs were responsible for getting the residents' meal choices. He said the charge nurses were responsible for reviewing the meal tickets. He said the dietary staff should ensure what was on the meal ticket was served. He said the residents could feel upset if their meal choices were not served. He said it was important to serve the residents their meal choice because of dignity and risk of weight loss. He said the Dietary Manger and ADM should ensure the staff were serving the residents their meal choices. During an interview on 8/26/25 at 6:13 p.m., the DON said the dietary and nursing staff were responsible for ensuring the residents received their meal choices. She said the staff should be checking the residents' meal tickets before they were served. She said the residents could be disappointed when they were not served their meal choices. She said the residents could choose not to eat and potential cause weight loss. She said the DON and ADM oversaw this process. She said they should oversee the process by monitoring meal service and getting feedback from the mangers involved during meal service. Record review of a facility's Inservice Record Log dated 7/8/25 indicated, .Dietary: Department.Date: 7/8/25.Subjects: Meals being served in a timely manner and items not being served per residents' choice.Dietary is to also notify nursing in a timely manner if the menu changes so that residents can be aware of the changes. Seven dietary staff members signed the in-service log. Record review of a facility's Resident Rights policy revised on 12/2016 indicated, .Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to. self-determination. exercise his or her rights as a resident of the facility.

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 22 residents (Residents #9), 1 of 1 laundry rooms, and 1 of 6 halls (Hall 100) reviewed for infection control practices. 1. The facility failed to ensure Resident #9's urinary catheter bag was not touching the floor on 8/26/25. 2. The facility failed to ensure the Housekeeping/Laundry Supervisor L did not let clean blankets touch the floor during the folding process on 8/26/25. 3. The facility failed to ensure proper infection control measures when CNA D served ice from the ice chest cooler located on Hall 100 on 08/24/2025.These failures could place residents at risk for cross contamination, at an increased risk of infection, and the spread of infection. Findings included: 1. Record review of Resident #9's face sheet dated 8/26/25 indicated he was [AGE] years old and was admitted to the facility on [DATE]. Resident #9 had diagnoses which included urinary tract infection, heart failure, chronic kidney disease, extended spectrum beta lactamase (ESBL) resistance (infection that has resistance to many common antibiotics), weakness and lack of coordination. Record review of Resident #9's admission MDS assessment dated [DATE] indicated Resident #9 had a BIMS score of 9, which indicated he had moderate cognitive impairment. Resident #9 required a wheelchair or walker for mobility. Resident #9 was dependent on staff for most ADL's, including toileting and transfers. Resident #9 had an indwelling urinary catheter (tube inserted into the bladder to drain urine out of the body). Record review of Resident #9's Care Plan indicated he had an indwelling catheter for urine retention. Resident #9 was on Enhanced Barrier Precautions (an infection control strategy that uses gloves/gowns during high-contact resident care to reduce the spread of multidrug-resistant organisms) and at risk for infection related to indwelling medical device. During an 8/26/2025 at 8:16 AM, Resident #9 was lying in bed asleep with his bed in the low position. Resident #9's urinary catheter drainage bag was attached to the side of his bed and was sitting on the floor. During an observation and interview on 8/26/2025 at 2:17 PM, Resident #9 said staff hang his urinary catheter drainage bag under his wheelchair, Resident #9's urinary catheter drainage bag was dragging the floor under his wheelchair in his room. Resident #9's RP was in the room visiting. During an interview on 8/26/25 at 2:22 PM, LVN K said the urinary catheter drainage bag should be stored on a non-moveable part of the bed or wheelchair and below the resident's bladder. LVN K said everyone would be responsible for ensuring the urinary catheter drainage bag was covered and stored properly. LVN K said the urinary catheter drainage bag should not be dragging the floor. LVN K said if the urinary catheter drainage bag drug the floor, it could pull the urinary catheter out of the resident. LVN K said it would be an infection control and could increase the resident's risk of infection. During an interview on 8/26/2025 at 2:38 PM, CNA A said she had worked at the facility since November of 2024. CNA A said she was assigned to the 400 hall, but she helped wherever needed. CNA A said the nurse or aide on duty would be responsible for ensuring the urinary catheter bag was covered and not dragging the floor. CNA A said if the urinary catheter drainage bag drug the floor, it could possibly get poked and cause leakage. CNA A said the urinary catheter bag should not be dragging the floor because it could cause a rip and leak, and it would contaminate the bag. CNA A said it would be an infection control issue. CNA A said if the urinary catheter bag drug the floor, it could cause an infection for the resident. During an interview on 8/26/2025 at 3:17 PM, CNA D said the urinary catheter bag should not touch the floor because it could get dirty and germs. CNA D said the urinary catheter bag would need to be replaced because it would be contaminated. CNA D said the nurse and the aides would be responsible for ensuring the urinary catheter bag was not touching the floor. During an interview on 8/26/2025 at 3:50 PM, the ADON said the urinary catheter bag should not be allowed to touch the floor because it increased the risk of infection for both the resident and other people. The ADON said it would be an infection control issue. During an interview on 8/26/2025 at 4:27 PM, the DON said the cover flap of the urinary catheter bag was for privacy. The DON said the urinary catheter bag should be hung below the resident's bladder and “definitely not” touching the floor, because of contamination. The DON said the urinary catheter bag dragging/touching the floor, could cause injury or infection to the resident. The DON said the CNAs and nursing staff would be responsible for ensuring the urinary catheter bag was not dragging/touching the floor. During an interview on 8/26/2025 at 4:52 PM, the ADM said he would expect the urinary catheter bag to be stored off the floor and not allowed to drag under a resident's wheelchair due to risk of infection. The ADM said allowing the urinary catheter bag to drag/touch the floor was an infection control issue and placed the resident at risk for infection. 2. During an interview and observation on 8/26/25 at 1:28 p.m., the HSK/Laundry Supervisor L said she had been employed at the facility for 6 years. During the interview process, HSK/Laundry Supervisor L took a clean, facility provided blanket out of a wire hamper and proceeded to fold the blanket. She allowed the corners of four facility provided blankets to touch the floor. She folded the four blankets and set them on the counter near other laundry items. HSK/Laundry Supervisor L became upset when questioned about the four blankets. She snatched the blankets off the counter and said, “we don't have big enough tables for them not to touch the floor!” She took the blankets to the dirty side of the laundry room. She said the blankets could not touch the floor because the floor was contaminated. During an interview on 8/26/25 at 3:00 p.m., the ADON N said the clean laundry should not touch the floor. She said the laundry personnel was responsible for ensuring the laundry did not get contaminated. She said but anyone who saw the laundry touching the floor was responsible. She said it was an infection control issue. She said it placed the residents at risk for getting an infection. During an interview on 8/26/25 at 5:44 p.m., the ADM said if clean laundry touched the floor, he expected it to be discarded. He said laundry could not touch the floor because of infection control. He said it placed the resident at risk for potentially getting an infection. He said the Laundry Supervisor should ensure infection control was followed but, the Supervisor was the one observed letting the laundry touch the floor. He said he oversaw the HSK/Laundry Supervisor L. He said the laundry department was contractual workers. During an interview on 8/26/25 at 6:13 p.m., the DON said she expected the laundry to be discarded if it touched the floor. She said laundry could not touch the floor because of infection control. She said it placed the resident at risk for cross-contamination. 3. During an observation on 08/24/2025 at 10:55 AM, CNA D filled a resident's water cup with ice directly over the ice cooler. The water overflowed, spilling into the cooler and running down CNA D's hand into the ice supply. CNA D continued to serve ice to the residents on Hall 100. During an interview on 08/25/2025 at 2:35 PM, CNA D stated she did not fill the cup over the ice cooler. CNA D stated the water did not overflow from the cup into the cooler. CNA D stated those practices could cause cross contamination and could make a resident sick. During an interview on 08/26/2025 at 4:00 PM, the DON stated the residents' cups should not be filled over the ice cooler containing ice for the rest of the residents. The DON said the risk of cross contamination was high in that scenario. The DON said all staff were responsible to ensure cross contamination was prevented by following infection control protocols daily. The DON said it was important to follow infection control protocols to keep the residents free of sickness and infections. During an interview on 08/26/2025 at 4:45 PM, the Administrator stated he expected infection control policies to be followed by all the staff and all staff was responsible to ensure cross contamination was not occurring in the facility. The Administrator said the staff were responsible to ensure fresh ice and water were served to the residents daily per the infection control policy. Record review of the facility's policy titled Catheter Care, Urinary dated revised September 2014 indicated . the purpose of the procedure was to prevent catheter-associated urinary tract infections … Infection Control … b. be sure the catheter tubing and drainage bag were kept off the floor …”. Record review of the facility's policy titled Infection Prevention and Control Program dated revised August 2016 indicated . The infection prevention and control program were a facility-wide effort involving all disciplines and individuals and was an integral part of the quality assurance and performance program … Prevention of Infection … a. important facets of infection prevention include … identifying possible infections or potential complications of existing infections … educating staff and ensuring that they adhere to proper techniques and procedures …”.

Based on observation, interviews, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 2 of 22 residents (Resident #9 and Resident #25) reviewed for resident rights.1. The facility failed to ensure Resident #9's urinary catheter bag was covered with the privacy cover flap. 2. The facility failed to ensure CNA D and CNA G knocked on Resident #25's door before entering on 8/25/25.3. The facility failed to ensure CNA D and CNA G closed Resident #25's privacy curtain during catheter care on 8/25/25.4. The facility failed to ensure CNA D and CNA G properly covered Resident #25 during catheter care on 8/25/25.These failures could place residents at risk of humiliation, diminished quality of life, loss of dignity and self-worth. Findings included: 1. Record review of Resident #9's face sheet dated 8/26/25 indicated he was [AGE] years old and was admitted to the facility on [DATE]. Resident #9 had diagnoses which included urinary tract infection, heart failure, chronic kidney disease, extended spectrum beta lactamase (ESBL) resistance (infection that has resistance to many common antibiotics), weakness and lack of coordination. Record review of Resident #9's admission MDS assessment dated [DATE] indicated Resident #9 had a BIMS score of 9, which indicated he had moderate cognitive impairment. Resident #9 required a wheelchair or walker for mobility. Resident #9 was dependent on staff for most ADL's, including toileting and transfers. Resident #9 had an indwelling urinary catheter (tube inserted into the bladder to drain urine out of the body). Record review of Resident #9's Care Plan indicated he had an indwelling catheter for urine retention. Resident #9 was on Enhanced Barrier Precautions (an infection control strategy that uses gloves/gowns during high-contact resident care to reduce the spread of multidrug-resistant organisms) and at risk for infection related to indwelling medical device. During an observation and interview on 8/24/2025 at 11:29 AM, Resident #9 was sitting in his wheelchair in his room and said he had just returned from a group activity. Resident #9 had a urinary catheter, and the privacy cover flap was bunched up under the hanging hook under his wheelchair and was not covering the urine in his drainage bag. During an observation on 8/24/2025 at 2:56 PM, Resident #9 was sitting in his wheelchair in the lobby area in front of the nurses' station. Resident #9's privacy cover of his urinary catheter bag continued to be bunched up under the hanging hook under the wheelchair and was not covering the urine in the urinary drainage bag. During an interview on 8/26/2025 at 2:17 PM, Resident #9 said he did not know his urinary catheter bag was not covered Sunday because the staff hung it under his wheelchair. Resident #9 said he would not want his urine in his bag to be seen by everyone when he was out in the hallways, and he did not like it. Resident #9 said even at his home, he kept his urinary catheter bag in a cloth bag to cover it. During an interview on 8/26/25 at 2:22 PM, LVN K said the urinary catheter drainage bag privacy cover flap was for the resident's privacy, it covered the resident's urine, so it was not exposed to everyone. LVN K said if the urinary catheter drainage bag was not covered, it could be embarrassing for some residents. LVN K said if the privacy flap was not covering the urinary catheter drainage bag, the resident could be embarrassed, have low self-esteem, and not want to have to answer questions to other residents. LVN K said all staff would be responsible for ensuring the urinary catheter drainage bag was covered and stored properly. LVN K said all staff could pull the privacy flap on the urinary catheter drainage bag down and reposition it. During an interview on 8/26/2025 at 2:38 PM, CNA A said she had worked at the facility since November of 2024. CNA A said she was assigned to the 400 hall, but she helped wherever needed. CNA A said the nurse or aide on duty would be responsible for ensuring the urinary catheter bag was covered. CNA A said most residents would not like letting everyone see their urine in the bag. CNA A said the cover for the urinary catheter bag was to provide privacy for the resident. CNA A said staff should make sure the urinary catheter bag cover flap was down and covering the urinary catheter bag when attaching it to the resident's wheelchair. CNA A said the nursing staff and aides would be responsible for ensuring the urinary catheter cover was covering the urine in the bag for the privacy of the resident. During an interview on 8/26/2025 at 3:17 PM, CNA D said the cover on the urinary catheter bag was for the privacy of the resident. CNA D said if the urine in the urinary catheter was not covered, it could cause the resident to be embarrassed. CNA D said the nurse and the aides would be responsible for ensuring the cover was covering the urinary catheter bag. During an interview on 8/26/2025 at 3:50 PM, the ADON said the cover on the urinary catheter bags was to cover the urine in the bag for the resident's privacy. The ADON said if the urinary catheter bag was not covered it could be embarrassing for the resident. During an interview on 8/26/2025 at 4:27 PM, the DON said the cover flap of the urinary catheter bag was for privacy. The DON said the CNAs and nursing staff would be responsible for ensuring the privacy cover was covering the urine in the bag. The DON said people could see the urine in the bag and cause the resident to not feel good about it. During an interview on 8/26/2025 at 4:52 PM, the ADM said he would expect the urinary catheter bag cover to cover the urine in the catheter bag for the privacy and dignity of the resident. The ADM said if the urinary catheter bag was not covered it could affect the resident's dignity. 2. Record review of Resident #25's face sheet dated 8/26/25 indicated Resident #25 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted [DATE]. Resident #25 had diagnoses including heart failure (is a condition where the heart muscle is weakened or stiffened, making it unable to pump blood effectively), neuromuscular dysfunction of bladder (a person does not have bladder control because of brain, spinal cord, or nerve problems), dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), major depressive disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and generalized anxiety disorder (is a chronic mental health condition characterized by excessive, persistent, and uncontrollable worry about various everyday events or situations). Record review of Resident #25's annual MDS assessment dated [DATE] indicated Resident #25 was usually understood and usually had the ability to understand others. Resident #25's BIMS score was 5 which indicated severe cognitive impairment. Resident #25 required substantial/maximal assistance for toileting hygiene. Resident #25 had an indwelling catheter. Record review of Resident #25's care plan dated 10/30/22 indicated Resident #25 had an ADL self-care deficit related to dementia. Intervention included required staff participant times 1 to use toilet. Record review of Resident #25's care plan dated 7/7/25 indicated Resident #25 had an indwelling catheter related to atonal bladder (is a condition where the bladder muscles are weak and do not contract properly, leading to difficulty or inability to urinate). Intervention included change catheter as indicated. During an observation on 8/25/25 at 4:00 p.m., CNA D and CNA G entered Resident #25's room without knocking. CNA D and CNA G washed their hands and donned gowns. CNA D lowered Resident #25's covers to his ankles. Resident #25 had a t-shirt and brief on. Resident #25 complained about being cold. CNA D unattached Resident #25's brief and exposed his perineal area. The surveyor remained at the foot of Resident #25's bed until catheter care started. The surveyor moved next to CNA D to closely observe catheter care being provided. Resident #25's privacy curtains were left open. Resident #25's roommate was in the room. During an interview on 8/26/25 at 2:18 p.m., the surveyor attempted to interview Resident #25 about catheter care performed on 8/25/25. Resident #25 had disorganized thinking and started talking about luggage in his room. Unable to interview Resident #25. During an interview on 8/26/25 at 2:20 p.m., CNA D said she knocked and introduced herself to Resident #25. She said she did not pull the privacy curtain because the surveyor was in the way. She said Resident #25's blankets should have been at his knees. She said it was important to knock before entering a residents' room, pull the privacy curtain, and cover the residents to provide them privacy. She said not providing the residents privacy could make them feel embarrassed or uncomfortable. During an interview on 8/26/25 at 2:31 p.m., LVN F said she expected the CNAs to knock on the residents' doors before entering. She said it provided privacy to the resident. She said she expected the CNAs to pull the privacy curtains during cares. She said if the CNAs felt like the surveyor was in the way of closing the privacy curtain, they should ask the surveyor to step in to close the curtain. She said it was important to close the privacy curtains during cares to provide privacy and dignity. She said during catheter care, the residents' body should be covered as much as possible. She said this provided comfort, dignity, and privacy. She said Resident #25 liked to be covered because he was always cold. She said the residents could feel like their rights were taken away and dignity not being honored. During an interview on 8/26/25 at 3:00 p.m., ADON N said she expected the nursing staff to knock before entering a residents' room, close privacy curtains and cover the resident during cares. She said it was the resident's right and dignity. She said if those things were not done, the resident could be embarrassed. She said nursing management did competency check offs upon hire and skill check offs to ensure staff did those things. During an interview on 8/26/25 at 5:44 p.m., the ADM said he expected the nursing staff to knock on the residents' doors before entering, cover the resident as much as possible and close privacy curtains during catheter care. He said it was important to do those things for dignity and privacy. He said when those things were not done, the resident could feel undignified. He said the facility ensured the nursing staff knew to do those things by doing competency check offs. During an interview on 8/26/25 at 6:13 p.m., the DON said she expected the nursing staff to knock on the residents' doors before entering, cover the resident as much as possible and close privacy curtains during catheter care. She said those things should be done for dignity. She said when those things were not done, it could have a negative effect on the resident. She said the nursing staff should be monitored to ensure those things were being done. She said the nursing staff was educated through training on resident rights. Record review of CNA D's, “C.N.A Proficiency Evaluation” dated 3/21/25 indicated, “…daily catheter care… explain procedure to the resident…provide privacy… met expectation…Director of Talent and Learning Q…” Record review of CNA G's, “C.N.A Proficiency Evaluation” dated 3/21/25 indicated, “…daily catheter care… explain procedure to the resident…provide privacy… met expectation…Director of Talent and Learning Q…” Record review of the facility's policy titled “Resident Rights” dated revised December 2016, indicated . employees shall treat all residents with kindness, respect, and dignity … federal and state laws guarantee certain basic rights to all residents of this facility … these rights include the resident's right to … a dignified existence … be treated with respect, kindness, and dignity …”. Record review of the facility's policy titled “Quality of Life - Dignity” dated revised August 2009, indicated . each resident shall be cared for in a manner that promoted and enhanced quality of life, dignity, respect and individually … residents shall be treated with dignity and respect at all times … residents' privacy space and property shall be respected at all times … staff will knock and request permission before entering residents' rooms … staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures … staff shall promote dignity and assist residents as needed by … a. helping the resident to keep urinary catheter bags covered …“. Record review of a facility's, “Perineal Care” policy revised 10/2010 indicated, “…The purposes of this procedure arc to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition… 4. Fold the bedspread or blanket toward the foot of the bed… 5. Fold the sheet down to the lower part of the body. Cover the upper torso with a sheet… Avoid unnecessary exposure of the resident's body…”.

Based on observation, interview and record review, the facility failed to consult with the resident's physician and representative when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 22 residents (Resident #61) reviewed for notification of change.The facility failed to notify the NP/MD of Resident #61's complaint of left foot pain on 8/21/25.This failure could place residents at risk of not receiving adequate and timely intervention and a decline in condition.Findings included: Record review of Resident #61's face sheet dated 8/26/25 indicated he was [AGE] years old and was admitted to the facility on [DATE]. Resident #61 had diagnoses which included cerebral infarction (stroke-disruption of blood flow to the brain causing tissue damage), hemiplegia and hemiparesis (paralysis (unable to move) and/or muscle weakness on one side of the body) of left side, chronic embolism and thrombosis (blood clot) of deep veins of right lower extremity, chronic pain syndrome, weakness and lack of coordination.Record review of Resident #61's quarterly MDS assessment dated [DATE] indicated Resident #61 had a BIMS score of 13, which indicated he was cognitively intact. Resident #61 was dependent on staff for bathing, toileting, and dressing and required moderate staff assistance for most other ADL's. Resident #61 received pain medications as needed. Resident #61's pain rarely or not at all affected his sleep, therapy activities, or day-to-day activities. Resident #61 received opioid medication (prescription pain medication used to treat moderate to severe pain).Record review of Resident #61's Care Plan dated and last reviewed on 8/11/25 indicated he had osteoarthritis and was at risk for pain, decline in ADLs and mobility with interventions including: five analgesics as ordered by the physician, observe/document/report to physician as needed, signs and symptoms or complications related to osteoarthritis, such as joint pain, joint stiffness, usually worse on wakening, swelling, decline in mobility, decline in self-care ability, pain after exercise or weight bearing and report to nurse any change in level of activity or ability to perform ADLs. Resident #61 had recurrent deep vein thrombosis to right lower extremity. Resident #61 had limited physical mobility. Resident #61 had potential for pain with interventions including: acknowledge presence of pain and discomfort, listen to the resident's concerns, administer pain medications per physician orders, and report complaints and non-verbal signs of pain. Record review of Resident #61's nurses' notes ranging from 8/01/25 to 8/26/25 did not reveal any documentation from 8/18/25 to 8/26/25, until after surveyor intervention on 8/26/25. There was no mention of Resident #61 reporting left foot pain. After surveyor intervention, LVN H documented on 8/26/25, the resident stated pain to his left foot that was more on the inside of the bottom of his foot. LVN H noted the physician, obtained an order for an x-ray, and administered as needed pain medication.Record review of Resident #61's Physical Therapy Treatment Encounter Note dated 8/21/25 indicated PTA Y reported resident's foot pain to nursing and she was going to consult physician in regards to possibly getting an x-ray.Record review of Resident #61's NP follow-up visit note dated 8/21/25 indicated he continued to get stronger, participated in therapy sessions with improvements. Resident #61's review of systems indicated he was positive for activity change, arthralgias (joint pain) and gait problem. Resident #61 had acute left knee pain. The NP note indicated Resident #61 was sitting in wheelchair in his room. There was no mention of Resident #61 complaining of left foot pain in the NP note.Record review of Resident #61's physician note dated 8/26/25 indicated the reason for visit was left foot pain and Resident #61 stated the pain began approximately six days prior after being treated in therapy with a foot vibrator and he found it difficult to walk on the foot because of the pain. The note indicated Resident #61 had acute left foot pain, suspected to be arthritic, and would check an x-ray as a precaution. The note indicated the plan was to obtain left foot films, Tylenol for pain, and other medications as before. Record review of Resident #61's pain log indicated he had no pain 8/21/25 through 8/25/25, but he had pain at a level 6 on a 1-10 scale with 10 being the worse pain on 8/26/25.During an observation and interview on 8/24/25 at 10:13 AM, Resident #61 said his left foot hurt so bad and he could not stand on it, so he could not do therapy. Resident #61 said the nurses were aware and he was waiting on an x-ray of his left foot, but did not know when it would be scheduled. Resident #61 said his only concern was needing his left foot checked out.During an observation and interview on 8/26/25 at 8:25 AM, LVN H was on 400 hall passing medications. LVN H said Resident #61 had not reported having left foot pain to her and he normally only report left knee pain. LVN H said she would go talk to him.During an observation and interview on 8/26/25 beginning at 8:30 AM, LVN H entered Resident #61's room and asked him how he was doing. Resident #61 reported having left foot pain to the inside of his foot to LVN H. LVN H attempted to assess Resident #61's left foot and he told her to stop touching it because it hurt. LVN H told Resident #61, she would notify the physician about his foot. Resident #61 told LVN H he was waiting on an x-ray. After exiting Resident #61's room, LVN H stated that morning was the first time she had heard of his left foot pain and did not see any documentation about pain except his chronic pain to his left knee. LVN H said she notified the physician and obtained a stat order for an x-ray. During an interview on 8/26/25 at 8:40 AM, LVN H said she had spoken with therapy and therapy assessed him 8/25/25 and felt it was a soft tissue injury.During an interview on 8/26/25 at 10:40 AM with the Director of Rehab and PTA Y, PTA Y said Resident #61 had complained to him about his left foot hurting last Thursday (8/21/25) and he reported it to Resident #61's nurse the same day and the nurse told him she would notify the physician to see about getting an x-ray. The Director of Rehab said the Physical Therapist assessed his left foot on 8/25/25 and felt it was a soft tissue issue. The Director of Rehab said she would email all the notes she had for Resident #61.During an interview on 8/26/25 at 12:04 PM, LVN Z said she had worked at the facility since October of 2024 full-time. LVN Z said she was not sure if she worked 8/21/25, but she would assume that the schedule was correct. LVN Z said the therapist did report to her about Resident #61 complaining of pain to the instep area of his foot and felt he needed an x-ray to rule out a fracture. LVN Z said the therapist said Resident #61 complained of pain during some type of massage. LVN Z said she had tried to reach the NP to report it but thought she was not able to reach the NP. LVN Z said if she did not document his left foot pain and attempting to notify the NP, she may have gotten busy and forgot to document it. LVN Z said she was pretty sure she told the on-coming staff so they could follow up with it, and it should have been put on the 24-hour report. LVN Z said if the NP was not notified of him having pain, then it could have delayed Resident #61's treatment.During an interview on 8/26/25 12:30 PM, NP AA said she sees residents on Thursdays at the facility. NP AA said she saw Resident #61 on 8/21/25. NP AA said she was not sure of what time she saw him. NP AA said the 7:39 AM time on the 8/21/25 visit note was when she scheduled the visit for the encounter and did that before seeing the resident usually from home to plan her day.NP AA said the other time documented on her 8/21/25 note of 4:16 PM was after she had left the building and had reviewed his electronic health record and closed his note. NP AA said when she saw Resident #61, he was scooted down to the end of the bed and the arch of his foot was resting on the foot board. NP AA said she moved him up in bed and placed a pillow between his foot and the foot board and Resident #61 reported that the pain was relieved. NP AA said she did not include his complaint of left foot pain in her note because she felt it was positional since the pain relieved and it was not an on-going issue. NP AA said Resident #61 had complained of the pain when she took off his sock to assess his feet and he told her about the pain. NP AA said the nurse did not report to her Thursday (8/21/25) that Resident #61 was having pain to his left foot. NP AA said she was on-call for the facility Monday-Friday, 8AM-5PM and her covering physician was on-call on after 5PM and on the weekends. NP AA said she would expect to be notified of a resident having new pain. NP AA said a nurse did notify her this morning (8/26/25) about the pain and her covering physician was in the building and saw him and ordered an x-ray. NP AA said Resident #61 had as needed pain medications and was on pain management. NP AA said if she had not seen the resident on 8/21/25 and she had not been notified by nursing of his foot pain, it could have delayed his treatment. NP AA said Resident #61 wanted to walk and if he was still having foot pain then he would have been uncomfortable, and he would not want to move and he had to bear weight to walk. During an interview on 8/26/25 at 2:22 PM, LVN K said if a resident reported new pain, she would assess the pain, what made it worse, what made it better, consult physical therapy if needed, and she would report to physician to obtain any new orders for therapy or an x-ray, medications, etc. LVN K said if the nurse did not notify the physician of a resident's new complain of pain, it could prolong their pain, the condition could worsen, and the resident would not receive proper care because the physician made the decisions related to the resident's care.During an interview on 8/26/25 at 3:50 PM, ADON N said if therapy reported to the nurse about a new pain area, the nurse would need to assess the resident for any abnormal findings. ADON N said sometimes therapy may not know the resident as well as the nursing staff, so it would just depend on if it was truly something new on what steps would need to be taken. ADON N said the nurse should notify the physician if there was an abnormal finding. ADON N said if they were not able to notify the physician then the nurse would need to notify nurse management. ADON N said they have two medical directors, and staff could always notify the other one if unable to reach one. ADON N said they chart by exception, which meant staff should chart about anything abnormal. ADON N said the NP saw Resident #61 between morning meeting at 9:00 AM to about 12:00 PM. ADON N said she was Resident #61's nurse on Sunday (8/24/25), and he denied pain or need for pain medication. ADON N said if the nurse did not notify the physician or NP of abnormal findings, the resident could have something wrong, and they would not be treated for it. During an interview on 8/26/25 at 4:27 PM, the DON said NP AA had left the facility by 1:00 PM on 8/21/25 and she had spoken to NP AA and was told that she had assessed his left foot pain. The DON said there was a lack of communication between the nursing staff and NP AA about Resident #61's left foot pain and there should have been documentation addressing the therapist notifying the nurse and NP AA assessing it. The DON said if the physician/NP was not notified of abnormal findings, then the resident would not receive the treatment they needed.During an interview on 8/26/25 at 4:52 PM, the ADM said he would expect there to be documentation of the change of condition and notification of physician/NP. The ADM said if the physician/NP was not notified of a change in condition, the resident could receive improper care.Record review of the facility's policy titled Change in a Resident's Condition or Status dated revised February 2012, indicated . Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status . 1. The nurse supervisor/charge nurse would notify the resident's attending physician or on-call physician when there had been: a. an accident or incident involving the resident . d. a significant change in the resident's physical/emotional/mental condition . i. instructions to notify the physician of changes in the resident's condition . 4. Except in medical emergencies, notifications would be made within twenty-four hours of a change occurring in the resident's medical/mental condition or status .

Based on observation, interview, and record review, the facility failed to ensure the right to be free from any physical restraints imposed for purposes of convenience and not required to treat medical symptoms for 1 of 1 resident reviewed for restraint use (Resident #8).The facility failed to ensure Resident #8 was free from physical restraints in the form of seatbelt located on the wheelchair that Resident #8 was unable to remove independently. This failure could place residents at risk for a decreased quality of life, a decline in physical functioning and injury. Findings included:Record review of a face sheet printed on 8/24/2025 indicated Resident #8 was an [AGE] year-old, female and was readmitted on [DATE] with diagnoses including Chronic pain syndrome (a long-term condition characterized by persistent pain that last for months or years, significantly affecting daily life), hemiplegia affecting left nondominant side (partial or total paralysis on one side of the body), hypertension (occurs when the pressure in your blood vessels is consistently too high), age-related osteoporosis (occurs when the body loses bone mass) and neuromuscular dysfunction of bladder (occurs when there is a problem with the brain, nerves, or spinal cord that affects bladder control). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #8 was understood and understood others. The MDS indicated Resident #8 had a BIMS score of 14 which indicated she was cognitively intact. The MDS indicated Resident #8 had no functional impairment in her upper extremities and was impaired to both lower extremities requiring the use of mobile device of wheelchair in the last 7 days of the assessment period. The MDS indicated Resident #8 required substantial assistance with personal care such as toileting, showering/bathing, and dressing upper/lower body. The MDS indicated physical restraints were not used for Resident #8. Record review of a care plan last revised on 6/20/2025, indicated Resident #8 was at moderate risk for falls related to gait and balance problems. The care plan interventions included to anticipate and meet the resident's needs, keep call light within reach and encourage resident to use it for assistance as needed, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. The care plan inventions did not include a seatbelt or restraint. During an observation and interview on 8/25/2025 at 8:47 Am, Resident #8 was observed sitting up in her power wheelchair in the main area near the nurse's station. Resident #8 was observed to have a black safety belt securing her in the powerchair. Resident #8 observed to have limited grasp in her upper extremities, and she said she was unable to remove the seatbelt independently. Resident #8 said she wanted the safety belt on because she slides out of her wheelchair. During an observation and interview on 8/25/2025 at 1:21 PM, Resident #8 sitting in her wheelchair with the safety belt across her chest just below her breast. Resident said she wanted the safety belt on to help keep her in her seat. During an interview on 8/26/2025 at 9:35 AM, CNA R said Resident #8 was unable to transfer herself. She said Resident #8 could navigate the environment in her motorized wheelchair. CNA R said resident was contracted in her upper hands and sometimes had difficulty turning on her powerchair. CNA R said technically, she had restraints because she had a seatbelt on her wheelchair, so she does not flip out. CNA R said Resident #8 had the seatbelt on since she had worked at the facility which was 3 months. CNA R said the LVN or RN maybe responsible for the assessment of residents with restraints. CNA R said it maybe care planned. CNA R said she did not have access to the care plans. CNA R said when Resident #8 returns to bed, she would unlock the seatbelt. CNA R said the seatbelt was like a baby seatbelt. CNA R said she makes sure the seatbelt is not suffocating her. CNA R said Resident #8 could not unlock her own seatbelt. CNA R said she would consider the seatbelt a restraint. CNA R said she could not think of how the restraint could negatively impact Resident #8. She said Resident #8 was in her right mind and would come to staff for assistance or if something hurt her. During an interview on 8/26/2025 at 10:30 AM, LVN U said a restraint was anything that was preventing a Resident from moving freely. LVN U said there were no residents on Hall 200 that currently had restraints. She said if a resident had restraints, the Nurse Practitioner would have to put in an order for seatbelt or a restraint. LVN U said she considered a seatbelt on a wheelchair a restraint. LVN U said Resident #8 did not have a restraint on her wheelchair. LVN U said the nurses were responsible to assessing a resident with a restraint. LVN U said she did not know Resident #8 used the strap on her wheelchair and said it could be the mechanical lift sling strap. LVN U said Resident #8 would not be able to unlock a seatbelt. LVN U said Resident #8 could have respiratory issues from the strap or if the strap was too tight, it could cause sores. LVN U said Resident #8 did not have any issues. She said the policy for the nursing home would be the guide to determine if a resident required a restraint. LVN U said there would be an order and care planned. LVN U said the DON and MDS nurse were responsible for updating the care plan. During an interview and observation on 8/26/2025 at 11:06 AM, observed Resident #8 in her wheelchair. LVN U was present and said there was a seatbelt, and she was unaware. LVN U said the seatbelt was part of the wheelchair and not the mechanical lift sling. During an interview on 8/26/2025 at 11:53 AM, MDS Coordinator B said Resident #8 did not have a care plan for restraints. MDS Coordinator B said the nurse would be responsible for putting in the care plan for restraints. MDS Coordinator B said she was unsure if Resident #8 could unlock the seatbelt by herself. She said the nurses would be responsible for ensuring a resident was able to unlock themselves from a seatbelt. MDS Coordinator B said it could cause harm due to discomfort. MDS Coordinator B said Resident #8 had an evaluation on 2/26/2025 in her chart for physical restraints, but the documentation had NA (Not applicable) for restraints that was completed by the Unit Manager. MDS Coordinator B said the care plans were updated quarterly, and the staff have morning meetings where they discuss things that need to be updated. MDS Coordinator B said both MDS nurses were responsible for updating quarterly care plans. During an interview on 8/26/2025 a 12:40 PM, the Director of Therapy T said wheelchairs normally come with seatbelts. She said the therapist must reposition Resident #8 frequently and position her every day. Director of Therapy T said she did not think Resident #8 could unlock the seatbelt. She said the therapist had worked with her on gripping a spoon and fork. Director of Therapy T said the facility was a restraint free facility and she was not aware of the seatbelt. She said she did not know who was putting the seatbelt on Resident #8. She said she was shocked to see it on her. Director of Therapy T was told by Resident #8 after hearing about the seatbelt that she felt safer with it on. Director of Therapy T said another therapist was trying to figure out a way to keep her safe in her wheelchair and the foam cushion instead of the pillow. During an interview on 8/26/2025 at 12:45 PM, OTR S said Resident #8 was not able to grab with her left hand. She said Resident #8 could not unclamp a seatbelt and said she had never seen her use the seatbelt that was attached to the wheelchair. During an interview on 8/26/2025 at 12:52 PM, the ADON said the facility does not use restraints. The ADON said a seatbelt is not considered a restraint if the resident could unhook it. The ADON said she had not observed Resident #8 with a seatbelt on. The ADON said it was possible that Resident #8 could unlock the seatbelt. The ADON said typically, the facility staff work with therapy to determine if Resident #8 was able to unlock her seatbelt if in use. The ADON said it would need to be care planned and a restraint assessment would need to be completed by the nurses. The ADON said a resident could get a skin injury or cut themselves. The ADON said she had never seen a seatbelt on Resident #8.During an interview on 8/26/2025 at 3:31 PM, the DON said she had a conversation with Resident #8 and was told by Resident #8 she had told the aide she wanted to use the seatbelt. The DON said she spoke with CNA R, and she told her she did not ask the nurse whether Resident #8 was supposed to wear the seatbelt. The DON said CNA R was going by what Resident #8 wanted and felt comfortable. She said CNA R did not know to go to the nurse. The DON said therapy had not seen a seatbelt on Resident #8. The DON said she educated CNA R to go to the nurse and educated on restraints, orders, assessment and care plans. The DON said therapy was getting involved to work with Resident #8. The DON said CNA R was a new CNA and had gone through the classes and orientation. The DON said she expected the CNAs to go to the nurse to ask before placing a seatbelt on any resident. The DON said she expected the residents to be assessed for restraints and expected there to be an order. The DON said the nurses were responsible for ensuring the residents were restraint free. The DON said a restraint could have a negative outcome if not addressed. She said it could cause skin injury. During an interview on 8/26/2025 at 4:12 PM, the ADM said he considered a seatbelt a restraint if the resident was unable to unlock the seatbelt without assistance. He said he expected the staff and CNA to ask nurses about orders, assessments prior to using a restraint. He said using a restraint could affect the resident's dignity and psychologically. The ADM said he expected an order in place with return demonstration. The ADM said the nurses were responsible for ensuring orders, assessments were in place with the use of any restraints. The ADM said it would also need to be care planned. Record review of a facility's Use of Restraints policy revised December 2008 indicated .restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully .restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the preventions of falls .physical restraints are defined as any manual method or physical or mechanical device .which restricts freedom of movement .the definition of a restraint is based on the functional status of the resident .practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted .

Based on interviews and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 22 residents (Resident #3) reviewed for MDS assessment accuracy. The facility did not ensure Resident #3's quarterly MDS identified a diagnosis of Diabetes and use of insulin. These failures could place residents at risk for not receiving care and services to meet their needs.Findings included:Record review of the face sheet dated 8/25/2025 indicated Resident #3 was [AGE] year-old female who was readmitted [DATE] with diagnoses including fracture of lower end of left tibia (a break in the shinbone which is the larger bone in the lower leg), neuromuscular dysfunction of bladder (refers to a condition where the bladder's ability to store and release urine is impaired due to problems with nervous system), malignant neoplasm of uterus (a cancerous tumors that develop when cells in the lining of the uterus) and Diabetes (a group of diseases that affect how the body uses blood sugar). Record review of the most recent MDS dated [DATE] indicated Resident #3 was understood and understood others. Resident #3 had a BIMS score of 14 indicating she was cognitively intact. The MDS did not indicate Resident #3 was a Diabetic. In section N0350 of the MDS indicated Resident #3 was receiving Insulin injections in the last 7 days and was not marked to receiving hypoglycemic (including insulin) in section N0415.Record review of Resident #3's care plan revised on 7/15/2025 did not indicate Resident #3 was a Diabetic. Record review of Resident #3's MAR dated 8/1/2025-8/31/2025 indicated Resident #3 was administered Insulin Glargine (a long-acting modified form of medical insulin used to manage Type I and Type II Diabetes) subcutaneously (under the skin) at bedtime and Lispro per sliding scale (a treatment approach that adjust insulin doses based on current blood sugar reading) before meals for diabetes. Record review of Resident #3's order summary report dated 8/25/2025 indicated she was ordered Insulin Glargine (a long-acting modified form of medical insulin used to manage Type I and Type II Diabetes) subcutaneously (under the skin) at bedtime and Lispro per sliding scale (a treatment approach that adjust insulin doses based on current blood sugar reading) before meals for diabetes. During an interview on 8/26/2025 at 10:30 AM, LVN U said the MDS nurse was responsible for updating the diagnosis on the computer. LVN U said she completes a head-to-toe assessment on the residents when they are admitted . She said the MDS nurse reviews the assessments, hospital records to enter in the MDS in the computer. She said the care plan was developed by the MDS nurse and the DON. She said a diagnosis of diabetes would need to be care planned as well as the insulin. She said it was important because the resident could have medical issues, and the nurse would not know to check for signs and symptoms. She said a resident could have signs and symptoms that may not get treated and a resident could go into a diabetic coma. LVN U said the aides do not have access to the care plans. LVN U said Resident #3 does have a diagnosis of diabetes. LVN U said she looked at the orders and not the care plan. LVN U said the care plans were for the patient, department heads, MDS and the families. LVN U said she does not have access to the care plans. LVN U said Resident #3 has an order for insulin for her diabetes and gets blood glucose checks three times daily. During an interview on 8/26/2025 at 11:53 AM, MDS Coordinator B said the last quarterly MDS assessment did not indicate Resident #3 had Diabetes. She said insulin was checked on the MDS. MDS Coordinator B said there was not a care plan indicating a Resident #3 was a diabetic. MDS Coordinator B said anyone on staff can access the care plan. MDS Coordinator B said it would be important for Diabetes to be on the care plan to ensure the residents' needs were being met. MDS nurse said there would need to be interventions for her Diabetes on the care plan. MDS Coordinator B said the resident was on insulin and Resident #3 had orders for insulin. MDS Coordinator B said it was not on her Diagnosis list. During an interview on 8/26/2025at 12:52 PM, ADON N said I am not the MDS nurse, but I would think the diagnosis would need to be on the MDS and care plan. She said she would expect the MDS nurse to document and code the MDS with accuracy. ADON B said the MDS drives the care plan. During an interview on 08/26/2025 at 3:53 PM, the DON said she expected the nurse to code the Diabetes. She said she expected the Diabetes to be on the care plan. The DON said the facility updated the care plan when there was a change in condition, quarterly, annually and as needed in team meetings. The DON said the MDS Coordinator and herself were responsible for updating the care plan. There could be a negative outcome. During an interview on 8/26/2025 at 4:12 PM, the ADM said the MDS nurse was responsible for ensuring the diagnosis of diabetes was coded on MDS for Resident #3. The ADM said the MDS was completed upon admission, quarterly and annually. He said he expected the diagnosis to be care planned. He said it was important for provision of care. It could negatively result in improper care. Record review of the facility's policy titled Resident Assessment Instrument undated indicated .comprehensive assessment of a resident's needs shall be made within fourteen (14)days of the resident's admission.a comprehensive assessment of the resident's needs will be made by the Interdisciplinary Assessment Team.must use the MDS 3.0 form currently mandated by Federal and state regulations to conduct the resident assessment following the RAI manual.the purpose of the assessment is to described the resident's capability to perform daily life functions and identify significant impairments in functional capacity.j. disease diagnosis and health conditions refer to only those disease that have a relationship to current ADL status, cognitive status, mood and behavior status, medical treatment, nursing monitoring or risk of death.n. Medication.refers to all prescription and over the counter medication taken by resident, including dosage, frequency of administration and recognition of significant side effects.r. documentation of summary information.refers to documentation concerning which care area assessment have been triggered.

Based on observation, interview and record review the facility failed to provide the resident and their representative with a summary of the baseline care plan for 2 of 6 residents (Resident #60 and Resident #114) reviewed for baseline care plans. The facility failed to provide Resident #60 and Resident #114, a copy of the summary of their baseline care plans. This failure could place residents at risk of not knowing their care and needs provided by the facility. Findings included:1. Record review of Resident #60's face sheet dated 8/26/25 indicated Resident #60 was a [AGE] year-old male admitted to the facility on [DATE]. Resident #60 had diagnoses including pneumonia (is an infection that inflames the air sacs in one or both lungs), type 2 diabetes (is a chronic condition that happens when you have persistently high blood sugar levels), and chronic obstructive pulmonary disease (is a chronic lung disease that causes inflammation and narrowing of the airways, leading to airflow obstruction). Resident #60 was his own responsible party. Record review of the MDS indicated Resident #60 was admitted to the facility less than 21 days ago. No MDS for Resident #60 was completed prior to exit.Record review of Resident #60's 48 Hour Care Plan dated 8/18/25, signed by MDS Coordinator C, did not reflect a copy of the summary of the baseline care plan was provided to Resident #60. Record review of Resident #60's medical records on 8/26/25 at 9:00 a.m., did not reflect a copy of the summary of the baseline care plan was provided to Resident #60.During an observation and interview on 8/24/25 at 11:38 a.m., a family member of Resident #60 was at the bedside with Resident #60. Resident #60 was hard of hearing. The family member of Resident #60 helped communicate with Resident #60. The family member of Resident #60 said he was with Resident #60 when he was admitted . The family of Resident #60 said he did not recall Resident #60 receiving a baseline care plan. The family member of Resident #60 asked Resident #60 about a baseline care plan. Resident #60 appeared confused and shook his head. 2. Record review of Resident #114's face sheet dated 8/25/25 indicated Resident #114 was a [AGE] year-old male admitted to the facility on [DATE]. Resident #114 had diagnoses including calculus of gallbladder with acute cholecystitis (is a condition where gallstones (calculi) in the gallbladder lead to inflammation of the gallbladder (cholecystitis)), type 2 diabetes is a chronic condition that happens when you have persistently high blood sugar levels), and heart failure (occurs when the heart muscle doesn't pump blood as well as it should). Resident #114's face sheet did not reflect a responsible party. Record review of the MDS indicated Resident #114 was admitted to the facility less than 21 days ago. No MDS for Resident #114 was completed prior to exit.Record review of Resident #114's care plan report dated 8/19/25 indicated Resident #114 was at moderate risk for falls related to gait/balance problems and had a code status of full code. Resident #114's care plan report did not reflect a copy of the summary of the baseline care plan was provided to Resident #114.Record review of Resident #114's admission Care Conference Summary dated 8/21/25, signed the ADON N, did not reflect a copy of the summary of the baseline care plan was provided to Resident #114. Record review of Resident #114's medical records on 8/26/25 at 9:10 a.m., did not reflect a copy of the summary of the baseline care plan was provided to Resident #114.During an interview on 8/25/25 at 3:31 p.m., Resident #114 said he did not get a copy of anything. During an interview on 8/26/25 at 9:20 a.m., the MDS Coordinator C said the bedside nurses were responsible for the baseline care plans. During an interview on 8/26/25 at 12:10 p.m., LVN H said she did not know about baseline or 48-hour Care Plans. During an interview on 8/26/25 at 3:00 p.m., the ADON N said a nurse or ADON saw the newly admitted resident within 24 hours to orient to the facility. The 48-hour care plan was then started. She said the MDS Coordinators then wrapped up the 48-hour care plan. She said there was a section on the 48-hour care plan that indicated the proof of a copy was given to the resident. During an interview on 8/26/25 at 5:16 p.m., the ADM said the IDT was responsible for the baseline care plan. He said the MDS Coordinators and Social Service should ensure the resident or responsible party received a copy of the summary of the baseline care plan. He said the staff should document in the residents' progress note or on the 48-hour care plan to indicate a copy was given to the resident or responsible party. He said it was important to give a copy of the summary, of the baseline care plan, for acknowledgement of provision of care. During an observation and interview on 8/26/25 at 6:13 p.m., the DON said the IDT was responsible for ensuring the resident or responsible party received a copy of the summary, of the baseline care plan. She said a copy of the summary was given to the resident or responsible party after the care conference meeting. She said on the 48-hour care plan there was an area that indicated the proof of a copy was given to the resident. The DON accessed her computer and reviewed Resident #114's medical records. She said she did not see where the document had an area that indicated the proof of a copy was given to the resident. She said it was important to provide the resident a copy of the summary, for knowledge of the plan of care. She said the resident could experience a negative outcome if they did not receive a copy. Record review of a facility's, Care Plans-Baseline policy revised 12/2016 indicated, .A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to. The initial goals of the resident. A summary of the resident's medications and dietary instructions. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.

Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 17 residents reviewed for ADLs (Residents #59.) The facility did not clean or trim Resident #59's fingernails.This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health.The findings were:Review of Resident #59's electronic face sheet dated 10/18/2024 revealed he was admitted to the facility on [DATE] with diagnoses of Dysphagia (difficulty swallowing), Parkinson's Disease (a progressive, chronic neurological disorder characterized by symptoms such as tremors, muscle stiffness, slow movement (bradykinesia), and impaired balance), Lack of Coordination (a neurological symptom characterized by awkward, clumsy movements affecting the whole body, limbs, or eyes, resulting from impaired muscle control and a disruption in how the brain controls voluntary movements).Record review of Resident #59's annual MDS dated [DATE] revealed a BIMS with a score of 15, which indicated resident #59 is cognitively intact. The MDS also revealed, Resident #59, required supervision and touching assistance with personal hygiene.During an observation and interview on 08/24/25 at 10:03 a.m., Resident #59 was observed with long and dirty fingernails. He said that he did not know where his nail clippers were or if staff clip his nails. His hands were shaking. During an observation on 08/25/25 at 11:30 a.m. Resident #59 he was observed with long and dirty fingernails.During an observation on 08/26/25 at 9:15 a.m. Resident #59 he was observed with long and dirty fingernails.During an interview on 08/26/25 at 1:57 p.m., CNA X said that it was the responsibility of CNAs to ensure that residents that were dependent for ADL care received the care they need. She said that included resident's fingernails.During an interview on 08/26/25 at 4:19 p.m., the Director of Nurses said CNAs were responsible to ensure that residents dependent for care had their nails trimmed and cleaned for them. She said that residents could be at risk of infections if their nails are consistently dirty. During an interview on 08/26/25 at 4:36 p.m., the Administrator said that CNAs were responsible to clean and trim the nails of residents that cannot do for themselves. He said there could be a risk of infection if their nails were not kept trimmed and cleaned. Record review of a facility's Quality of Life-Dignity policy revised on 08/2009, indicated . Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Residents shall be groomed as they wish to be groomed (hair styles, nails, facial hair, etc.) .

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 residents (Resident #3) reviewed for accidents and supervision. The facility failed to ensure CNA G performed a safe mechanical lift transfer for Resident #3.This failure could place residents at risk of injury.Findings include:Record review of Resident #3's face sheet dated 8/26/25 indicated she was [AGE] years old and admitted to the facility on [DATE]. Resident #3 had diagnoses which included history of left tibia (lower leg bone), diabetes (high blood sugar), history of falls, rheumatoid arthritis (chronic inflammation disorder usually affecting small joints in the hands and feet), hypertension (high blood pressure), and heart failure.Record review of Resident #3's quarterly MDS dated [DATE] indicated had a BIMS score of 14, which indicated she was cognitively intact. Resident #3 used a wheelchair for mobility. Resident #3 required moderate assistance with most ADLs.Record review of Resident #3's Care Plan dated and last reviewed on 7/15/25 indicated she had an ADL self-care performance deficit related to disease process and required two staff participation with transfers. Resident #3 was at risk for falls.During an observation on 8/26/2025 beginning at 9:32 AM, CNA G and CNA D placed a lift pad under Resident #3. CNA G positioned the mechanical lift over Resident #3 in bed, then CNA G and CNA D attached to the mechanical lift pad to the lift. CNA G then lifted Resident #3 up off bed with the mechanical lift legs straight (not in wide position) and did not lock the lift wheels during lifting, CNA G then pulled Resident #3 back away from over the bed with the mechanical lift legs not in wide position and turned the mechanical lift to the right and then pushed Resident #3 toward the wheelchair. CNA G then opened the mechanical lift legs to the wide position and pushed Resident #3 over the wheelchair and then lowered her into the wheelchair and did not lock the mechanical lift wheels while being guided by CNA D. During an interview on 8/26/2025 at 3:17 PM, CNA D said she had worked at the facility for two years. CNA D said CNA G worked Resident #3's hall and she was just helping CNA G during the mechanical lift transfer. CNA D said the mechanical lift wheels should be locked when raising or lowering the resident during the mechanical lift transfer. CNA D said the mechanical lift legs should be in the wide position when going around the wheelchair. CNA D said the mechanical lift legs should be in the wide position during moving of the mechanical lift to balance the lift. CNA D said the mechanical lift could tilt over and the resident could get hurt if the mechanical lift legs were not in the wide position during the transfer. CNA D said she just assisted CNA G during the mechanical lift transfer and guided Resident #3 and positioned her in the chair while CNA G lowered Resident #3 into the wheelchair. During an interview on 8/26/2025 at 3:32 PM, CNA G said the wheels of the mechanical lift should be locked when lifting a resident, but not during lowering to allow for the mechanical lift to move to adjust for the resident's feet and comfort. CNA G said the legs of the mechanical lift should be in the wide position during lifting the resident and not in the wide position during moving the resident across the room to be able to safely maneuver the mechanical lift. CNA G said the legs of the mechanical lift should be in wide position when lifting the resident for stability of the lift and to go around the wheelchair. CNA G said during moving/transferring the resident, the legs of the mechanical lift would not be opened to wide position. CNA G said the wheels of the mechanical lift should be locked when lifting the resident to ensure the lift did not move, for the safety of the resident.During an interview on 8/26/2025 at 3:50 PM, the ADON said the wheels of the mechanical lift should be locked during raising and lowering the resident for safety and stabilization of the lift. The ADON said the mechanical lift legs should be in the wide position when the lift was bearing the weight of the patient. The ADON said the mechanical lift legs should be opened to wide position during moving of the resident. The ADON said the mechanical lift legs should be in the wide position for stability of the lift. The ADON said the resident could tip over if the mechanical lift legs were not in the wide position during transfers and the wheels were not locked. The ADON said the resident could get hurt. During an interview on 8/26/2025 at 4:27 PM, the DON said the base of the mechanical lift should be in the wide position when lifting and moving the resident and the wheels of the mechanical lift should be locked during lifting and lowering of the resident. The DON said the mechanical lift could tilt and cause an injury to the resident if the base was not in the wide position during lifting, lowering and moving the resident and the wheels were not locked when lifting and lowering the resident. During an interview on 8/26/2025 at 4:52 PM, the ADM said he would expect staff to perform safe mechanical lifts. The ADM said unsafe mechanical lift transfers placed the resident at risk for injury.Record review of the facility's policy titled Lifting Machine, Using a Mechanical dated revised July 2017, indicated . purpose of the procedure was to establish the general principles of safe lifting using a mechanical lifting device . mechanical lifts may be used for tasks that require . transferring a resident from bed to chair . 4. prepare the environment . clear an unobstructed path for the lift machine . 7. Make sure the lift was stable and locked .Record review of Patient Lifts by the U.S. Food and Drug Administration (FDA), (Patient Lifts | FDA) was accessed on 9/02/25 indicated . the FDA has compiled a list of best practices that, when followed, can help mitigate the risks associated with patient lifts . users should . keep the base (legs) of the patient lift at maximum open position and situate the lift to provide stability . Record review of Best Practices for Using Patient Lifts by the U.S. Food and Drug Administration (FDA), Best Practices For Using Patient Lifts (fda.gov) was accessed on 9/02/25 indicated . patient lifts were designed to lift and transfer patients from one place to another . found improper use of patient lifts have led to patient falls . resulted in head traumas, fractures, deaths . can mitigate risks by doing the following . receive training and understand how to operate the lift . keep the base (legs) of the patient lift in the maximum open position .

Based on observation, interviews, and record review, the facility failed to ensure a resident with urinary incontinence, based on the resident's comprehensive assessment, received appropriate treatment and services to prevent urinary tract infections (UTI) for 1 of 2 residents (Residents #25) reviewed for urinary catheters. The facility failed to ensure Resident #25 had an indwelling (foley) catheter securement device on 8/25/25.The facility failed to ensure on 8/25/25, CNA D provided catheter care per the facility's policy and procedure on Resident #25.These failures could place residents at risk for indwelling urinary catheter dislodgement, urethral (empties urine from the bladder and out of the body) damage, pain, and urinary tract infections.Findings included:Record review of Resident #25's face sheet dated 8/26/25 indicated Resident #25 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #25 had diagnoses including neuromuscular dysfunction of bladder (a person does not have bladder control because of brain, spinal cord, or nerve problems), dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), extended spectrum beta lactamase (ESBL) resistance (occurs when bacteria produce enzymes (ESBLs) that break down beta-lactam antibiotics), and chronic kidney disease (is a condition where the kidneys gradually lose their ability to filter waste products from the blood), stage 4.Record review of Resident #25's annual MDS assessment dated [DATE] indicated Resident #25 was usually understood and usually had the ability to understand others. Resident #25's BIMS score was 5 which indicated severe cognitive impairment. Resident #25 required substantial/maximal assistance for toileting hygiene. Resident #25 had an indwelling catheter.Record review of Resident #25's care plan dated 7/7/25 indicated Resident #25 had an indwelling catheter related to atonal bladder (is a condition where the bladder muscles are weak and do not contract properly, leading to difficulty or inability to urinate) and urinary retention due to neuromuscular dysfunction (9/25/24). Resident #25's responsible party requested he only wear a leg bag and not a drainage bag due to Resident #25 forgetting that the bag is attached to the bed. Foley has been pulled out multiple times. Education was provided on the risk of wearing the leg bag. On 6/2/25, Resident #25's responsible party was ok with only using a foley drainage bag instead of the leg bag. Intervention included change catheter as indicated. Record review of Resident #25's order summary dated 8/26/25 indicated:*Foley catheter 18 French 30 cubic centimeter bulb to drainage bag. Diagnosis: Urinary retention due to neuromuscular dysfunction of bladder, two times a day for monitor. Start date 1/8/25. *Foley catheter care every shift and as needed, every shift for monitor. Start date 2/5/24. During an observation on 8/25/25 at 4:00 p.m., CNA D lowered Resident #25's covers to his ankles. Resident #25 had a t-shirt and brief on. Resident #25 complained about being cold. CNA D unattached Resident #25's brief and exposed his perineal area. The surveyor remained at the foot of Resident #25's bed until catheter care started. The surveyor moved next to CNA D to closely observe catheter care being provided. Resident #25's privacy curtain was open. Resident #25 did not have a catheter securement device. CNA D started catheter care by cleaning Resident #25's lower abdomen, groin creases, underside of penis then moved towards the urethra and junction of indwelling catheter tubing. During the catheter care, Resident #25's catheter tubing was not secured and pulled. During an interview on 8/26/25 at 2:18 p.m., the surveyor attempted to interview Resident #25 about catheter care performed on 8/25/25. Resident #25 had disorganized thinking and started talking about luggage in his room. Unable to interview Resident #25. During an interview on 8/26/25 at 2:20 p.m., CNA D said during catheter care, the cleaning was supposed to start at the groin creases. She said Resident #25 did not have on a catheter securement device. She said after catheter care, she did not let the nurse know Resident #25 did not have a securement device. She said a catheter securement device was important so the catheter tubing did not pull. She said she did not feel like Resident #25's catheter tubing was pulling during catheter care. She said pulling could cause swelling. She said not cleaning the catheter right could cause an infection. During an interview on 8/26/25 at 2:31 p.m., LVN F said it was the nurse's responsibility to ensure a resident with an indwelling catheter had a securement device. She said Resident #25 pulled the securement devices off. She said she did not know if Resident #25's behavior was care planned. She said the securement device prevented pulling, dislodgement, and trauma. She said during catheter care, cleaning should start at the urethra then wash downwards. She said it was important to clean away from the urethra to prevent contamination. She said the catheter tubing should be held during catheter care, so it did not move around to prevent pulling. During an interview on 8/26/25 at 3:00 p.m., the ADON N said Resident #25 was care planned for removing his catheter securement devices. She said the catheter cleaning should start inside to outside. She said that way it took the bacteria away from the urethra opening. She said the catheter securement devices were important to prevent trauma caused from movement. She said not providing proper catheter care placed the resident at risk for an infection. She said the pulling of the catheter tubing placed the resident at risk for damage to the urethra and being hurt. She said the nursing management ensured catheter care was performed properly by doing the competency check off upon hire, skill fairs, and an outside company assessment. During an interview on 8/26/25 at 5:44 p.m., the ADM said a resident with an indwelling catheter should have a securement device. He said if the resident removed the securement device, the behavior should be care planned. He said the catheter securement devices were important for dignity and infection control. He said he expect the nursing staff to provide catheter care per the facility's policy and procedure. He said it was important to do it per the facility's policy and procedure, to do it the right way. He said when those things were not done, the residents' needs were not meet. He said the nursing administration oversaw the nursing staff. He said the nursing administration oversaw these things by doing competency check offs.During an interview on 8/26/25 at 6:13 p.m., the DON said Resident #25 did not like catheter securement devices. She said Resident #25's behavior should be care planned. She said catheter securement devices decreased the risk of pulling. She said Resident #25's behavior should be care planned to know how to care for him. She said she expected the nursing staff to provide the catheter care per the facility's policy and procedure and how they were trained. She said when the catheter care was not provided per the facility's policy and procedure and securement devices were not used, the resident could have a negative outcome. She said the nursing management oversaw these things by doing competency check offs and skills checks. Record review of CNA D's, C.N.A Proficiency Evaluation dated 3/21/25 indicated, .daily catheter care. explain procedure to the resident.provide privacy. position residents' legs apart.use the premoistened disposable washcloths.men.using the pre-moistened disposable wash cloth, clean catheter moving away from the body.ensure catheter tubing is not kinked, pulling.met expectation.Director of Talent and Learning Q.Record review of a facility's, Perineal Care policy revised 10/2010 indicated, .The purposes of this procedure arc to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. 4. Fold the bedspread or blanket toward the foot of the bed. 5. Fold the sheet down to the lower part of the body. Cover the upper torso with a sheet. Avoid unnecessary exposure of the resident's body. For male resident. b. Wash perineal area starting with urethra and working outward. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area.) . Continue to wash the perineal area including the penis, scrotum and inner thighs. Do not reuse the same washcloth or water to clean the urethra. c. Thoroughly rinse perineal area in same order, using fresh water and clean washcloth. (Note: If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter.

Based on observation, interview and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or others for 1 of 6 residents (Resident #1) reviewed for reasonable accommodations of needs . The facility failed to ensure Resident #1 had a functioning call light. This failure could place residents at risk of possible falls, major injuries, hospitalization , and unmet needs. Findings include: Record review of Resident #1's, undated, face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Cerebral Infarction (a serious condition that occurs when blood flow to the brain is blocked, causing an area of dead brain tissue), Urinary Tract Infection (a bacterial infection that affects the urinary tract, which includes the bladder, ureters, kidneys, and urethra), and Repeated Falls. Record review of Resident #1's significant change in status MDS, dated [DATE], reflected Resident #1 was understood and understood others. Resident #1's BIMs score was an 11, which indicated moderate impaired cognition. Resident #1 required substantial or maximal assistance with all ADLs. Record review of Resident #1's, undated, care plan reflected Resident #1 was at risk for falls related to history of falling, anti-anxiety medication use, and use of hypnotic therapy. The interventions included to ensure the call light was within reach and encourage her to use it to call for assistance as needed. During an interview on 11/15/24 at 10:30 a.m., the Family Member said Resident #1 had a fall this morning. He said he was informed by Resident #2 who called him at about 6:46 a.m. He said he also had a camera in the room that showed Resident #1 sitting on the floor in his room. He said Resident #2 was hollering for help and no one went to help him after Resident #2 pushed the call light button. He said he lived nearby and drove to the facility. He said the nurses were all at the nurse's station not helping Resident #1. He said he asked them why they were not helping, and they said they did not know Resident #1 pushed their call light button . He said the nurses said room [ROOM NUMBER] Resident's #1 and #2 are in did not fully work . He said they told him the light at the door would turn on but the indicator at the nurse's station would not make an audible noise. He said Resident #1 was not hurt but he was upset that no one answered the call light in a timely manner. He said he did not know the names of the nurses he spoke to. During an observation on 11/15/2024 at 10:43 a.m. of an undated (no time stamp approximately 5 seconds long) camera footage provided by Family Member it was observed that Resident #1 was sitting on the floor of his room. Resident #2 was interacting with the resident. Resident #2 yelled, help twice. Resident #1's bed was in the low position and a fall matt was on the floor with Resident #1 pushing it away from himself. During an observation on 11/15/2024 at 10:56 a.m. revealed Resident #1 and Resident #2's call light was pressed in room [ROOM NUMBER] . A light was observed above the door of the room. Upon going to the nurse's station and with a staff present the call light did not make an audible noise or light to indicate the call light in the room had been activated . During an interview on 11/15/24 at 11:07 a.m. with LVN A, she said she worked the 6:00 a.m. to 6:00 p.m. shifts. She said she worked the morning on 11/15/24 when Resident #1 slipped out of bed. She said she knew Resident #1 slid out of bed because she was informed by the Family Member of Resident #1 and #2. She said she was the nurse on duty assigned to the 600-hall which included room [ROOM NUMBER] . She said at about 6:46 she was at the nurse's station at the medication cart getting ready to pass medications. She said there were two CNAs working with her. She said she was standing in front of the nurse's station and could not see room [ROOM NUMBER] light was on neither from the doorway or the screen at the nurse's station that lit up. She said normally there was an audible noise when a call light was pushed but room [ROOM NUMBER] light was not working at the nurse's station screen nor the audible noise it made so she was unaware Resident #1 or #2 had pushed their button. She said she could not hear Resident #2 calling for help either. She said she did not know where CNA B or C was. She said she would answer call lights as well as the CNA's. She said after she was notified of the fall by Resident #1 and Resident #2's family member she checked the resident who was sitting on his bottom, on his fall matt, with the bed in a low position. She said she would never let a call light go off for that long, but she did not know it had been activated. During an interview on 11/15/24 at 11:20 a.m., CNA B said she worked with Residents #1 and #2 today as she was assigned to their hall. She said she was informed Resident #1 slipped out of his bed by Resident #1's family member. She said she did not know Resident #1 had pushed their call button as she was not within eyesight of the door light of the room nor could she hear the audible call light noise that was made when the call light was activated . She said the last time she worked previous to 11/15/24 was on 11/12/24 and she believed the call light made an audible noise that day. She said when she came to work at 6:00 a.m. on 11/15/24 the morning shift did not report anything or note for the 600 hall. She said along with herself two others were working the 600 hall. She said there were a total of 12 residents on this hall. She said there were plenty of staff to work the 600 hall. She said when they went to see the resident after their family member said he slipped they found Resident #1 sitting on the fall mat and his bed was in the low position. During an interview on 11/15/2024 at 11:50 a.m., with Resident #1 he said he slipped onto the floor this morning. He said he was not hurt. He said he slipped down to his fall mat then pushed his fall mat away from him but could not get back up. He said he did not know how long he was on the floor, but it was more than 30 minutes . He said it seemed like hours. He said his Family Member came into the room and helped him up. During an interview on 11/15/2024 at 11:53 a.m., with Resident #2 she said she noticed Resident #1 was on the floor around 6:00 a.m. to 6:20 a.m. She said she pushed her help button, but no one came. She said she started to panic, so she called her Family Member. He wasn't hurt but he couldn't get back into bed. She said her Family Member came and nurses came to help Resident #1 into bed. During an interview on 11/15/24 at 12:07 p.m. with the Administrator, he said he was notified Resident #1 slipped from his bed at 9:00 a.m. today. He said the Maintenance Director said the audible notification the call light made when the button was pushed was not working. He said the company that serviced their system was notified and staff were in serviced this morning on call light systems to notify him of a malfunction and to give residents a bell to ring. During an interview on 11/15/2024 at 2:10 p.m., CNA C said she worked on 11/15/24 on the night shift. She said she worked with Resident #1. She said she knew Resident #1's room, had a malfunctioning call light system. She said last night (11/15/24) Resident #1 had pushed his call light a few times and she entered the room but the audible noise it made when the call light was pushed was not working. She said she could see his light turned on at his room door. She said his call light had not worked since last Sunday, 11/10/24, that she knew of. She said she was not sure the exact date it has been malfunctioning, but she knew it hadn't worked since last Sunday . She said she placed in the digital charting an order to Maintenance and told LVN D that it was not working . During an interview on 11/15/24 at 2:18 p.m., LVN D said she worked last night, 11/15/24, on the night shift with Resident #1. She said she knew his call light was coming on because she could see his light turn on in the hallway above his door. She said she did not know the audible noise that was made when a call light was pushed was not working for Residents #1's room. She said CNA C reported to her several days prior the call light was not working right but she saw the call light was coming on above the door so she disregarded what CNA C told her since she saw it was working. She said she did not know the audible noise was malfunctioning. To her knowledge Resident #1 had not fallen last night on her shift. She said no one reported to her that Resident #1 had fallen on her shift. During an interview on 11/15/2024 at 2:40 p.m., the Maintenance Director said in room [ROOM NUMBER] he fixed the call light system last Monday 11/11/24. He said he replaced the shower box to the call light system. He said he fixed it in response to a staff that reported the call light system not functioning the day prior. He said the light was showing up outside the door, but the call light was not making an audible noise. He said someone had pulled the shower box wiring out of the wall. He said he replaced the entire unit last Monday in the bathroom. He said last Monday once he fixed the shower box it was making an audible noise and a visual light when he tested the call light from the shower box. He said he did not replace the call box in the bedroom just the call box in the bathroom. He said he was new to the online system for reporting maintenance issues, so he doesn't know how to bring up work orders he has completed. He said he can see current work orders but work orders that are finished he cannot pull up. He said since he put the new shower box in last Monday he had been going back in every other day checking the call light system and it had worked fine. During an interview on 11/15/24 at 3:45 p.m., the Administrator said he expected the call light system worked in the facility. He said the Maintenance Director replaced the shower box for the call light system this past Monday. He said he believed the call light system just stopped working this morning. He said he understood his staff could not provide a timeline of when the call light system was and was not working but he believed it stopped working just today only. He said the work order that was placed last week by CNA C fixed the call light system even though just the bathroom box was replaced, and the bed box was not replaced. During an interview on 11/15/2024 at 3:50 p.m., the Director of Nurses said she expected the call light system functioned properly. She said residents could be placed at risk of falls if the system was not functioning properly. Record review of the facility's policy and procedure, revised October 2010, titled, Answering the Call Light reflected The purpose of the procedure is to respond to the resident's requests and needs . Answer the call light as soon as possible .Some residents may not be able to use their call light. Be sure you check these residents frequently.

Based on interview, and record review, the facility failed to consider the views of a resident group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life and failed to demonstrate their response and rationale for such response in a timely manner 3 (February, March, and April 2024) of 6 months reviewed for resident group response, in that: The documentation of the facility's effort to resolve resident grievances of medicine being left at bedside, not having their beds made, bedding not being changed on shower days, no snacks being provided, and the facility running out of toilet paper collected at Resident Council meetings on 02/01/2024, 03/21/2024, and 04/04/2024 were not made until between 05/07/2024 and 05/18/2024. This failure placed residents at risk of not having grievances addressed or provided a rational for facility decisions for issues identified in a timely manner. Findings included: Record review of Resident Council Meeting Forms dated 02/01/2024, 03/21/2024, and 04/04/2024 indicated the group council voiced their beds were not being made, their linens were not being changed, they were not receiving snacks, and the facility was running out of toilet paper frequently. The AD signed the Resident Council meeting form on 02/21/2024. The DON responded to the resident council grievance on 05/07/2024 about the beds being made with the response. Ambassadors will make rounds. The dietary manager responded to the resident council grievance about snacks on 05/16/2024 with the response, things are very chaotic right now and we are doing the best we can. The housekeeping supervisor responded to the grievance about the toilet paper shortage on 05/08/2024 with the response, manager will in service staff on leaving a larger supply out to ensure toilet paper does not run out. During an interview on initial tour on 07/08/2024 between 6:20 a.m. - 4:00 p.m., 2 confidential residents voiced their bed was not made and they were not receiving snacks. These confidential residents stated they made these concerns known during resident council meetings in February, March, April, May, and June of 2024. During a confidential group interview on 07/09/2024 at 10:00 a.m., 7 of 7 confidential residents said they had experienced not having their beds made and linens changed, not getting snacks, and running out of toilet paper over the last 6 months. 7 of 7 residents said they were concerned they were not receiving prompt responses to the grievances they were making during resident council. During an interview on 07/10/2024 at 9:10 a.m., the Housekeeping Supervisor stated the facility discussed the issues voiced in the resident council in the morning meetings and resolutions were made verbally during those meetings. The Housekeeping Supervisor stated she thought AD K was going to relay the resolution to the residents, because that is who asked for the resolution in the morning meeting. The Housekeeping Supervisor stated she did an in service with her staff around mid-May to leave out extra toilet paper. She stated the in service was done verbally. During an interview on 07/10/2024 at 12:10 p.m., the Dietary Manager stated she was new and had only been in the facility for a couple weeks. She stated she met with the residents and introduced herself and asked about problems they were having with their food. She stated one of their concerns was snacks being available and she promptly addressed that by speaking with her staff and setting up snack times for 10 a.m., 2 p.m., and bedtime. The dietary staff was preparing trays of snacks and leaving them at the nurses' station for the nursing staff to distribute. She said this began around the 1st of July. Attempted to contact DM J (previous dietary manager) on 07/08/2024 at 11:20 a.m., 07/09/2024 at 2:15 p.m. and 07/10/2024 at 8:15 a.m., with no call back. During an interview on 07/10/2024 at 12:30 p.m., the DON stated she knew the policy for responding to grievances was 5 days. The DON stated she had been employed at the facility for about 3 weeks. The DON stated she was unsure why the previous DON had not responded to the resident council grievances for over 3 months. She stated not responding could make the resident's feel disrespected and could cause depression. Attempted to contact previous DON on 07/08/2024 at 10:20 a.m., 07/09/2024 at 4:15 a.m., and 07/10/2024 12:40 p.m. There was no response and no call back. During an interview on 07/10/2024 at 1:15 p.m., the AD stated she typed up the resident council minutes after each resident council meeting and presented a copy to each department head in the next morning meeting. She stated the DON, housekeeping supervisor and dietary manger were all present, along with the Administrator at these meetings. She stated she reminded the department heads that responses were needed to the resident council grievances daily during the morning meeting. She stated she did not receive responses for nearly 4 months on council meetings held at the first part of the year. She stated all at once the department heads handed in the same response to attach to multiple months resident council grievances. She stated the resident council was becoming frustrated because they felt they were being ignored. During an interview on 07/10/2024 at 2:09 p.m., the ADM stated he expected the grievances to be resolved in its entirety. The ADM said the grievance officer was the social worker, but each department would address the grievance in their area. The ADM stated he expected beds to be made, snacks to be served, toilet paper to be available to residents and staff, and the grievances be resolved within 5 business days. He stated he was not the ADM when the lack of attention occurred, but he would ensure they resident council did not feel ignored again. The ADM stated not responding to the resident council could leave the residents feeling like their voice does not matter in the facility, when their voice matters most. Record review of the Grievance Policy dated 2001, revealed the following: 1. The Administrator has assigned the responsibility of investigating grievances and complaints to the Social Service Director. 2. Upon receiving a grievance and complaint report, the Social Service Director will begin an investigation into the allegations. The department director of an involved employee will be notified of the nature of the complaint and that an investigation is underway. The investigation and report will include, as applicable: a. The date and time of the alleged incident; b. The circumstances surrounding the alleged incident; c. The location of the alleged incident; d. The names of any witnesses and their accounts of the alleged incident; e. The resident's account of the alleged incident; f. The employee's account of the alleged incident; g. Accounts of any other individuals involved (i.e., employee's supervisor, etc.); and h. Recommendations for corrective action. 3. The Resident Grievance/Complaint Investigation Report Form must be filed with the Administrator within five (5) working days of the incident. 4. The resident, or person acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended, within 5 working days of the filing of the grievance or complaint. Copies of all reports must be signed and will be made available to the resident or person acting on behalf of the resident.

Based on interviews and record review, the facility failed to ensure each Minimum Data Set (MDS) was electronically completed and transmitted to the CMS System within 14 days after completion for 4 of 32 residents (Resident #149, Resident #24, Resident #16, and Resident #5) reviewed for MDS transmittal. The facility did not ensure Resident # 149's quarterly MDS assessment dated [DATE] was completed and successfully electronically transmitted within 14 days The facility did not ensure Resident # 24's quarterly MDS assessment dated [DATE] was completed and successfully electronically transmitted within 14 days . The facility did not ensure Resident # 16's quarterly MDS assessment dated [DATE] was completed and successfully electronically transmitted within 14 days . The facility did not ensure Resident # 5's quarterly MDS assessment dated [DATE] was completed and successfully electronically transmitted within 14 days This deficient practice could place residents at risk of not having their assessments transmitted and accepted in a timely manner and causing a delay in payments for the facility. The findings included: 1. Record review of Resident #149's face sheet dated 07/09/24 indicated Resident #149 was an [AGE] year-old female, admitted to the facility on [DATE]. Resident #149 had diagnoses including stroke, hemiplegia and hemiparesis affecting right dominant side (paralysis to one side of the body), and heart failure. Record review of Resident #149's admission MDS dated [DATE] indicated Resident #149 had a BIMS of 13, indicating intact cognition. Resident #149 required maximum assistance with ADLs. The MDS was signed by the MDS Nurse on 07/05/24. Record review of Resident #149's electronic medical record accessed 07/08/24 -07/10/24 indicated the MDS dated [DATE] was transmitted on 07/08/24. 2. Record review of Resident #24's face sheet dated 01/27/24 indicated she was an [AGE] year-old female who admitted to the facility on [DATE]. Resident #24 had diagnoses including Acute Kidney Failure (A condition in which the kidneys suddenly can't filter waste from the blood), Parkinson's Disease (A disorder of the central nervous system that affects movement, often including tremors), and Anemia (A problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues). Record review of Resident # 24's quarterly MDS assessment dated [DATE] indicated Resident #24 had a BIMS score of 00, which indicated severe cognitive impairment. Resident #24 was dependent on staff for assistance with ADLs. Record review of Resident #24's electronic health records on 7/8/24 at 9:20 a.m. indicated the MDS dated [DATE] was transmitted on 07/08/24. 3.Record review of Resident #16's face sheet dated 07/09/24 indicated Resident #16 was an [AGE] year-old female, admitted to the facility on [DATE]. Resident #16 had diagnoses including stroke, aphasia ( a disorder that affects how one communicates usually occurring after a stroke, and heart failure. Record review of Resident #16's quarterly MDS assessment dated [DATE] indicated Resident #16 had a BIMS of 08, indicating moderately impaired cognition. Resident #16 required maximum assistance with ADLs. The MDS sections A-Q were signed completed on 07/05/2024 by LVN E. The MDS was signed reviewed and complete by RN L on 05/20/2024. Record review of the CMS transmittal report dated 07/08/2024, indicated Resident #16's quarterly assessment that was due to be completed and transmitted no later than 06/04/2024, was not completed until 07/05/2024 and not transmitted until 07/08/2024. The MDS was accepted with the CMS Warning Record, submitted late. This submission date is more than 14 days after the Z0500B (date the RN signed the assessment is completed 05/20/2024) on this new assessment. 4. Record review of Resident #5's face sheet dated 07/09/24 indicated Resident #5 was a [AGE] year-old female, admitted to the facility on [DATE]. Resident #5 had diagnoses including metabolic encephalopathy (brain function is disrupted due to different disease and toxins in the body), type II diabetes (a metabolic disorder in which the body has high glucose levels for prolonged periods of time), and dementia ( a group of symptoms that affect memory, thinking, and daily life). Record review of Resident #5's quarterly MDS assessment dated [DATE] indicated Resident #5 had a BIMS of 08, indicating moderately impaired cognition. Resident #5 required moderate assistance with ADLs. The MDS sections A-Q were signed completed on 07/05/2024 by LVN E. The MDS was signed reviewed and complete by RN L on 05/18/2024. Record review of the CMS transmittal report dated 07/08/2024, indicated Resident #5's quarterly assessment that was due to be completed and transmitted no later than 06/01/2024, was not completed until 07/05/2024 and was not transmitted until 07/08/2024. The MDS was accepted with the CMS Warning Record, submitted late. This submission date is more than 14 days after the Z0500B (date the RN signed the assessment is completed 05/18/2024) on this new assessment. During an interview on 07/09/2024 at 11:10 a.m., LVN E stated she was aware there were several MDS assessments that were late being finished and transmitted to CMS. LVN E stated she was the corporate regional support for the MDS Coordinator at the facility and she was attempting to help her get caught up. She stated it can be a challenge for one person to keep up with the number of MDSs and care plans that are due monthly in a facility like this facility She stated they had a plan in place now to ensure the MDS assessments stayed up to date and were transmitted timely . LVN E stated not completing the MDS timely affected revenue for the facility and how the plan of care was updated to reflect resident's individualized care. During an interview on 07/10/2024 at 11:15 a.m., the MDS Coordinator stated she was the sole MDS nurse and her job duties included: reviewing clinical records for admission, prioritizing diagnoses on new admissions, entering PASRR information into the LTC portal, completing all LTCMI's (form that proves medical necessity for Medicaid services in a NF), baseline care plans, comprehensive care plans, updating care plans with new MDS information, completing all entry, discharge, admission, quarterly, significant change, state optional and Medicare MDSs. She stated she also gathered and reported all clinical and therapy information to insurances companies for continued skilled services for the residents at the facility for skilled nursing and several meetings each day with other members of the IDT and family members. The MDS Coordinator stated she knew there were MDSs that were behind and her regional support nurse (LVN E) had come up with a plan to get the facility caught up. She stated MDSs should be completed timely to ensure the staff was aware of the current level of care needed for each resident. The MDS Coordinator stated the facility followed RAI guidelines and CMS guidelines. During an interview on 07/10/2024 at 1:00 p.m., the DON stated she was not aware of the late MDS assessments, but she had only been at the facility for about 3 weeks. The DON stated the MDS nurse had many responsibilities and she was more than competent to complete the required work. The DON stated she recently started allowing a nurse to come assist the MDS Coordinator with care plans 2 days per week. During an interview on 07/10/2024 at 1:15 p.m., the ADM stated he was aware of the late MDS assessments because he had been informed of them by LVN E. He stated the facility had a nurse now that would come help with care plans 1-2 days per week in an attempt to provide support to the MDS Coordinator. The ADM stated it was his expectation that all MDS assessments be completed and submitted timely. The ADM stated it could affect revenue and resident care if they MDS assessment was not finished and transmitted timely. Review of the facility policy titled MDS Submission Timeframes, dated 2001, indicated the admission MDS assessment for a resident should be transmitted no later than 31 days after the admission assessment was completed. The policy indicated a quarterly MDS assessment should be transmitted no later than 31 days following the R2b(completion) date. The Assessment Coordinator or designee shall be responsible for ensuring that resident assessments are submitted to the State MDS database in accordance with current federal and stated guidelines. 44596 45643

Based on interviews and record review the facility failed to ensure allegations of neglect were thoroughly investigated to prevent further elopement and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency within 5 working days of the incident and if the alleged violation is verified appropriate corrective action must be taken for 1 (Resident #1) of 4 residents reviewed for neglect. The facility failed to immediately investigate, protect the resident, and report allegations of neglect when: Resident #1 eloped from the facility for an unknown amount of time and was found down the street approximately 150 yards from the facility by law enforcement. She had crossed a street and was in a 30 mile per hour area. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 11/4/23 at 7:25 p.m. While the IJ was removed on 11/6/23 at 11:20 a.m., the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that is not an Immediate Jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of their corrective systems. This failure could affect residents by placing the residents at risk for harm. Findings include: Record review of a Face Sheet dated 11/4/23 for Resident #1 indicated she admitted to the facility on [DATE] and she is [AGE] years old with diagnoses of chronic obstructive pulmonary disease, cognitive communication deficit, type II diabetes mellitus, unspecified dementia, unspecified psychosis, abnormalities of gait and mobility, and lack of coordination. Record review of a care plan dated 10/4/2023 for Resident #1 indicated she is an elopement risk/wander and needed to be monitored frequently by staff. A Quarterly MDS dated [DATE] indicated Resident #1 has impairment in thinking with a BIMS score of 3. She requires supervision when walking in room and corridor and with locomotion on and off the unit. Record review of Incident Log dated 11/4/23 indicated Resident #1 had an elopement on 10/8/23 at 11:00 a.m. Record review of the In-Service book indicated an Elopement In-service was initiated on 10-18-23. There were a total of 23 names listed on the sign in sheet for this training. Record review of a nurse progress note dated 10/8/23 by nurse A indicated Resident #1 was found outside of the facility and was brought back inside. During an interview on 11/4/23 at 12:53 p.m., CNA B said she's been employed at the facility for 5 months. She said on 10/8/23 she was one of the CNAs caring for Resident #1. She said she last remember seeing Resident #1 at breakfast. She said she began looking for Resident #1 around 9:30 a.m. She said she had last saw Resident #1 at 9:00 a.m. but had not seen her again. She said she searched halls and rooms but was unable to locate her. She said she notified LVN A she was unable to locate Resident #1 and they both searched for Resident #1. She said after being unable to locate Resident #1 in the facility she went outside and was looking up and down the street. She said she located Resident #1 approximately 200 yards down the street talking to law enforcement. She said when she got to Resident #1, she appeared confused and upset. She said she attempted to get Resident #1 to walk back to the facility with her, but Resident #1 refused. She said a few minutes later LVN A arrived on the scene and attempted to get Resident # 1 to return to the facility. She said Resident #1 said she wanted the police to take her back to the facility. She said law enforcement agreed to follow Resident #1 to the facility. She said LVN A persuaded Resident #1 to get in LVN A car and she transported Resident #1 back to the facility with the police closely following. She said she did not tell the administrator about the incident because she heard LVN A talking to the administrator about the incident. She denied the DON or administrator asked her about the situation. During an interview on 11/4/23 at 12:59 p.m., CNA C said she's been employed at the facility for 2 months. She said she was at work on the day of the elopement of Resident #1. She said she helped search for her in the facility, but she denied going outside to look for Resident #1. She denied anyone questioned her regarding the elopement of Resident #1. She also denied receiving training/in-service on abuse/neglect or elopement. During an interview on 11/4/23 at 1:10 pm., with Corporate Nurse said she's worked in the facility for the past 3 weeks. She said she was aware of the elopement of Resident #1. She said the DON was terminated and she came in to assist the facility. She said she was not sure if an investigation was completed prior to her arrival at the facility nor was she aware if the incident had been called in to the state agency. During an interview on 11/4/23 at 2:20 p.m., the Administrator identified himself as the Administrator and acknowledged he is the abuse coordinator. He said he has worked at the facility for the past 4 months. He said he was made aware of the elopement of Resident #1 on the day of the elopement. The administrator said he did not report the incident to the state agency because he was told Resident #1 was let out of the facility by another resident's family but was immediately re-directed back in the facility. He denied investigating the incident. He said he instructed the DON to investigate. He denied having record of the DON's investigation. The Administrator said the DON did not investigate and was terminated for not being unable to fulfill her job duties. During an interview on 11/4/23 at 3:38 p.m., LVN A said she's worked at the facility 4 years. She said she works the 6 AM - 6 PM and she works every other weekend. She said she was Resident #1 nurse on the day of the incident. She said Resident #1 has a habit of wandering around the facility. She said she was notified by CNA B that Resident #1 was missing but didn't remember the time of day she was notified. She said both she and CNA B searched for Resident #1 inside the facility. She said she notified the Administrator of the resident missing after being unable to locate her inside the facility. She said after searching inside they went outside and began searching. She said she got in her car and began driving down the road. She said was driving up the street when she received a call from the HR Manager. She said the HR Manager told her Resident #1 had been located, and she was the opposite direction in which she was traveling. She said she turned around and headed to where Resident # 1 was located. She said when she arrived Resident #1 was there with CNA B and law enforcement. She said Resident #1 appeared upset and confused when she spoke to her. She said she tried to calm Resident #1 down and coax her to get in the car but Resident #1 refused. She said Resident #1 said she wanted the police to take her back to the facility. LVN A said law enforcement told Resident #1 they would follow her back to the facility in their car, if she rode with LVN A. She said Resident #1 agreed and got LVN A car. She said she called the Administrator and informed him Resident #1 had been found. She said after they returned to the facility. She did a head-to-toe assessment on Resident #1 and no injuries were found. She said called Resident #1 daughter and nurse practitioner and notified them of the incident. She said she notified the DON and was told to place Resident #1 on one-on-one and to not allow Resident #1 out of her site. She said the DON told her to only document, Resident #1 got out of the facility and was found. LVN A said she only documented what she was told in the chart. LVN A said she was not questioned on the incident by the administrator or the DON. She also denied receiving in-service/training on elopement or abuse/neglect after the incident. During an interview on 11/6/23 at 10:33 a.m., CNA D said she was here on the day of the elopement, but she was working on the other side of the facility. She denied talking to the DON or the administrator about the incident. She also denied the DON or administrator spoke to her about the incident. Record Review of the facility's abuse/neglect policy dated December 2009 stated the following; Policy Statement: All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management; A completed copy of documentation forms and written statements from witnesses, if any, must be provided to the Administrator. An immediate investigation will be made and a copy of the findings of such investigation will be provided to the Administrator. The Administrator will provide a written report of the results of all abuse investigations and appropriate actions taken to the state agency and certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, within five (5) working days of the reported incident. On 11/4/23 at 7:25 p.m., the Administrator was informed an Immediate Jeopardy (IJ) was identified due to the above failure. The IJ template was provided to the Administrator and a Plan of Removal (POR) was requested. The plan of removal indicated the following: Residents residing in the facility have the potential to be affected by the failure to investigate allegations of neglect. Resident #1 was placed on one-on-one supervision. Resident will be removed from one-on-one and placed on Q15 checks after evaluation from NP. Resident will be removed from Q15 with no episode of elopement for 72 hours. MD was notified, resident was treated for UTI 10/9 to help with confusion. Residents care plan updated to address elopement risk. Speaking with Physician on 11/6 monthly CBC ordered to monitor white blood cell count to help identify and treat potential confusion. The facility initiated an investigation to identify the cause and implement interventions. All residents residing in the facility have the potential to be affected by this deficiency. An audit was completed to ensure other residents with the potential for elopement were given the same interventions. One other resident was identified for elopement risk were place on 15min q checks. 2. The following actions were initiated immediately on 11/4/23. A. On 11/4/23 an in-service was initiated with the Administrator/DON by the RVP on the need to report and thoroughly investigate allegations of abuse and neglect to include allegations of elopement to ensure proper interventions are placed for residents' safety. The incident will be reported to HHSC. B. On 11/4/23 an in-service was initiated by the Administrator with All facility staff on the need to report allegations of abuse and neglect including allegations of elopement to the abuse coordinator to ensure proper interventions are placed for residents' safety. Staff will not be allowed to work on the floor without receiving the in-service completion date for training will be 11.5.23 C. An audit was completed on 11/4/23 by the Administrator of the 72-hour summary Report and grievances for all residents residing in the facility for any reported neglect allegations, none were identified. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 11/4/23 with the Medical Director. The Medical Director has reviewed and agrees with this plan. The Plan of Removal was accepted on 11/6/23 at 11:20 a.m. On 11/7/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Observations were performed on 11/7/23 2:10 p.m. to 6:18 p.m. Resident #1 was observed with staff always with her during the visit. Interviews with 3 Licensed Nurses (on all shifts 6 a.m.- 6 p.m., 6 p.m.-6 a.m.), 1 RN (6 a.m.- 2 p.m.,10 p.m.- 6 a.m., 6 p.m.- 6 a.m.) and 6 CNAs ( 2 p.m.-10- p.m., PRN) were performed on 11/6/23. All staff were able to correctly identify the abuse coordinator. They stated they had received in-services on abuse/neglect, elopement, and who and when to report abuse/neglect allegations. The staff stated they learned to report missing residents over the intercom system immediately, and to notify the charge nurse and abuse coordinator/administrator. During an interview on 11/15/23 at 11:44 a.m., the Administrator said staff were in-serviced on abuse/neglect, and elopement. The Administrator said staff not in-serviced will be in-serviced prior to their shift. The Administrator said he and the cooperate nurse are monitoring the staffing schedule to ensure all staff on the schedule have been trained or still need to be. The Administrator said the employee files were reviewed and updated with the required trainings and files will be audited bi-weekly for 1 month, monthly for 3 months and then quarterly to ensure all employees have completed the required trainings. The Administrator said employee file audits will be discussed monthly during the monthly Quality Assurance meeting or as needed. The Administrator said staff will be in-serviced upon hire and annually. He said Resident #1 was being moved on 11/17/23 to a different facility where her needs could be met. The Administrator said the incident was called into the state agency and he will call in all any further reports of abuse/neglect to the state agency in the allotted time as required by the state. On 11/7/23 at 5:36 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that is not an Immediate Threat and a scope of isolated due to the facility's need to evaluate the effectiveness of their corrective systems.

Based on interviews, and record review the facility failed to provide adequate supervision to prevent elopement for 1 of 3 residents (Resident #1) reviewed for accidents, hazards, and supervision in that: Resident #1 eloped from the facility for an unknown amount of time and was found approximately 150 yards away from the facility by a neighboring facility and law enforcement. She had crossed a street and was in a 30 mile per hour area. An Immediate Jeopardy (IJ) was identified on 11/4/23 at 7:25 p.m. While the IJ was removed on 11/6/23 at 11:20 a.m., the facility remained out of compliance at no actual harm with a potential for more than minimal harm that is not an Immediate Jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of their corrective systems. This failure could affect residents by placing the residents at risk for harm. Finding include: Record review of a Face Sheet dated 11/4/23 for Resident #1 indicated she admitted to the facility on [DATE] and she was [AGE] years old with diagnoses of chronic obstructive pulmonary disease, cognitive communication deficit, type II diabetes mellitus, unspecified dementia, unspecified psychosis, abnormalities of gait and mobility, and lack of coordination. A Quarterly MDS dated [DATE] indicated Resident #1 had impairment thinking with a BIMS score of 3. She required supervision when walking in room and corridor and with locomotion on and off the unit. Record review of a care plan dated 10/4/2023 for Resident #1 indicated he was an elopement risk/wander and needed to be monitored frequently by staff. Record review of a nurse progress note dated 10/8/23 by nurse A indicated Resident #1 was found outside of the facility and was brought back inside. Record review of Incident Log dated 11/4/23 indicated Resident #1 had an elopement on 10/8/23 at 11:00 a.m. Record review of the In-Service book indicated an Elopement In-service was initiated on 10-18-23. During an observation on 11/4/23 at 11:47 a.m. with Resident #1 was found seated in the activities room with another resident. The assistant activities director was seated in her office with the door open. During an interview on 11/4/23 at 12:53 p.m., CNA B said she's been employed at the facility for 5 months. She said on 10/8/23 she began looking for Resident #1 around 9:30 a.m. She said she had last saw Resident #1 at 9:00 a.m. but had not seen her again. She said she searched halls and rooms but was unable to locate her. She said she notified LVN A, and they both searched for Resident #1. She said after being unable to locate Resident #1 in the facility she went outside and was looking up and down the street. She said she located Resident #1 approximately 200 yards down the street talking to law enforcement. She said she got to Resident #1 she appeared confused and upset. She said she attempted to get Resident #1 to walk back to the facility with her, but Resident #1 refused. She said a few minutes later LVN A arrived on the scene and attempted to get Resident # 1 to return to the facility. She said Resident #1 said she wanted the police to take her back to the facility. She said law enforcement agreed to follow Resident #1 to the facility. She said LVN A persuaded Resident #1 to get in LVN A car and she transported Resident #1 back to the facility with the police closely following. During an interview on 11/4/23 at 1:48 p.m., Human Resource Manager said she worked at the facility 9 years. She said she was working on the day of Resident #1s elopement. She said LVN A was looking for Resident #1 when she received a call from the facility across the street. She said the person on the phone told her a Resident #1 was located down the street and they believed she was from this facility. She said she notified LVN A. She said when Resident #1 was brought back to the facility she appeared upset and confused. During an interview on 11/4/23 at 2:20 p.m., the Administrator identified himself as the Administrator and acknowledged he was the abuse coordinator. He said he has worked at the facility for the past 4 months. He said he was made aware of the elopement of Resident #1 on the day of the elopement. He said LVN A called him and told him Resident #1 was missing but was found shortly after staff began looking for her. He said he called and notified the DON of the elopement. He denied coming to the facility on the day of the incident. He said he was notified of the elopement after the resident had returned to the facility. The administrator said he did not report the incident because he was told Resident #1 was let out of the facility by another resident's family but was immediately re-directed back in the facility. He said he was not aware of the length of time Resident #1 was outside the facility. He said he was made aware of law enforcement involvement until 10/19/23. He said the DON initiated 15-minute checks on Resident #1. He denied investigating the incident. He said he instructed the DON to investigate. During an interview on 11/4/23 at 3:38 p.m., LVN A said she's worked at the facility 4 years. She said she worked the 6 AM - 6 PM and she works every other weekend. She said she was Resident #1s nurse. She said Resident #1 has a habit of wandering around the facility. She said she was notified by CNA B that Resident #1 was missing but did not remember the time of day she was notified. She said both she and CNA B searched for Resident #1 inside the facility. She said she notified the Administrator of the resident missing after being unable to locate her inside the facility. She said after searching inside they went outside and began searching. She said she got in her car and began driving down the road. She said was driving up the street when she received a call from the HR Manager. She said the HR Manager told her Resident #1 had been located in the opposite direction in which she was traveling. She said she turned around and headed to where Resident # 1 was located. She said when she arrived Resident #1 was there with CNA B and law enforcement. She said Resident #1 appeared upset and confused when she spoke to her. She said she tried to calm Resident #1 down and coax her to get in the car but Resident #1 refused. She said Resident #1 said she wanted the police to take her back to the facility. LVN A said law enforcement told Resident #1 they would follow her back to the facility in their car, if she rode with LVN A. She said Resident #1 agreed and got LVN A car. She said she called the Administrator and informed him Resident #1 had been found. She said after they returned to the facility. She did a head-to-toe assessment on Resident #1 and no injuries were found. She said called Resident #1 daughter and nurse practitioner and notified them of the incident. She said she notified the DON and was told to place Resident #1 on one-on-one and to not allow Resident #1 out of her site. She said the DON told her to only document, Resident #1 got out of the facility and was found. LVN A said she only documented what she was told in the chart. During an interview on 11/4/23 at 3:55 p.m., the Administrator said the facility set up 15- minute checks on Resident #1 for 3 days following the incident. He said the Nurse Practitioner ordered a urinalysis completed on Resident #1. He said Resident #1 was found to have a urinary tract infection and she was treated per the nurse practitioner's orders . The administrator said for safety precautions, a sign was placed on the door stating, Do not allow anyone outside of the facility except yourself. He said the DON was terminated by the facility on 10/16/23 for not being able to fulfill her job duties. Record Review of the facility's abuse/neglect policy dated December 2009 stated the following; Policy Statement: It is the responsibility of our employees, facility consultants, Attending Physicians, family members, visitors, etc., to promptly report any incidents or suspected incidents of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management; Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. On 11/4/23 at 7:25 p.m., the Administrator was informed an Immediate Jeopardy (IJ) was identified due to the above failure. The IJ template was provided to the Administrator and a Plan of Removal (POR) was requested. The plan of removal indicated the following: Residents residing in the facility have the potential to be affected by the failure to provide adequate supervision to prevent elopement. Resident #1 was placed on one-on-one supervision. Resident will be removed from one-on-one and placed on Q15 checks after evaluation from NP. MD was notified, resident was treated for UTI 10/9 to help with confusion. Residents care plan updated to address elopement risk. Speaking with Physician on 11/6 monthly CBC ordered to monitor white blood cell count to help identify and treat potential confusion. The facility initiated an investigation to identify the cause and implement interventions. All residents residing in the facility have the potential to be affected by this deficiency. An audit was completed to ensure other residents with the potential for elopement were given the same interventions. One other resident was identified for elopement risk and placed on Q15 checks, based on evaluation Q15 checks are adequate to meet the patient's needs. 1. The following actions were initiated immediately on 11/4/23. a. One other resident identified for elopement risk, placed on Q15 min checks to be conducted by the nurses. The checks will be documented on the Q 15 form. Nurses in-serviced on _11/15 _ by the DON. The NP will evaluate the patient 11/7 to /determine if q15 is to be removed. b. On 11/4/23 an in-service was initiated with the Director of Nursing and Administrator by the Regional Nurse on the need to identify residents who are at risk for harm because of unsafe wandering to ensure adequate supervision is provided. If a resident is identified at risk for unsafe wandering a staff member will be placed with resident, physician will be notified, and DON and administrator will be notified to adjust staffing schedules. c. On 11/4/23 an in-service was initiated for the licensed nursing staff by the DON/ Designee on the need to identify residents who are at risk for harm because of unsafe wandering to ensure adequate supervision is implemented. All untrained Nursing staff (Nurses, CNA, CMA) will not be allowed to work on the floor without receiving the in-service. This will be completed by 11/5/23 midnight. d. An audit was completed on 11/4/23 on wander-risk residents to determine adequate supervision. One other resident was identified at risk and placed on Q15 minute checks residents care plan updated for elopement risk. MD ordered UA pending results. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 11/4/23 with the Medical Director. The Medical Director has reviewed and agrees with this plan. The Plan of Removal was accepted on 11/6/23 at 11:20 a.m. On 11/7/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Observations were performed on 11/7/23 2:10 p.m. to 6:18 p.m. Resident #1 was observed with staff always with her during the visit. Interviews with 3 Licensed Nurses (on all shifts 6 a.m.- 6 p.m., 6 p.m.-6 a.m.), 1 RN (6 a.m.- 2 p.m.,10 p.m.- 6 a.m., 6 p.m.- 6 a.m.) and 6 CNAs ( 2 p.m.-10- p.m., PRN) were performed on 11/6/23. All staff were able to correctly identify the abuse coordinator. They stated they had received in-services on abuse/neglect, elopement, and who and when to report abuse/neglect allegations. The staff stated they learned to report missing residents over the intercom system immediately, and to notify the charge nurse and abuse coordinator/administrator. During an interview on 11/15/23 at 11:44 a.m., the Administrator said staff were in-serviced on abuse/neglect, and elopement. The Administrator said staff not in-serviced will be in-serviced prior to their shift. The Administrator said he and the cooperate nurse are monitoring the staffing schedule to ensure all staff on the schedule have been trained or still need to be. The Administrator said the employee files were reviewed and updated with the required trainings and files will be audited bi-weekly for 1 month, monthly for 3 months and then quarterly to ensure all employees have completed the required trainings. The Administrator said employee file audits will be discussed monthly during the monthly Quality Assurance meeting or as needed. The Administrator said staff will be in-serviced upon hire and annually. He said Resident #1 is being moved on 11/17/23 to a different facility where her needs could be met. On 11/7/23 at 5:36 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that is not an Immediate Threat and a scope of isolated due to the facility's need to evaluate the effectiveness of their corrective systems.

Based on observation, interview, and record review the facility failed to immediately consult with the resident physician when there was a significant change in the resident physical condition for 1 of 6 residents reviewed for change in condition. (Resident #1) The facility failed to notify the physician when Resident #1 experienced nausea and vomiting for 3 days after receiving new medications. Resident #1 was prescribed 5 different medications on 9/27/23 and 4 of them had side effects of nausea and vomiting. Resident #1 received the medications on 9/27/23. She vomited on 9/28/23, 9/29/23 and 9/30/23 and nurses noted in the clinical record no adverse reactions to medications. On 10/1/23 Resident #1 was sent to the ER with decreased blood pressure, decreased heart rate, and oxygen levels. On arrival to the hospital, she was found to have a low body temperature and sepsis. On 10/1/23 Resident #1 was sent to the ER with decreased blood pressure, decreased heart rate, and oxygen levels. On arrival to the hospital, she was found to have a low body temperature and sepsis. An immediate Jeopardy (IJ) situation was identified on 10/11/23 at 1:45 p.m. The IJ template was provided to the facility on [DATE] at 4:00 p.m. While the IJ was removed on 10/12/23 at 6:40 p.m. the facility remained out of compliance at actual harm with a scope of pattern due to the facilities need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk of not having their physician consulted on changes in condition requiring medical intervention. caused harm and could have resulted in the death of the resident. Finding included: Record review of Resident #1's face sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were chronic respiratory failure, asthma, obesity, bronchitis, unspecified dementia, high blood pressure, rheumatoid arthritis, and gout( form of arthritis characterized by severe pain) of the right knee. Record review of a quarterly MDS dated [DATE] indicated Resident #1 had moderate cognitive impairment, and she required extensive assistance of two people with all ADLs. She required one-person extensive assist with dressing and supervision for eating. Record review of Resident #1's care plan dated 4/16/23 indicated a Focused Area of a potential for respiratory distress related to Asthma. One of the interventions was to observe for signs of respiratory distress, rapid breathing, cyanosis (bluish discoloration of skin resulting from inadequate oxygenation of the blood), shortness of breath, nasal flaring, retractions, and wheezing. Record review of Resident #1's computerized physician's orders indicated and order for BIPAP (a machine that helps breathing) to be placed at night and removed in the mornings. Ondansetron (Zofran) HCL 4m as needed for nausea and vomiting. Budesonide Inhalation suspension 0.5 mg inhale orally every 12 PRN. Record review of Resident #1's nursing note dated 9/27/23 at 5:42 p.m. indicated the resident retuned from a doctor's appointment with new orders for 5 new medications. Signed by LVN K. Record review indicated Resident#1 was given new order on 9/27/23 by a Rheumatoid Arthritis Doctor for the following medications:. Sulfasalazine 500 mg QD- side effects feeling sick nausea, vomiting, stomach pain. Neurontin 600 mg QD- side effects fell ing sick nausea and or vomiting. Prednisone 5mg bid - side effects decrease in the amount of urine, fast, slow, pounding, or irregular heartbeat, or pulse, rattling breathing. Tramadol HCL 50 mg every 6 hours-routine- side effect fatigue or drowsiness, loss of appetite, nausea, and vomiting. Allopurinol 100 mg QD- the most common side effect upset stomach, nausea, diarrhea, or drowsiness. Record review of Resident #1's September 2023 MAR indicated on 9/27/23 Neurontin 600 mg at 5 p.m. ( initial dose) was administered by MA M. Record review of Resident #1's nursing notes dated 9/28/23 at 12:42 a.m . indicated at 9:00 p.m. the resident stated that she went to the doctor today and got some new medications. Medication education was given related to Tramadol, 50mg for pain every 6 hours. Neurontin 600 mg two times a day, uric Acid, and Alopurinol 100 mg the resident received education on these medications. Signed by RN J. Record review of a nursing note dated 9/28/23 at 11:33 a.m. indicated the resident was give Ondansetron for nausea. At 2:00 p.m. the medication was noted to be effective. Signed by LVN K. Record review of nursing note dated 9/28/23 at 6:00 p.m. indicated the resident had no adverse effects to new medications and would continue to monitor. At 9:01 p.m. the resident was given Ondansetron for nausea. At 10:18 p.m. it was noted to be effective. Signed by LVN K. Record review of Resident #1's nursing notes dated 9/28/23 at 9:45 p.m. indicated Ondansetron (Zofran) was given for nausea. At 10:18 p.m. it was effective. At 11:35 a.m. the resident vomited Signed by RN J. Record review of nursing note dated 9/28/23 at 11:35 p.m. indicated at 9:30 p.m. rResident #1 vomited undigested food particle. O2 stat 97 percent with oxygen infusing at 2.5 liters per minute . HR 60, 18 respiration, temperature 97.4 and BP 110/77, Zofran given for nausea and vomiting. The Resident requested to leave the CPAP for now. Head of bed elevated. Will continue to monitor. Written by RN J. Record review of Resident #1's September 2023 MAR indicated: on 9/28/23 Neurontin 600 mg at 9:00 a.m. and 5 p.m. was given by MA I. Allopurinol 100 mg was given at 9:00 a.m. ( initial dose) by MA M. Sulfasalazine 500 mg was given at 9:00 a.m. ( initial dose) by MA M. Prednisone 5mg was given at bedtime ( initial dose) was given by RN J. Tramadol 50mg was given at 3:00 a.m. by RN J ( initial dose) -Tramadol 50 mg was given at 9:00 a.m. and 3:00 p.m. by MA I , and Tramadol 50 mg given at 9:00 p.m. by RN J. Record review of the Facility 24-hour report for Resident #1 on the night of 9/28/23 through 9/29/23 indicated on the 6p to 6 a shift indicated at 9:30 p.m. Resident #1 complained of nausea and vomited one time. Record review of nursing notes dated 9/29/23 at 4:32 a.m. indicated Resident #1 was asleep with the head of bed elevated and oxygen infusing at the prescribed rate. No adverse reactions noted to the new medications. Push or encourage fluids was done. Written by RN J. Record review of nursing notes dated 9/29/23 at 5:19 p.m. no adverse reaction noted to new medications give food with meds. Written by LVN E. Record review of Resident #1's September 2023 MAR indicated on 9/29/23 MA X administered Neurontin 600 mg at 9:00 a.m. and 5 p.m. Allopurinol 100 mg was given at 9:00 a.m. by MA X Sulfasalazine 500 mg was given at 9:00 a.m. by MA X On 9/29/23 Prednisone 5mg was given in the morning and bedtime by MA X. On 9/29/23 Tramadol 50mg was given at 3:00 a.m. by RN J -Tramadol 50 mg given at 9:00 a.m. and 3:00 p.m. by MA X, and Tramadol 50 mg for 9:00 p.m. was not administered; the MAR was blank with no reason documented for not administered. Record review of nursing notes dated 9/30/23 at 8:59 a.m. indicated day three of new medication no adverse reactions noted. Written by LVN E. Record review of nursing notes dated 9/30/23 at 7:05 p.m. Ondansetron gives for nausea at 10: 16 pm effective. Written by LVN C. Record review of Resident #1's September 2023 MAR indicated on 9/30/23 MA X administered Neurontin 600 mg at 9:00 a.m. and 5 p.m. Sulfasalazine 500 mg was given at 9:00 a.m. by MA X Allopurinol 100 mg was given at 9:00 a.m. by MA X Prednisone 5mg was given in the morning and bedtime by MA X. On 9/30/23 Tramadol 50 mg. At 3:00 a.m. the Tramadol was not administered; the MAR was blank with no reason documented for not administered. Tramadol 50 mg given at 9:00 a.m. and 3:00 p.m. by MA X, and Tramadol 50 mg . At 9:00 p.m. Tramadol was not administered; the MAR was blank with no reason documented for not administered. Record review of the Facility 24-hour report for Resident #1 on the night of 9/30/23 through 10/1/23 indicated on the 6p to 6 a shift the Tramadol was held due to nausea and possible reaction to the drug. There was no vomiting after 8 p.m. the resident was non-compliant with cpap, or oxygen pulled both off o2 stats remained in the upper 90 checked every hour and oxygen replaced . Record review of nurses note dated 10/1/23 at 8:45 a.m. Resident #1's family member stated the resident is not right. This nurse assessed the resident and bp was 118/72 pulse 60, respirations 18, the resident is a bit lethargic but is talking, notified the DON, instructed to send to the hospital. The resident vomited before this shift. Written by LVN E. Record Review of a nursing note dated 10/1/23 at 9:36 a.m. indicated at this time nurse was asked by LVN E to assist with patients' assessment. Upon entering the room this nurse met by family member and was brought up to date on the situation with Resident #1. When this nurse observed the patient lying on her back in bed with the head of the bed raised at 45 degrees angle, the resident appearance prompted the nurse to ask LVN E to call 911. The nurse continued with the patient's assessment pulse )O2 reading 54 percent on 2 LPM with heart rate 52. The nurse asked family member if patient had a diagnosis of COPD (constriction of air way and difficulty breathing), and she said no raised O2 to 4 liters. Blood pressure was manually taken and was 118/72 . uUpon palpating pulse, it was noted to be light and thready (difficult to feel. The Resident's lower legs were noted to be discolored with yellow splotches and cold to touch, no pulse noted to feet, popliteal ( back of the knee) pulse and the feet was the same. Light and thready. At this time EMS times 2 attendants arrived. [NAME] by LVN F Record review of nursing noted dated 10/1/23 at 7:45 p.m. indicate a late entry for 9/30/23 at 9:40 p.m. Resident #1 vomited two times and Zofran administered the resident was monitored the rest of the night with now as non-compliant with nasal cannula and the cpap r eplaced both several times oxygen stats remained over 90 precent q hour all night. Written by LVN C Record review of Resident #1's an EMS report indicated they received a call at 8:36 a.m. They arrived at the facility at 8:44 a.m. The patient was lying on her back on the bed awake and alert. She was found to be pale and cool to the touch. The patient responded to all questions appropriately but would occasionally fall asleep intermittently. She stated she felt fine and had no complains but felt tired. The nurse stated that the patient was acting lethargic (sleepy and drowsy), and she felt she was having difficulty breathing. Upon assessment the patient was found to be breathing normally but was found to have symptomatic bradycardia ( low heart rate less than 60 beats per minute). The patients' radial pulses and blood pressure was palpated ( by touch) at 70 pulses. The patient was symptomatic but was also awake and alert with no complaints. She was moved to the cot and transported to the hospital. The patient was given IV with atropine ( medication used to reduce low heart rate) 1mg after a dose of atropine the patient's heart rate increase to 55 and the blood pressure increased. The patient continuously reassessed and remained stable. Upon arrival to the hospital the patient was moved to a bed and left with the ER staff the transfer of care was at 9:20 a.m. Record review of the hospital ED Physician Documentation dated 10/1/23 indicated Resident #1 had arrived at 9:12 a.m. at 9:57 a.m. she had shortness of breath. EMS was called to the nursing home for shortness of breath. When they arrived, they found the patient did not seem to have a lot of shortness of breath. However, her vital signs found she had a heart rate in the high 20s and low 30s and was sinus on the monitor . The patients initial blood pressure was 70/40. They gave the patient 2 doses of atropine end route. When she arrived at the ER her heartrate was in the 50s and was junctional rhythm . Her blood pressure though head had decreased, and her initial blood pressures were 50s over 30s. tThe patient was still awake and alert, talking and said she felt fine. Record Review of a Critical Care Hospital and Physical dated 10/1/23 indicated. On presentation to the hospital, she was severely bradycardia with heart rate of 29. She was hypotensive ( low blood pressure), and hypothermia ( low body temperature) with a temperature of 94 degrees. She had been started on dopamine. She still required additional Levophed ( used to treat low BP) to the dopamine because of hypotension. She was given Maxipine ( used to treat infections) in the ER for probable sepsis. Her urine output was extremely poor with Foley placed in the ER. The impression was Sepsis ( harmful microorganisms in the blood), Anemia, Bradycardia , and acute urinary tract infection. The plan was to gently warm the patient while treating for sepsis with antibiotic and IV fluids. The patient will be intubated (insertion of a tube down the mouth or nose into the windpipe to open airways) and mechanically ventilated. The patient is unstable and was critically ill with life in imminent threat . Record review of a Grievance Complaint Report dated 10/1/23 indicated the Family member of Resident # 1 made a report to the Administrator and the DON that indicated the LVN E did not send Resident #1 to the Hospital in a timely manner. The actions taken was a one-on-one meeting with the charge nurse. Record review of Resident #1's nursing notes dated 10/2/23 at 8:05 a.m. indicated the nurse called the hospital for an update on the resident condition. The nurse was informed the resident was intubated in ICU with no date of discharge at this time. [NAME] by LVN K During an interview on 10/3/23 at 9:59 a.m. the DON said they had received a complaint from the family member of Resident #1. She said the family member complained that it took LVN E too long to send Resident #1 to the hospital on 10/1/23. The DON said Resident #1's blood pressure was normal, but her oxygen level was low. They had sent her to the hospital, they knew she was in ICU because the family member said as much, but they did not know the status of Resident #1. The DON said she did an in service with LVN E and investigated the allegations but did not have hospital records. During an interview on 10/3/23 at 10:45 a.m. Resident #3 ( roommate to Resident #1) said the staff were all saying they thought Resident was sick because of her new medications. Resident #3 said on Saturday, 9/30/23 Resident #1 was real quite all day. She said on Saturday after the family member left Resident #1 started throwing up and when they got her cleaned up and she would throwed up again. Resident #3 said when they were all in the room the CNA A told the LVN C Resident #1 needed to go to the hospital. Resident said over in the night Resident #1 was talking out of her head to someone named sis and that was unusual. During an interview on 10/3/23 at 10:50 CNA H said she worked from 6 a to 12 p.m. on Saturday 9/30/23 . She said while she was at work Resident#1 did not throw up that day, but she had thrown up the night before because her sheets, blanket, and gown had vomit on them. She had cleaned her up and told LVN E. CNA H said Resident #1 said she was not feeling well and had thrown up. She said on Sunday 10/1/23 she arrived at work at 6:00 a.m. and saw LVN E come out of Resident #1's room about 6:30 a.m. She said when she went in the room about 7:20 a.m. or so the family member was in the room. The resident had thrown up and they started to clean her up. CNA H said the family member went and got LVN E to take Resident #1's blood pressure and the nurse could not. She fumbled around for about an hour and the family member just wanted Resident #1 sent to the hospital. The aide said she told LVN E Resident #1 needed to go to the hospital because she was not herself. She said the LVN E acted like she did not want to send the Resident to the hospital . CNA H said LVN E finally went and got LVN F and LVN A left the room. She said EMS arrived a few minutes later and Resident #1 was taken to the hospital. During an interview on 10/3/23 at 11:03 a.m. CNA G said she worked the weekend and Resident #1 was sick on Saturday. She said the resident was not really a complainer, she was just not herself and she would not eat. CNA G said she told LVN E on Saturday, 9/30/23 several times Resident #1 was not feeling well and not eating. She said she arrived to work at 6:00 on 10/1/23. She said Resident #1 refused her breakfast and was groggy. She said LVN E knew she was not feeling well the last few days. CNA G said around 7:20 a.m. the family member came and told us she had thrown up on 9/29/23 at night. We ( me and CNA H) told LVN E-to send Resident #1 out, but it was not until about 9:00 a.m. when Resident #1 was sent to the hospital. She said LVN E did not want to send Resident #1 out and the family member said she needed to go to the hospital several times. During an interview on 10/3/23 at 11:14 a.m. LVN F said she worked Sunday 10/1/23 at the other nurse's station. She said on 10/1/23 she saw a patient she never met before. She said LVN E came and got her to assist with the assessment of Resident #1 and to help her make the decision whether to send the resident to the hospital or not. LVN F said LVN E could not find a pulse Ox . LVN F said she had her own. She said LVN E was not familiar with central supply closet where they kept the little crash cart that had everything, such as blood pressure cup and pulse Ox. LVN F sad LVN E had already came and gotten another nurse's manual blood pressure cup from the other nurse's station. LVN F said what she saw when she entered Resident #1's room was an African American female whose skin was grayish. She said the moment she walked into the room told LVN E to call 911. LVN F said Resident #1's lower legs to knees were cold and she looked almost white, her 02-level was 54 percent on 2 liters of oxygen, and heart rate 52. She said she asked the family member to turn the oxygen up to 4 liters, because she was on that side of the bed and she watched where she put the level. LVN F said her check of Resident #1's blood pressure was 118/72 and the 72 was very light., her pulse was weak and thready. She said Resident #1 opened her eyes and winked at her but never spoke a word. LVN F said she counted 12 respirations a minute. She said she was told LVN E had come to get her once and the family member had come to get her, but she was in a room. She said she the aides had told her they had told LVN E to send Resident #1 to the hospital the day before. LVN F said shortly after they left with Resident #1 the family member called and said they had put Resident #1 in ICU. She said when LVN E came and got her, she left the room to call 911, she never came back. She said EMS took Resident #1's blood sugars and they were 132. During an interview on 10/3/23 at 11: 20 a.m. the family member of Resident #1 said they had come to the facility on Saturday evening and the resident was drowsy and not eating. She had thrown up her food. She said she had already thrown up because there was vomit in the trash can. The family member said Resident#1's gown and everything had vomit on it. She said prior to leaving she asked the nurse LVN C not to give her the night dose of tramadol because she was so sleepy. The family member said on Sunday morning she had come early because she wanted to see how Resident #1 was doing. The family member said arrived about 7:30 a.m. Resident #1 was so sleepy she could hardly talk. The family member said she went and got LVN E to take her blood pressure and LVN E could not find a blood pressure cup that worked the battery was low or something. The family member said after about 30 minutes LVN E went and got a manual blood pressure cup. The family member said when LVN E took Resident #1's blood pressure the family member said they did not believe LVN E knew what she was doing the blood pressure was 117/72. The family member asked for an oxygen status, and for a second opinion or to just send Resident #1 to the hospital. The family member said after about 30 more minutes LVN F accompanied LVN E in the room. The family member said LVN F took one look at the Resident #1 and told to LVN E to send her to the hospital. The family member said LVN E left the room, and she did not come back that she remembered. The family member said Resident #1's feet were cold and when she got to the hospital, they had to warm her body up because she was cold. The family member said LVN F was able to take Resident #1's oxygen status and it was low. The family member said when the resident arrived at the hospital her oxygen level was 52 and her bp was 88/53. The family member said at when the nursing home took it manually it was 117/72 and they did not do it right. The family member said the aides said they had told LVN E, the resident did not look good and needed to go to the hospital, but she would not listen. The family member said at the hospital they put the catheter in Resident #1 and got no urine output. The family member said when Resident #1 arrived at the hospital they said she was septic, the had to put some type of warming blanket on her, and they had intubated the resident and put her in ICU, she was not doing well at the current time. During an interview on 10/3/23 at 11:40 a.m. the DON said the family member was upset because she felt the resident was not sent to the hospital timely. She said LVN E called her to say Resident #1's O2 stat was low, and she was kind of lethargic. She said told her the family wanted Resident #1 sent to the hospital, and she had told her if the family wanted her sent out then send her out. The DON said she called LVN E to check on Resident #1 and did a follow up to make sure the resident had gotten to the hospital. She said someone said something about the resident had thrown up, during morning meeting on Friday, 9/29/23, but she was not aware Resident #1 continued vomiting. During an interview on 10/3/23 at 12:35 p.m. the NP said on 9/29/23 she was informed Resident#1 had thrown up on Friday during morning meeting. She said she worked at the facility Monday through Friday and if there were any issues the staff notified her. If she had questions or concerns, she would notify the physician. She said she was only informed that one time Resident #1 had vomited. She said she was not informed the resident continued to throw up the next two days. She said Resident #1 went to a Rheumatoid doctor on 9/27/23 and came back with prescriptions for 5 different medications. She said she told the nursing staff to make sure Resident #1 ate before giving her the medications and no one informed her she continued to throw up. The NP said the resident continued vomiting could have been due to the new medications. She said if she had been informed the resident was throwing up for 3 days, she would have requested labs, pushed fluids, and looked at some other interventions for the resident. If she continued to vomit, she would have sent her to the hospital for an evaluation. During an interview on 10/3/23 at 1:05 p.m . the DON said that she would look for the one on one in service she had conducted with LVN E. She then said she had conducted the interview over the phone and did not have it written down at the current time. During an interview on 10/4/23 at 9:25 a.m. LVN E said she had worked at the facility for 4 days and on Sunday 10/1/23, it was her third time working with Resident #1. She said she did not remember the aides telling her anything about Resident #1 being sick and not eating. She said she had not consulted with the physician or the NP during the weekend . She said after she sent Resident #1 to the hospital, she had sent the NP a text. She said when she came in and the nurse on the night shift said Resident #1 had vomited. She went to the room to check the roommates blood sugars. She walked over to Residen#1's side of the room and touched her hand, and the resident was doing fine, she did not note anything out of the ordinary. She said around 7:30 a.m. or so the resident's family member came and asked her to check Resident #1's blood pressure. She said the batteries were down in the one she had, and she could not find another one. She had gone to the nurse's station on the other hall and gotten one a manual BP cup from a coworker. She said Resident #1's BP was 117/70. Pulse 60 and R 18. The family member told her she wanted someone else to do it. She went and got the nurse from across the way. She said that nurse had a pulse Ox, and she could not find one. She said the residents O2 stat was 50 and she left to call 911. She said she did call the DON first and then 911. She said the resident temp was 97 . She said her feet were cold she had stayed in the room probably 20 minutes with the family member and Resident #1. During an observation and interview on 10/4/23 at 1:00 p.m. at the hospital with Resident #1 and the ICU nurse. Resident #1 was observed in the ICU in a hospital bed. She was laying on her back with monitors hooked up and IVs flowing. She was awake and fidgety. She shook her head yes when asked if she had been sick a few days prior to coming to the nursing home. The only other communication was she whispered her name. The ICU RN said her intubation was removed yesterday. He said she appeared to have decreased memory and more confusion. Observation of Resident #1 wanted the nurse to open the suction tubing for her to suction her throat, several times she kept repeating open. She was coughing up mucus and wanted to continue to use the tube. The RN explained to her several times she was clear and did not need the tube. Resident #1 did calm down a appeared to rest. The nurse said they did not have any discharge plans for the resident at this time. During a telephone interview on 10/5/23 at 3:20 a.m. LVN C said she worked Saturday, 9/30/23 night going into Sunday, 10/1/23 morning. She said on the Saturday evening about 8 p.m. the family member came and told her Resident #1 was nauseated, she gave her some Zofran and she threw that up. She gave her another one and put that one under her tongue and the resident went to sleep. She said she checked on her all through the night and kept putting the oxygen on her. She said about 3:00 a.m. the resident said she wanted to get up, but she did not. She said on Sunday morning she went in to check on her and she was fine she said she gave her a routine breathing treatment, she did not have any breathing issues and her O2 stat was never under 90. Said the aides did tell her she was none responsive around 5:30 a.m., but when they went in to check on about 5:45 a.m. she was talking. She said she took her O2 stats at that time but did not write them down. She told the oncoming nurse to check on her because she was not feeling well and to keep check on her O2 status. She said the resident's status had changed since they put her on the new medications. She had held the tramadol because she was so sleepy. She had put on the MAR refused because there were only so many choices. She said she had put that information on the 24-hour report. During a telephone interview on 10/5/23 at 3:26 a.m. with CNA A said she worked at the facility for about a month. On Friday night Resident#1 complained of being nauseous. She said when she came in Saturday at 6:00 p.m. about two hours into the shift she said Resident #1 was nauseated and she threw up several times. The last time she saw her was about 5:30 a.m. on 10/1/23 when she and CNA B went in to change her. CNA A said Resident #1 was not coherent. She said they tried to wake her up and could not. She said they told LVN C about the Resident #1's condition. CNA A said Resident #1 had her oxygen on at that time, and the oxygen was on around 3:00 a.m. when they had gone into the room. During a telephone interview on 10/5/23 at 3:29 a.m. CNA B said he worked at the facility for 7 years. He said on Friday night the Resident #1 was fine but complained of being nauseated. He said Resident #1 was a two person assist and most of the time when CNA A went into the room, he was with her. He said Resident #1 was sick all-night Saturday, 9/30/23 they told the nurse several times. He said about 5:30 a.m. when then did the last round Resident #1 seemed dead. They could not get her to open her eyes, they changed her and told the nurse. She had her oxygen on at that time. During an interview on 10/5/23 at 5:53 a.m. CNA A said they had informed LVN C several times on Saturday night Resident #1was sick. She said she never saw her go into her room. She said Resident #1 was wet each time they went into change her and she had her oxygen on. She said what they did to Resident #1 was not right. They knew she was sick all weekend and did nothing. A statement written by CNA A dated 10/5/23 indicated on Friday 9/29/23 Resident #1 was responsive and said she was nauseated. On Saturday, 9/30/23 Resident #1 was responsive at 6:00 p.m. and complaining about being nauseated. She started throwing up around 8-8:30 p.m. as the night progressed, she started to get worse. She said we, ( Me and CNA B) told LVN C she needed to go to the hospital. CNA A said LVN C said she was going to give her some more anti-nausea pills. She said around 5:30 a.m. Resident #1 was incoherent and they ( she and CNA B) could not wake her up. She said they told LVN C. She said LVN C went to check on Resident #1 one time when she was throwing up and did not go back to check on her during the night. During an interview on 10/5/23 at 5:57 a.m. CNA B said when they went in to change Resident #1 her brief was wet. He said she was different and sick for the last couple of nights. He said they all thought it was because of the new medications they had given her because she was not like that before. He said they told LVN A several times that night and that morning the resident was sick. He said at 5:30 a.m. they told LVN C, Resident #1 was not responsive. He said he never saw her move to go toward her room. During an interview on 10/5/23 at 6:10 a.m. LVN C said she had held Residents #1'sTramadol on the night of 10/1/23 because she was throwing up and she felt it had something to do with the medications. She had not called the physician with any of her concerns. During an interview on 10/5/23 at 7:00 a.m. LVN E said on 10/1/23 when the night nurse ( LVN C) left, she told her Resident #1 had been throwing up. She said LVN E said she had looked in on Resident #1 and she was okay. She said she did not give her any medications that morning before she left for the hospital, the medication aide gave the medications. The medication aide did not arrive until 8:00 a.m. LVN E said Resident #1 could have been having a reaction to the medications. She said the nurses were the ones that wrote the notes in the chart about no adverse reactions to the medications. She thought it was somewhere on the nurse MAR that they put that information. During an interview with on 10/5/23 at 8:30 a.m. MA I said she did not write anything in the cart about adverse reactions to medications, that was the nurses that did that . She said Resident #1 had some new medications and she gave them as prescribed. She said Resident #1 always took her medication without any problems. MA I said she did not know anything about Resident #1 being sick. During an interview on 10/11/23 at 2:55 p.m. the DON said it was the facility policy that nurses give the initial dose of new medications to residents. She said after that the MAs give the medication, but the nurses are to check for adverse reactions to the medications. She said it was her policy that the nurses

Based on observation, interview, and record review the facility failed to ensure a resident received the treatment and care in accordance with professional standards of practice for 1 of 5 residents reviewed for quality of care.(Resident #1), in that: The facility failed to ensure Resident #1 was not having adverse reactions to new medication. Resident #1 was prescribed 5 different medications on 9/27/23 and 4 of them had side effects of nausea and vomiting. Resident #1 received the medications on 9/27/23. She vomited on 9/28/23, 9/29/23 and 9/30/23 and nurses noted in the clinical record no adverse reactions to medications. They failed to assess Resident #1 and notify the physician when she experienced adverse reaction to new medications. On 10/1/23 Resident #1 was sent to the ER with decreased blood pressure, decreased heart rate, and oxygen levels. On arrival to the hospital, she was found to have a low body temperature and sepsis. An immediate Jeopardy (IJ) situation was identified on 10/11/23 at 1:45 p.m. The IJ template was provided to the facility on [DATE] at 4:00 p.m. While the IJ was removed on 10/12/23 at 6:40 p.m., the facility remained out of compliance at actual harm with a scope of pattern due to the facilities need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk of not receiving care and services to meet their needs caused harm and could have resulted in the death of the resident. Finding included: Record review of Resident #1's face sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were chronic respiratory failure, asthma, obesity, bronchitis, unspecified dementia, high blood pressure, rheumatoid arthritis, and gout( form of arthritis characterized by severe pain) of the right knee. Record review of a quarterly MDS dated [DATE] indicated Resident #1 had moderate cognitive impairment, and she required extensive assistance of two people with all ADLs. She required one-person extensive assist with dressing and supervision for eating. Record review of Resident #1's care plan dated 4/16/23 indicated a Focused Area of a potential for respiratory distress related to Asthma. One of the interventions was to observe for signs of respiratory distress, rapid breathing, cyanosis(bluish discoloration of skin resulting from inadequate oxygenation of the blood), shortness of breath, nasal flaring, retractions, and wheezing. Record review of Resident #1's computerized physician's orders indicated and order for BIPAP (a machine that helps breathing) to be placed at night and removed in the mornings. Ondansetron(Zofran) HCL 4m as needed for nausea and vomiting. Budesonide Inhalation suspension 0.5 mg inhale orally every 12 PRN. Record review of Resident #1's nursing note dated 9/27/23 at 5:42 p.m. indicated the resident retuned from a doctor's appointment with new orders for 5 new medications. Signed by LVN K. Record review indicated Resident#1 was given new order on 9/27/23 by a Rheumatoid Arthritis Doctor for the following medications. Sulfasalazine 500 mg QD- side effects feeling sick nausea, vomiting, stomach pain. Neurontin 600 mg QD- side effects fell ing sick nausea and or vomiting. Prednisone 5mg bid- side effects decrease in the amount of urine, fast, slow, pounding, or irregular heartbeat, or pulse, rattling breathing. Tramadol HCL 50 mg every 6 hours-routine- side effect fatigue or drowsiness, loss of appetite, nausea, and vomiting. Allopurinol 100 mg QD- the most common side effect upset stomach, nausea, diarrhea, or drowsiness. Record review of Resident #1's September 2023 MAR indicated on 9/27/23 Neurontin 600 mg at 5 p.m. ( initial dose) was administered by MA M. Record review of Resident #1's nursing notes dated 9/28/23 at 12:42 a.m. indicated at 9:00 p.m. the resident stated that she went to the doctor today and got some new medications. Medication education was given related to Tramadol, 50mg for pain every 6 hours. Neurontin 600 mg two times a day, uric Acid, and Alopurinol 100 mg the resident received education on these medications. Signed by RN J. Record review of a nursing note dated 9/28/23 at 11:33 a.m. indicated the resident was give Ondansetron for nausea. At 2:00 p.m. the medication was noted to be effective. Signed by LVN K. Record review of nursing note dated 9/28/23 at 6:00 p.m. indicated the resident had no adverse effects to new medications and would continue to monitor. At 9:01 p.m. the resident was given Ondansetron for nausea. At 10:18 p.m. it was noted to be effective. Signed by LVN K. Record review of Resident #1's nursing notes dated 9/28/23 at 9:45 p.m. indicated Ondansetron (Zofran) was given for nausea. At 10:18 p.m. it was effective. At 11:35 a.m. the resident vomited Signed by RN J. Record review of nursing note dated 9/28/23 at 11:35 p.m. indicated at 9:30 p.m. resident #1 vomited undigested food particle. O2 stat 97 percent with oxygen infusing at 2.5 liters per minute. HR 60, 18 respiration, temperature 97.4 and BP 110/77 Zofran given for nausea and vomiting. The Resident requested to leave the CPAP for now. Head of bed elevated. Will continue to monitor. Written by RN J. Record review of Resident #1's September 2023 MAR indicated: on 9/28/23 Neurontin 600 mg at 9:00 a.m. and 5 p.m. was given by MA I. Allopurinol 100 mg was given at 9:00 a.m. ( initial dose) by MA M. Sulfasalazine 500 mg was given at 9:00 a.m. ( initial dose) by MA M. Prednisone 5mg was given at bedtime ( initial dose) was given by RN J. Tramadol 50mg was given at 3:00 a.m. by RN J ( initial dose) -Tramadol 50 mg was given at 9:00 a.m. and 3:00 p.m. by MA I , and Tramadol 50 mg given at 9:00 p.m. by RN J. Record review of the Facility 24-hour report for Resident #1 on the night of 9/28/23 through 9/29/23 indicated on the 6p to 6 a shift indicated at 9:30 p.m. Resident #1 complained of nausea and vomited one time. Record review of nursing notes dated 9/29/23 at 4:32 a.m. indicated Resident #1 was asleep with the head of bed elevated and oxygen infusing at the prescribed rate. No adverse reactions noted to the new medications. Push or encourage fluids was done. Written by RN J. Record review of nursing notes dated 9/29/23 at 5:19 p.m. no adverse reaction noted to new medications give food with meds. Written by LVN E. Record review of Resident #1's September 2023 MAR indicated on 9/29/23 MA X administered Neurontin 600 mg at 9:00 a.m. and 5 p.m. Allopurinol 100 mg was given at 9:00 a.m. by MA X Sulfasalazine 500 mg was given at 9:00 a.m. by MA X On 9/29/23 Prednisone 5mg was given in the morning and bedtime by MA X. On 9/29/23 Tramadol 50mg was given at 3:00 a.m. by RN J -Tramadol 50 mg given at 9:00 a.m. and 3:00 p.m. by MA X, and Tramadol 50 mg for 9:00 p.m. was not administered the MAR was blank with no reason documented for not being administered. Record review of nursing notes dated 9/30/23 at 8:59 a.m. indicated day thee of new medication no adverse reactions noted. Written by LVN E. Record review of nursing notes dated 9/30/23 at 7:05 p.m. Ondansetron [NAME] for nausea at 10: 16 pm effective. Written by LVN C. Record review of Resident #1's September 2023 MAR indicated on 9/30/23 MA X administered Neurontin 600 mg at 9:00 a.m. and 5 p.m. Sulfasalazine 500 mg was given at 9:00 a.m. by MA X Allopurinol 100 mg was given at 9:00 a.m. by MA X Prednisone 5mg was given in the morning and bedtime by MA X. On 9/30/23 Tramadol 50 mg. At 3:00 a.m. the Tramadol was not administered; the MAR was blank with no reason documented for not being administered. Tramadol 50 mg given at 9:00 a.m. and 3:00 p.m. by MA X, and Tramadol 50 mg . At 9:00 p.m. Tramadol was not administered the MAR was blank with no reason documented for not being administered. Record review of the Facility 24-hour report for Resident #1 on the night of 9/30/23 through 10/1/23 indicated on the 6p to 6 a shift the Tramadol was held due to nausea and possible reaction to the drug . There was no vomiting after 8 p.m. the resident was non-compliant with cpap, or oxygen pulled both off o2 stats remained in the upper 90 checked every hour and oxygen replaced. Record review of nurses note dated 10/1/23 at 8:45 a.m. Resident #1's family member stated the resident is not right. This nurse assessed the resident and bp 118/72 pulse 60, respirations 18, the resident is a bit lethargic but is talking, notified the DON, instructed to send to the hospital. The resident vomited before this shift. Written by LVN E. Record Review of a nursing note dated 10/1/23 at 9:36 a.m. (late entry) indicated at this time nurse was asked by LVN E to assist with patients' assessment. Upon entering the room this nurse met by family member and was brought up to date on the situation with Resident #1. When this nurse observed the patient lying on her back in bed with the head of the bed raised at 45 degrees angle, the resident appearance prompted the nurse to ask LVN E to call 911. The nurse continued with the patient's assessment pulse )O2 reading 54 percent on 2 LPM with heart rate 52. The nurse asked family member if patient had a diagnosis of COPD (constriction of air way and difficulty breathing), and she said no raised O2 to 4 liters. Blood pressure was manually taken and was 118/72 . uUpon palpating pulse, it was noted to be light and thready (difficult to feel. The Resident's lower legs were noted to be discolored with yellow splotches and cold to touch, no pulse noted to feet, popliteal ( back of the knee) pulse and the feet was the same. Light and thready. At this time EMS times 2 attendants arrived. [NAME] by LVN F Record review of nursing noted dated 10/1/23 at 7:45 p.m. indicate a late entry for 9/30/23 at 9:40 p.m. Resident #1 vomited two times and Zofran administered the resident was monitored the rest of the night as non compliant with nasal cannula and the cpap CPAP replaced both several times oxygen stats remained over 90 precent q hour all night. Written by LVN C Record review of Resident #1's an EMS report indicated they received a call at 8:36 a.m . They arrived at the facility at 8:44 a.m. The patient was lying on her back on the bed awake and alert. She was found to be pale and cool to the touch. The patient responded to all questions appropriately but would occasionally fall asleep intermittently. She stated she felt fine and had no complains but felt tired. The nurse stated that the patient was acting lethargic (sleepy and drowsy), and she felt she was having difficulty breathing. Upon assessment the patient was found to be breathing normally but was found to have symptomatic bradycardia ( low heart rate less than 60 beats per minute). The patients' radial pulses and blood pressure was palpated ( by touch) at 70 pulses. The patient was symptomatic but was also awake and alert with no complaints. She was moved to the cot and transported to the hospital. The patient was given IV with atropine( medication used to reduce low heart rate) 1mg after a dose of atropine the patient's heart rate increase to 55 and the blood pressure increased. The patient continuously reassessed and remained stable. Upon arrival to the hospital the patient was moved to a bed and left with the ER staff the transfer of care was at 9:20 a.m. Record review of the hospital ED Physician Documentation dated 10/1/23 indicated Resident #1 had arrived at 9:12 a.m. at 9:57 a.m. she had shortness of breath. EMS was called to the nursing home for shortness of breath. When they arrived, they found the patient did not seem to have a lot of shortness of breath. However, her vital signs found she had a heart rate in the high 20s and low 30s and was sinus on the monitor. The patients initial blood pressure was 70/40. They gave the patient 2 doses of atropine end route. When she arrived at the ER her heartrate was in the 50s and was junctional rhythm . Her blood pressure though head decreased, and her initial blood pressures were 50s over 30s. the patient was still awake and alert, talking and said she felt fine. Record Review of a Critical Care Hospital and Physical dated 10/1/23 indicated. On presentation to the hospital, she was severely bradycardia with heart rate of 29. She was hypotensive ( low blood pressure), and hypothermia( low body temperature) with a temperature of 94 degrees. She had been started on dopamine. She still required additional Levophed( used to treat low BP) to the dopamine because of hypotension. She was given Maxipine ( used to treat infections) in the ER for probable sepsis. Her urine output was extremely poor with Foley placed in the ER. The impression was Sepsis( harmful microorganisms in the blood), Anemia, Bradycardia , and acute urinary tract infection. The plan was to gently warm the patient while treating for sepsis with antibiotic and IV fluids. The patient will be intubated(insertion of a tube down the mouth or nose into the windpipe to open airways) and mechanically ventilated. The patient is unstable and was critically ill with life in imminent threat . Record review of a Grievance Complaint Report dated 10/1/23 indicated the Family member of Resident # 1 made a report to the Administrator and the DON that indicated the LVN E did not send Resident #1 to the Hospital in a timely manner. The actions taken was a one-on-one meeting with the charge nurse. Record review of Resident #1's nursing notes dated 10/2/23 at 8:05 a.m. indicated the nurse called the hospital for an update on the resident condition. The nurse was informed the resident was intubated in ICU with no date of discharge at this time. [NAME] by LVN K. During an interview on 10/3/23 at 9:59 a.m. the DON said they had received a complaint from the family member of Resident #1. She said the family member complained that it took LVN E too long to send Resident #1 to the hospital on 10/1/23. The DON said Resident #1's blood pressure was normal, but her oxygen level was low. They had sent her to the hospital, they knew she was in ICU because the family member said as much, but they did not know the status of Resident #1. The DON said she did an in service with LVN E and investigated the allegations but did not have hospital records. During an interview on 10/3/23 at 10:45 a.m. Resident #3 ( roommate to Resident #1) said the staff were all saying they thought Resident was sick because of her new medications. Resident #3 said on Saturday, 9/30/23 Resident #1 was real quite all day. She said on Saturday after the family member left Resident #1 started throwing up and when they got her cleaned up and she would throwed up again. Resident #3 said when they were all in the room the CNA A told the LVN C Resident #1 needed to go to the hospital. Resident said over in the night Resident #1 was talking out of her head to someone named sis and that was unusual. During an interview on 10/3/23 at 10:50 CNA H said worked from 6 a to 12 p.m. on Saturday 9/30/23 . She said while she was at work Resident#1 did not throw up that day, but she had thrown up the night before because her sheets, blanket, and gown had vomit on them. She had cleaned her up and told LVN E. CNA H said Resident #1 said she was not feeling well and had thrown up. She said on Sunday 10/1/23 she arrived at work at 6:00 a.m. and saw LVN E come out of Resident #1's room about 6:30 a.m. She said when she went in the room about 7:20 a.m. or so the family member was in the room. The resident had thrown up and they started to clean her up. CNA H said the family member went and got LVN E to take Resident #1's blood pressure and the nurse could not. She fumbled around for about an hour and the family member just wanted Resident #1 sent to the hospital. The aide said she told LVN E Resident #1 needed to go to the hospital because she was not herself. She said the LVN E acted like she did not want to send the Resident to the hospital . CNA H said LVN E finally went and got LVN F and LVN A left the room. She said EMS arrived a few minutes later and Resident #1 was taken to the hospital. During an interview on 10/3/23 at 11:03 a.m. CNA G said she worked the weekend and Resident #1 was sick on Saturday. She said the resident was not really a complainer, she was just not herself and she would not eat. CNA G said she told LVN E on Saturday, 9/30/23 several times Resident #1 was not feeling well and not eating. She said she arrived to work at 6:00 on 10/1/23. She said Resident #1 refused her breakfast and was groggy. She said LVN E knew she was not feeling well the last few days. CNA G said around 7:20 a.m. the family member came, and told us she had thrown up on 9/29/23 at night. We ( me and CNA H) told LVN E-to send Resident #1 out, but it was not until about 9:00 a.m. when Resident #1 was sent to the hospital. She said LVN E did not want to send Resident #1 out and family member said she needed to go to the hospital several times. During an interview on 10/3/23 at 11:14 a.m. LVN F said she worked Sunday 10/1/23 at the other nurse's station. She said on 10/1/23 she saw a patient she never met before. She said LVN E came and got her to assist with the assessment of Resident #1 and to help her make the decision whether to send the resident to the hospital or not. LVN F said LVN E could not find a pulse Ox . LVN F said she had her own. She said LVN E was not familiar with central supply closet where they kept the little crash cart that had everything, such as blood pressure cup and pulse Ox. LVN F sad LVN E had already came and gotten another nurse's manual blood pressure cup from the other nurse's station. LVN F said what she saw when she entered Resident #1's room was an African American female whose skin was grayish. She said the moment she walked into the room told LVN E to call 911. LVN F said Resident #1's lower legs to knees were cold and she looked almost white, her 02-level was 54 percent on 2 liters of oxygen, and heart rate 52. She said she asked the family member to turn the oxygen up to 4 liters, because she was on that side of the bed and she watched where she put the level. LVN F said her check of Resident #1's blood pressure was 118/72 and the 72 was very light., her pulse was weak and thready. She said Resident #1 opened eyes and winked at her but never spoke a word. LVN F said she counted 12 respirations a minute. She said she was told LVN E had come to get her once and the family member had come to get her, but she was in a room. She said she the aides had told her they had told LVN E to send Resident #1 to the hospital the day before. LVN F said shortly after they left with Resident #1 the family member called and said they had put Resident #1 in ICU. She said when LVN E came and got her, she left the room to call 911, she never came back. She said EMS took Resident #1's blood sugars and they were 132. During an interview on 10/3/23 at 11: 20 a.m. the family member of Resident #1 said they had come to the facility on Saturday evening and the resident was drowsy and not eating. She had thrown up her food. She said she had already thrown up because there was vomit in the trash can. The family member said Resident#1's gown and everything had vomit on it. She said prior to leaving she asked the nurse LVN C not to give her the night dose of tramadol because she was so sleepy. The family member said on Sunday morning she had come early because she wanted to see how Resident #1 was doing. The family member said arrived about 7:30 a.m. Resident #1 was so sleepy she could hardly talk. The family member said she went and got LVN E to take her blood pressure and LVN E could not find a blood pressure cup that worked the battery was low or something. The family member said after about 30 minutes LVN E went and got a manual blood pressure cup. The family member said when LVN E took Resident #1's blood pressure the family member said they did not believe LVN E knew what she was doing the blood pressure was 117/72. The family member asked for an oxygen status, and for a second opinion or to just send Resident #1 to the hospital. The family member said after about 30 more minutes LVN F accompanied LVN E in the room. The family member said LVN F took one look at the Resident #1 and told to LVN E to send her to the hospital. The family member said LVN E left the room, and she did not come back that she remembered. The family member said Resident #1's feet were cold and when she got to the hospital, they had to warm her body up because she was cold. The family member said LVN F was able to take Resident #1's oxygen status and it was low. The family member said when the resident arrived at the hospital her oxygen level was 52 and her bp 88/53. The family member said at the nursing home took it manually it was 117/72 and they did not do it right. The family member said the aides said they had told LVN E, the resident did not look good and needed to go to the hospital, but she would not listen. The family member said at the hospital they put the catheter in Resident #1 and got no urine output. The family member said when Resident #1 arrived at the hospital they said she was septic, the had to put some type of warming blanket on her, and they had intubated the resident and put her in ICU, she was not doing well at the current time. During an interview on 10/3/23 at 11:40 a.m. the DON said the family member was upset because she felt the resident was not sent to the hospital timely. She said LVN E called her to say Resident #1's O2 stat was low, and she was kind of lethargic. She said told her the family wanted Resident #1 sent to the hospital, and she had told her if the family wanted her sent out then send her out. The DON said she called LVN E to check on Resident #1 and did a follow up to make sure the resident had gotten to the hospital. She said someone said something about the resident had thrown up, during morning meeting on Friday, 9/29/23, but she was not aware Resident #1 continued vomiting. During an interview on 10/3/23 at 12:35 p.m. NP said on 9/29/23 she was informed Resident#1 had thrown up on Friday during morning meeting. She said she worked at the facility Monday through Friday and if there were any issues the staff notified her. If she had questions or concerns, she would notify the physician. She said she was only informed that one time Resident #1 had vomited. She said she was not informed the resident continued to throw up the next two days. She said Resident #1 went to a Rheumatoid doctor on 9/27/23 and came back with prescriptions for 5 different medications. She said she told the nursing staff to make sure Resident #1 ate before giving her the medications and no one informed her she continued to throw up. The NP said the resident continued vomiting could have been due to the new medications. She said if she had been informed the resident was throwing up for 3 days, she would have requested labs, pushed fluids, and looked at some other interventions for the resident. If she continued to vomit, she would have sent her to the hospital for an evaluation. During an interview on 10/3/23 at 1:05 p.m. the DON said that she would look for the one on one in service she had conducted with LVN E. She then said she had conducted the interview over the phone and did not have it written down at the current time. During an interview on 10/4/23 at 9:25 a.m. LVN E said she had worked at the facility for 4 days and on Sunday 10/1/23, it was her third time working with Resident #1. She said she did not remember the aides telling her anything about Resident #1 being sick and not eating. She said she had not consulted with the physician or the NP during the weekend. She said after she sent Resident #1 to the hospital, she had sent the NP a text. She said when she came in and the nurse on the night shift said Resident #1 had vomited. She went to the room to check the roommates blood sugars. She walked over to Residen#1's side of the room and touched her hand, and the resident was doing fine, she did not note anything out of the ordinary. She said around 7:30 a.m. or so the resident's family member came and asked her to check Resident #1's blood pressure. She said the batteries were down in the one she had, and she could not find another one. She had gone to the nurse's station on the other hall and gotten one a manual BP cup from a coworker. She said Resident #1's BP was 117/70. Pulse 60 and R 18. The family member told her she wanted someone else to do it. She went and got the nurse from across the way. She said that nurse had a pulse Ox, and she could not find one. She said the residents O2 stat was 50 and she left to call 911. She said she did call the DON first and then 911. She said the resident temp was 97 . She said her feet were cold she had stayed in the room probably 20 minutes with the family member and Resident #1. During an observation and interview on 10/4/23 at 1:00 p.m. at the hospital with Resident #1 and the ICU nurse. Resident #1 was observed in the ICU in a hospital bed. She was laying on her back with monitors hooked up and IVs flowing. She was awake and fidgety. She shook her head yes when asked if she had been sick a few days prior to coming to the nursing home . The only other communication was she whispered her name. The ICU RN said her intubation was removed yesterday. He said she appeared to have decreased memory and more confusion. Observation of Resident #1 wanted the nurse to open the suction tubing for her to suction her throat, several times she kept repeating open. She was coughing up mucus and wanted to continue to use the tube. The RN explained to her several times she was clear and did not need the tube. Resident #1 did calm down a appeared to rest. The nurse said they did not have any discharge plans for the resident at this time. During a telephone interview on 10/5/23 at 3:20 a.m. LVN C said she worked Saturday, 9/30/23 night going into Sunday, 10/1/23 morning. She said on the Saturday evening about 8 p.m. the family member came and told her Resident #1 was nauseated, she gave her some Zofran and she threw that up. She gave her another one and put that one under her tongue and the resident went to sleep. She said she checked on her all through the night and kept putting the oxygen on her. She said about 3:00 a.m. the resident said she wanted to get up, but she did not. She said on Sunday morning she went in to check on her and she was fine she said she gave her a routine breathing treatment, she did not have any breathing issues and her O2 stat was never under 90. Said the aides did tell her she was none responsive around 5:30 a.m., but when they went in to check on about 5:45 a.m. she was talking. She said she took her O2 stats at that time but did not write them down. She told the oncoming nurse to check on her because she was not feeling well and to keep check on her O2 status. She said the resident's status had changed since they put her on the new medications. She had held the tramadol because she was so sleepy. She had put on the MAR refused because there were only so many choices. She said she had put that information on the 24-hour report. During a telephone interview on 10/5/23 at 3:26 a.m. with CNA A said she worked at the facility for about a month. On Friday night Resident#1 complained of being nauseous. She said when she came in Saturday at 6:00 p.m. about two hours into the shift she said Resident #1 was nauseated and she threw up several times. The last time she saw her was about 5:30 a.m. on 10/1/23 when she and CNA B went in to change her. CNA A said Resident #1 was not coherent. She said they tried to wake her up and could not. She said they told LVN C about the Resident #1's condition. CNA A said Resident #1 had her oxygen on at that time, and the oxygen was on around 3:00 a.m. when the had gone into the room. During a telephone interview on 10/5/23 at 3:29 a.m. CNA B said he worked at the facility for 7 years. He said on Friday night the Resident #1 was fine but complained of being nauseated. He said Resident #1 was a two person assist and most of the time when CNA A went into the room, he was with her. He said Resident #1 was sick all-night Saturday, 9/30/23 they told the nurse several times. He said about 5:30 a.m. when then did the last round Resident #1 seemed dead. They could not get her to open her eyes, they changed her and told the nurse. She had her oxygen on at that time. During an interview on 10/5/23 at 5:53 a.m. CNA A said they had informed LVN C several times on Saturday night Resident #1was sick. She said she never saw her go into her room. She said Resident #1 was wet each time they went into change her and she had her oxygen on. She said what they did to Resident #1 was not right. They knew she was sick all weekend and did nothing. A statement written by CNA A dated 10/5/23 indicated on Friday 9/29/23 Resident #1 was responsive and said she was nauseated. On Saturday, 9/30/23 Resident #1 was responsive at 6:00 p.m. and complaining about being nauseated. She started throwing up around 8-8:30 p.m. as the night progressed, she started to get worse. She said we, ( Me and CNA B) told LVN C she needed to go to the hospital. CNA A said LVN C said she was going to give her some more anti-nausea pills. She said around 5:30 a.m. Resident #1 was incoherent and they ( she and CNA B) could not wake her up. She said they told LVN C. she said LVN C went to check on Resident #1 one time when she was throwing up and did not go back to check on her during the night. During an interview on 10/5/23 at 5:57 a.m. CNA B said when they went in to change Resident #1 her brief was wet. He said she was different and sick for the last couple of nights. He said they all thought it was because of the new medications they had given her because she was not like that before. He said they told LVN A several times that night and that morning the resident was sick. He said at 5:30 a.m. they told LVN C, Resident #1 was not responsive. He said he never saw her move to go toward her room. During an interview on 10/5/23 at 6:10 a.m. LVN C said she had held Residents #1'sTramadol on the night of 10/1/23 because she was throwing up and she felt it had something to do with the medications. She had not called the physician with any of her concerns. During an interview on 10/5/23 at 7:00 a.m. LVN E said on 10/1/23 when the night nurse ( LVN C) left, she told her Resident #1 had been throwing up. She said LVN E said she had looked in on Resident #1 and she was okay. She said she did not give her any medications that morning before she left for the hospital, the medication aide gave the medications. The medication aide did not arrive until 8:00 a.m. LVN E said Resident #1 could have been having a reaction to the medications. She said the nurses were the ones that wrote the notes in the chart about no adverse reactions to the medications. She thought it was somewhere on the nurse MAR that they put that information. During an interview with on 10/5/23 at 8:30 a.m. MA I said she did not write anything in the cart about adverse reactions to medications, that was the nurses that did that. She said Resident #1 had some new medications and she gave them as prescribed. She said Resident #1 always took her medication without any problems. MA I said she did not know anything about Resident #1 being sick. During an interview on 10/11/23 at 2:55 p.m. the DON said it was the facility policy that nurses give the initial dose of new medications to residents. She said after that the MAs give the medication, but the nurses are to check for adverse reactions to the medications. She said it was her policy that the nurses notify her of any change in condition before they send someone out to the hospital. She said if the family request the nurses send them out and call her after. She said she had a procedure written down th [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure residents environment was free of accident hazards for 1 of 2 residents reviewed for falls (Resident #1). The facility failed to prevent a trip hazard in the hallway on the 200 hall. This failure caused Resident #1 to trip and fall. That fall resulted in an arm fracture and a dislocated shoulder both caused severe pain. This facility failure could cause harm to residents that used that hallway. Findings included: Review of Resident #1's Admission Record - Information Sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were unsteadiness on feet, difficulty walking, lack of coordination, mild cognitive impairment, and history of falling. Review of the Resident #1's MDS dated [DATE] indicated her BIMS (Brief Interview Mental Status) was a 12(8-12 moderately cognitively impaired.) Her functional status-her ability to perform daily actives such as bed mobility required two people. Resident #1 required supervision to transfer between services with one person, walking between locations in her room was indicated as supervision with one person. Walking in the corridor and on the unit required supervision of one person. Review of Resident #1's Care Plan initiated on 3/25/22, with a revision date of 4/28/22. The Care Plan indicated she had actual falls 12/22/21, 12/26/21, and 2/13/22 with not injury. The last fall was 4/26/22 indicated right shoulder dislocation with fracture and some of the interventions were anticipated and meet needs, encourage resident to keep room free of clutter, nonskid material to wheelchair seat, place frequently used personal items within easy reach. On 4/26/22 the Care Plan indicated the resident family educated on utilization of proper footwear, and safety devices (walker and wheelchair.) The Care Plan indicated no falls through next review with a revision date of 3/2/21. Some of the interventions were ensure a safe environment, floors even, and free from spills, or clutter, adequate light, bed in low position and personal items in reach. Reinforce need to call for assistance. Resident #1 had a Focus are of inappropriate behaviors such as resistive to treatment and care, she refuses to elevate legs, showers and would treatment at times. Some of the interventions were to check with family for the best approaches to resident, leave and try again later, inform of options ahead of time, maintain timing and consistency. Review of a nurses note dated 4/26/22 at 8:48 a.m. indicated the nurse was in the dining room and heard a CNA call for help. Upon entering the hallway observed Resident #1 lying on the floor in the middle of the hallway. Noted rubber carpet strip sticking up and resident shoe torn. Resident stated. I tripped over the floor and fell . The resident was ambulating without a walker or wheelchair to go to the dining room for breakfast. Assessed the resident for injury and checked vitals. The resident stated her right shoulder hurt bad. The nurse stayed with the resident and notified the nurse practitioner. She was assessed, an order was given to send the Resident to the hospital. Note signed by LVN A. Review of a Facility Provider Investigation Report dated 4/26/22 indicated at 8:48 a.m. Resident #1 had a fall. The report indicated the resident had no special supervision, ambulating independently, and was able to make informed decisions. There were no witnesses to the incident. The investigation summary indicated the residents suffered a fall she is independently ambulatory but with a shuffling gait and was wearing a clog type shoe with no back. The shoe separated as she was walking causing her to stumble and fall while walking down the hallway. The resident shoe came apart and a part of it caught on the carpet strip. Resident denied that anyone caused any harm to her and no one was around when she fell . The resident has a BIMS score of 13 and is alert and oriented. The provider's response was the facility immediately assessed the resident for injury. The resident stated her shoulder was hurting. The nurse practitioner assessed and gave an order to send the resident to the ER for further evaluation and treatment. The responsible party was notified. Upon return from the ER. She was assessed for pain. She was returned to the facility with a diagnosis of humerus (long bone in the arm that runs from the shoulder to the elbow) fracture and dislocation of shoulder the resident was to follow up with an appointment for an orthopedic in three to four days. Review of a Hospital Discharge Instruction for Resident #1 dated 4/26/22 indicated two-part displaced fracture of surgical neck of right humerus, initial encounter for closed fracture, other dislocation of right shoulder. Use shoulder immobilizer, follow-up with physician in 3 or 4 days. Review of nursing note dated 4/26/22 at 4:16 p.m. indicated Resident #1 was returned the facility with a diagnosis of humerus fracture and dislocation of the right shoulder. At 4:55 p.m. the resident as given 2 Tylenol 325 mg as need for pain in right shoulder. The follow up pain scale was zero. (scale 0-10- 0 no pain-10 the worst pain) Review of Resident #1's physicians orders indicated an order for Tylenol tablet 325 mg give two by mouth every four hours as needed for pain dated 12/27/21. An order for Tylenol with [MEDICATION(S)] #4 tablet 300 -06 mg give one tablet by mouth every four hours as needed for pain dated 4/28.22. Review of a Daily Nursing Skill Note dated 4/27/22 at 6:03 AM indicated the Resident #1 was alert, her speech was clear, and no behaviors were exhibited. The resident's memory recall was she was aware of her current room location, staff names and faces and she was aware she was in a nursing home. The resident's physical functioning was bed mobility transfer, and locomotion off the unit were all independent. The nursing note indicated the resident walked slowly but steadily. She ambulated to the nurse's station and sat down to watch television. Later she ambulated to her room with a slow and steady gate, she denied pain or discomfort. Review of nursing notes dated 4/27/22 at 9:19 a. m. indicated Resident #1 was given Tylenol with [MEDICATION(S)] #4 300-60 mg by mouth for pain. At 10:56 a.m. follow up to medication administration indicated it was effective, with a pain scale of zero. {Review of a NP note dated 4/27/22 at 9:38 AM indicated she was called to come see a resident that had fallen this morning she reported that she was walking down the hallway towards the dining room when she fell . The resident right shoe sole was split from top half of the shoe after fall. The resident was lying in the hall after she fell . Staff reported that they had been unable to get her up from the floor due to her severe pain to the right shoulder. The resident is presently pleasantly confused at baseline but is able to tell provider that she fell . She does not remember hitting her head. The resident stated that her shoulder and down her humerus area is very painful. She refused to let the nurse practitioner fully assess her arm due to the pain. The nurse practitioner was able to get her arm bent at the elbow and hold it across her abdomen in attempting to put a sling in place, but she refused. EMS was ultimately called as a resident was having significant pain, not allowing nurse practitioner to properly examine. Nurse notified family member, attempted several times to get the resident up from sitting position but each time she began to cry and become very upset hollering, no no.} Review of nursing notes dated 4/27/22 at 10:30 a.m. indicated IDT met to review fall from previous day. Resident #1 was walking in the hallway with improper footwear on, clog type opened back shoes. The Resident walks with a slow shuffled gate and was no utilizing a walker or wheelchair as normal. The resident was walking over the transition strip, the resident shoe came apart causing fall. During the fall the resident shoe pulled up the transition strip from the carpet. The resident complained of pain to arm and was sent to the ER for evaluation and treatment. The resident retuned with orders to follow up with orthopedic. IDT felt most appropriate to reeducate the resident and family on utilizing proper footwear during ambulation. Review of a nursing note dated 4/27/22 at 11:10 p.m. indicated the Resident was given Tylenol with [MEDICATION(S)] #4 300-60mg for complaints of pain in the right shoulder at 9:00 p.m. The follow up indicated the medication was effective with a pain scale of 3 noted. During an interview on 5/4/22 at 8:42 a.m. LVN A said she worked for the facility since the end of January 2022. She said Resident #1 had moments when she was confused. Somedays were better than others. Resident #1 ambulated independently. She should use a walker and was reminded frequently to use the walker. Sometimes she refused to use the walker. Resident #1 had moments when she was unstable but did walk independently. On 4/26/22 no one witnessed the fall. LVN A said she was in the dining room and saw Resident #1 laying on the floor. The carpet strip was sticking up. The LVN said she thought her shuffling gait got caught up on that rubber piece. LVN A said when the incident happened, the NP was in the building and was called. Resident #1 was sent to the hospital, they stabilized the shoulder, but the resident was not candidate for surgery according to the family. During an interview on 5/4/22 at 8:49 a.m. CNA B said Resident #1 walked independently. The staff reminded Resident #1 to use her walker, but she was non-compliant. Sometimes she was confused. When Resident #1 fell on [DATE], her shoe was torn up, but were still on her foot (not sure which one). The brown strip that connected the carpet to the wood was sticking up. The Resident was headed to the dining room. CNA B said she did not see her fall. Resident #1 did not holler, CNA B said she heard her whimper, and saw her on the floor. The shoes were new; they were slip on house shoes, with the back out and the toes were covered. Her family took the shoes home. During an interview and observation on 5/4/22 at 9:11 a.m. Resident #1 was seen sitting in her wheelchair ambulating about the room using her feet and her left arm only. The right arm was down at her side. She did not have a sling on her arm and said she did not know where it was. Resident #1 said she had pain in her right shoulder. It felt like it could have been from a fall. The Resident said she did not remember a fall. Resident # 1 said she did remember on one side of the hallway something was kind of bubbled up and that was what she tripped over. She did not remember her shoes. The Resident said her shoulder hurt a lot. The Resident said it was not her walking that caused the fall, it was the bubble in the floor. Resident #1 said she had a sling but did not know if it helped or not. During an interview and observation on 5/4/22 at 9:15 a.m. the Maintenance Man said he had worked at the facility for 3 months. Observation of the hallway on the 200-hall showed two places where there was blue tape across the hallway on the transition strips (strips that prevent carpet edges from fraying, vinyl floor seams from curling and creates a smooth transition between different flooring.) The transition strips raised the area in the floor about 5/8 of an inch high. Part of the hallway was carpeted, and part was laminated wood, there were transition strips in those areas where the wood changed to carpet and where the carpet changed to wood. The Maintenance Man said he put tape on the transition strips on the 200 hall. He said he glued down the transition strips, and the tape was there to make sure the glue had time to set. The Maintenance man said he was told a resident's shoe got caught on the strip. He said he put the glue down Friday, 4/29/22. When the tape was removed the strip looked like it was attached to the floor. However, it was not. After observation of the strip, the Maintenance Man said it did not stick, it was still loose. When the tape was removed. Observation of the strip to the end of left and end of the right side of the hallway showed they were not secured to the floor. The strip was not sticking up, it laid flat, it was noted to be loose when moved. The maintenance man said he placed the tape to make sure no one would trip over it again while he was trying to repair it. There was glue residue on the underside of the strip, but it was not secured to the floor. The strip just lifted without any effort about 6 to 8 inches in the air. He said he put the tape down to prevent falls. He said he wanted to make sure the glue had sealed before the tape was removed. He said otherwise there was a potential for someone else to trip. During an observation and interview on 5/4/22 at 9:27a.m. the NP on the 200 hall where she was working. The NP said on 4/26/22 the day of Resident #1 fell . When she arrived Resident #1 was on the floor. Resident #1's shoes were on her feet and the NP said she took the shoes off. The NP said one of the shoes (not sure which one) had spit open. The sole of the shoe was separated from the other part of the shoe. The shoes appeared to be relatively new. The Resident was incontinent and sometimes none complaint with care, and she did not like people to change her. Her shoes smelled like urine and were stuck to her feet. The NP said the corner of the transition strip was pulled out into the floor about seven inches. Observation of strip revealed it was the one that was observed earlier to be loose, however; the tape appeared to keep it secure. The NP said Resident #1 would not let the NP touch her. She complained of severe pain. The shoulder was put back in place in the hospital, and they did a reduction(a none surgical technique to put the shoulder back in place.) The doctor did not want to do surgery unless necessary. The doctor wanted it to heal naturally. Resident #1 would not let the staff bring her arm out. Before she would not let them touch it, now she was a little bit better, not as tearful, and not crying. The NP said before Resident #1 complained of back pain, and now it was just the arm pain that she complained about. During an interview on 5/4/22 at 9:38 a.m. MA C said since Resident #1 hurt her shoulder she had complained of pain more. Prior to the shoulder incident she hardly ever complained of pain. Since the shoulder injury Resident #1 requested pain medications when she passed medications. The MA said she would tell nurse and nurse would give them. During an interview on 5/4/22 at 9:42 a.m. LVN A said prior to the shoulder injury Resident #1 never complained of pain. If Resident #1 said she hurt before the shoulder injury and was offered regular Tylenol. Resident #1 would refuse to take the medications. However, now she took the Tylenol #4 with [MEDICATION(S)] regularly. During and observation and interview with the Maintenance Man on 5/4/22 at 10:00 a.m. he had glue and tape with him on the 200 hall. He said he reglued and retaped the areas. He said it should take a couple of days to set. Observation of the hallway revealed yellow and black caution tape across the hallway in two places. With the tape over the areas they were not loose. During an observation and interview on 5/4/22 at 10:07 a.m. Resident #1was in the hallway in her wheelchair she used her left arm only to propel. She rolled up to the nurse and asked for a pain pill. LVN A confirmed Resident #1 asked for a pain pill due to pain. During an interview on 5/4/22 a t10:55 a.m. the Administrator was informed of concerns with Resident #1. She said was not told the transition strip was loose and caused the fall. She was told the residents improper footwear was the cause of the fall. The Administrator said there were statements with the facility report. There were no statements with the Facility Provider Investigation Report. She said the DON had statements since they were not with the report. During an interview on 5/4/22 at 11:05 a.m. the Maintenance Man said he wanted to clarify his statement. He was told he needed to repair the floor because it was damaged. He did not know what came first the shoe got caught and pulled up the strip, or the strip being loose and catching the shoe. He said he was informed Resident #1's shoe caught the transition and pulled it up. However as far as he is aware there were no witnesses to the fall. During an interview on 5/4/22 at 11:11 a.m. the NP said she wanted to clarify her statements. She said she did not say the resident tripped over the transition strip. Just that strip was out in the floor. She did not see the fall. During an interview on 5/4/22 at 11:45 a.m. the DON provided 7 statements. All 7 statements said on the morning of 4/26/22 the staff had been on hall 200 and not seen the transition strip loose. The DON said she thought those statements were with the facility self-report. During an interview on 5/4/22 at 1:14 p.m. the DON said the MDS, the Nursing Daily Skilled notes, and Resident #1's actual abilities did not match. The discrepancy between MDS and Nursing Daily Skilled Notes were the nurse's note was for just one day and one shift. The MDS is over a look back period of several days. Resident #1's level of need depended on the time of day or what kind of day the resident was having. Sometimes she was independent, and sometimes she required assistance. Review of the incident reports for the last three months did not indicate any falls related to accident hazards. Review of the Grievance logs for the last 3 months did not indicate any complaints about accident hazards.

Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff to provide nursing services to assure resident safety and maintain the highest practicable physical, mental and psychosocial well-being determined by resident assessments and plans of care and considering the number, acuity and [DIAGNOSES REDACTED]. (Resident #s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, and 19) The facility did not provide sufficient nursing personnel on the COVID-19 unit to: * Provide wound care according to physician's orders [REDACTED]. * Assess skin and identify new or worsening pressure injuries for Resident #s 2, 3, 4 and 5; * Provide skin assessments according to their facility schedule for Resident #s 2, 3, 4, 6, 7, 8, 9,10,11,12,13,14,15,16,17,18 and 19; *Provide showers and baths according to the facility schedule for Resident #s 1,2,3,4,5,6,7,8,9,10,11,13,14,15,16,17,18 and 19. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm that is not immediate with a scope identified as pattern due to the facility's need to complete in-servicing and evaluate the effectiveness of the corrective systems. This failure could place the residents at risk of not receiving care and services to meet their needs, decreased quality of life, injury, illness and death. Findings included: The resident census dated [DATE] indicated there were 33 residents residing on the COVID-19 positive unit. Staff timecard records from [DATE] to [DATE] for the COVID-19 positive unit indicated staffing as follows: *[DATE] - Day shift: 1 RN (5:45 a.m. to 6:25 p.m.) 1 CNA (6:00 a.m. to 6:00 p.m.) 1 MA (8:00 a.m. to 10:00 p.m.) Night shift: 1 RN (5:45 a.m. to 6:20 p.m.) 1 CNA 6:10 p.m. to 6:00 a.m.) *[DATE] - Day shift: 1 RN (5:00 a.m. to 6:35 p.m.) 1 CNA (6:00 a.m. to 6:00 p.m.) 1 MA (8:00 a.m. to 10:00 p.m.) Night shift: 1 LVN (5:00 p.m. to 8:30 a.m.) 1 CNA (6:30 p.m. to 6:30 a.m.) *[DATE] - Day shift: 1 LVN (5:45 a.m. to 9:30 p.m.) 1 CNA (6:00 a.m. to 6:00 p.m.) 1 MA (8:00 a.m. to 10:00 p.m.) 1 CNA (2:00 p.m. to 2:25 a.m.) Night shift: 1 LVN (5:45 p.m. to 7:10 a.m.) 1 CNA (6:00 p.m. to 6:15 a.m.) *[DATE] - Day shift: 1 LVN (5:45 a.m. to 7:10 p.m.) 1 CNA (6:00 a.m. to 6:00 p.m.) 1 MA (8:00 a.m. to 10:00 p.m.) Night shift: 1 LVN (5:00 p.m. to 6:20 a.m.) 2 CNA (6:00 p.m. to 6:00 a.m.) *[DATE] - Day shift: 1 RN (5:00 a.m. to 6:40 p.m.) 1 CNA (6:00 a.m. to 6:00 p.m.) 1 MA (8:00 a.m. to 10:00 p.m.) Night shift: 1 LVN (3:30 p.m. to 9:00 a.m.) 1 CNA (6:00 p.m. to 6:00 a.m.) *[DATE] - Day shift: 1 LVN (no documentation provided) 2 CNAs (6:00 a.m. to 6:00 p.m.) 1 MA (8:00 a.m. to 10:00 p.m.) Night shift: 1 LVN (4:30 p.m. to 6:00 a.m.) 2 CNAs (6:00 p.m. to 6:00 a.m.) *[DATE] - Day shift: 1 RN (5:00 a.m. to 6:45 p.m.) 2 CNAs (6:00 a.m. to 6:00 p.m.) 1 MA (8:00 a.m. to 10:00 p.m.) Night shift: 1 LVN (5:30 p.m. to 7:00 a.m.) 2 CNAs (6:00 p.m. to 6:00 a.m.) *[DATE] - Day shift: 1 RN (5:30 a.m. to 10:00 p.m.) 1 CNA (6:00 a.m. to 6:00 p.m.) 1 CNA (7:00 a.m. to 2:00 p.m.) 1 MA (8:00 a.m. to 10:00 p.m.) Night shift: 1 RN (5:30 p.m. to 6:30 a.m.) 1 LVN (6:30 p.m. to 5:00 a.m.) 1 CNA (6:00 p.m. to 6:30 a.m.) 1 CNA (6:00 p.m. to 6:00 a.m.) (no time turned in) During an observation on the COVID-19 positive unit on [DATE] at 5:05 p.m., there was 1 nurse, 1 MA, and 2 CNAs. LVN A received a new resident on the COVID-19 positive unit and spoke with non-emergent transport regarding 2 additional new admissions. During an interview on [DATE] at 5:41 p.m., LVN A said she was the only nurse working on the COVID-19 positive unit for her shift (6 a.m. to 6 p.m.). She said 1 nurse on the COVID-19 hall was not enough. She said she put in her notice because the amount of work the facility expected 1 nurse to complete on the COVID-19 hall was too much. She said she currently had 28 residents. She said she received 2 new admissions earlier in the day and 2 more new admissions were on their way. She said she begged the unit manager for help but she did not get help. She said none of the managers ever came to the COVID-19 positive hall. She said completing 1 admission took several hours and just entering the orders could take 90 minutes. She said she currently had 10 residents with blood sugar checks. She said it took about 25 minutes per resident to check a blood sugar, administer insulin, and document. She said there was only 1 laptop between the nurse and MA, so she had to come back to the nursing station to document the blood sugar then document if insulin was administered. She said there were 3 residents with feeding tubes. She said the residents with feeding tubes required water flushes and feedings, and she was responsible for administering their medications. She said each resident with a feeding tube took approximately 30 minutes to administer medications with water flushes. She said nurses were required to administer all oral antibiotics, anticoagulant medications, breathing treatments, and PRN medications. She said 1 resident had intravenous (IV) antibiotics ordered every 8 hours. She said the day shift nurse was required to complete respiratory assessments on all residents every 8 hours. She said she was responsible for completing 2 respiratory assessments for every resident during her shift. She said a daily skilled nursing note was required for every resident on the COVID-19 hall. She said she had not seen the treatment nurse on the hall and there were probably 6 or 7 daily wound treatments that the nurses were expected to complete. She said there was not enough time to complete wound care and wound care was sometimes not completed during the shift. She said the nurse on the COVID-19 positive hall was expected to complete weekly skin assessments. She said she prioritized her duties and skin was left for the end of the day and sometimes assessments were unable to be completed during the shift. She said the facility did not staff enough CNAs on the COVID-19 positive hall. She said most of the residents required ADL assistance and residents are unable to get baths or get repositioned every 2 hours when 1 CNA was scheduled for 30 residents. LVN A said she would work several hours past her shift because she was unable to complete all the documentation that was required during her 12-hour shift. During an interview on [DATE] at 5:56 p.m., CNA D said she worked 12 hours shifts on the day shift. She said sometimes she was the only CNA working on the day shift. She said all 3 meals were passed on the day shift and she was responsible for passing trays and also had to pick up the trays after residents were finished eating because the facility was no longer using disposable dinnerware for residents on the COVID-19 positive hall. She said it took about 20 minutes to pass meal trays and 20 minutes to pick up meal trays for each meal. She said she provided incontinent care when she made rounds and it took her about 15 minutes to provide incontinent care for each resident and she would reposition dependent residents after providing incontinent care. She said assisting residents with getting dressed took about 20 minutes per resident. She said it was difficult to assist residents with baths or showers when she was the only CNA working and residents did not always get their scheduled baths or showers. During an interview on [DATE] at 6:05 p.m., CNA L said today was her first day working at the facility and she came in a 2:00 p.m. She said most of the residents on the COVID-19 positive unit required ADL assistance and she did not think 1 CNA could provide care for all the residents for a 12-hour shift. She said many of the residents said they have not been receiving their scheduled showers. During an interview on [DATE] at 6:15 p.m., MA E said she worked 12 hour shifts and administered scheduled medications. She said she tried to help the CNAs when she was not passing medications. She said most of the residents on the COVID-19 positive hall required assistance with ADLs. She said managers did not come onto the COVID-19 hall. She said there was 1 nurse, 1 MA, and 1 or 2 CNAs on the COVID-19 hall during the day and 1 nurse and 1 CNA on the night shift. During an interview on [DATE] at 6:21 p.m., CNA M said she worked 12 hour shifts at night and had been the only CNA working on the night shift on the COVID-19 positive hall until tonight. She said she tried to get all her tasks completed during the shift and she would notify the next shift if she was unable to complete resident care. During an interview on [DATE] at 2:26 p.m., the unit manager of the COVID-19 positive hall said there were currently 28 residents on the COVID-19 positive hall. She said corporate only approved 1 nurse per 12-hour shift on the COVID-19 positive hall. She said the nurses begged for more help but when she or the DON asked the clinical services director (CSD) to approve another nurse, the CSD asked how many residents were on the COVID-19 hall and said 1 nurse could handle 35 residents, if they had better time management. The unit manager said corporate approved a MA to work on the COVID-19 positive hall but the nurses still had to administer medications that the MA was not allowed to administer including antibiotics, anticoagulants, insulin, and breathing treatments. She said sometimes 1 CNA and sometimes 2 CNAs were scheduled for a shift. She said staffing on the COVID-19 positive unit was not sufficient because there was not enough staff to provide the care the residents required. She said she was the unit manager of the COVID-19 positive unit, but corporate would not allow her to go onto the COVID-19 unit. She said she had not been allowed to go onto the COVID-19 unit since it opened 8 months ago. During an interview on [DATE] at 2:41 p.m., the staffing coordinator said staff worked 12 hour shifts on the COVID-19 positive unit. She said 1 nurse and 2 CNAs were staffed for 6:00 a.m. to 6:00 p.m. and 1 nurse and 2 CNAs were staffed for 6:00 p.m. to 6:00 a.m. She said a MA was staffed from 8:00 a.m. to 8:00 p.m. She said the second CNA on the night shift was just hired and today was her first day. She said there had been 1 CNA on the night shift but now there were 2 CNAs scheduled on the night shift. She said staff on the COVID-19 positive unit told her they needed more staff. The staffing coordinator said the DON suggested having 2 nurses on the COVID-19 positive unit but he was off today, and 1 nurse was still being scheduled for each shift. She said she asked for volunteers to work on the positive hall, but no staff volunteered. During an interview on [DATE] at 1:55 p.m., the administrator said about a month ago, the facility began accepting COVID-19 positive residents from other facilities and from hospitals. She said several of the facility's residents also tested positive. She said the facility completed routine testing of negative residents on [DATE] and received 11 positive results on [DATE]. She said currently there were 27 COVID-19 positive residents in the facility and 4 in the hospital. She said staff on the COVID-19 positive unit worked 12-hour shifts. During an interview on [DATE] at 4:48 p.m., the administrator said corporate decided how many nurses were allowed to work on the COVID-19 positive hall, not the DON. She said they were working on getting more staff on the COVID-19 positive hall. During an interview on [DATE] at 9:39 a.m., the unit manager said the administrator and DON were both out of the facility today ([DATE]). She said the facility stopped taking admissions on the COVID-19 positive unit on [DATE]. She said there were currently 33 residents on the COVID-19 positive unit. She said there was 1 nurse, 1 MA, and 2 CNAs currently working on the positive unit and that was not enough staff to provide necessary care for 33 residents. The unit manager said they have not placed a second nurse on the COVID-19 unit. She said corporate would not allow her to go onto the COVID-19 unit to work as the second nurse. During an interview on [DATE] at 12:17 p.m., RN B said she worked the day shift on the COVID-19 positive unit. She said she was supposed to be off today, but she was called into work. She said she told the unit manager, DON, and staff coordinator for months that a second nurse was needed on the COVID-19 positive hall. She said currently there were 33 residents on the COVID-19 positive hall and there had been more than 30 residents on the COVID-19 positive hall for the last week. RN B said 8 residents required blood sugar checks and insulin. She said blood sugars were checked in the morning, at lunch, before dinner, and at night. She said she completed the morning, lunch, and dinner blood sugar checks and administered insulin. She said there were 2 residents that were on continuous peg tube feedings and she was responsible for administering medications through their feeding tubes. She said she was required to complete respiratory assessments on all residents twice during her shift and all residents required a daily skilled note. She said there were 3 residents she was aware of with wound treatments. She said the nurses were responsible for the weekly skin assessments and they were due when they popped up in red. RN B said there were a lot of late skin assessments that were past due. She said when she prioritized her duties, skin assessments and treatments were last to be done. She said wound treatments and skin assessments were not always completed during the shift. She said a resident fell the night before and she was required to perform neurological checks on the resident during her shift in addition to all of her other duties. She said the nurse and MA had to share a laptop, so she had to constantly go from resident rooms to the computer at the nursing station to document. She said 1 resident had a PICC line and received IV antibiotics every 8 hours. RN B said she was responsible for administering oral antibiotics to 12 residents. She said she was responsible for administering anticoagulant medication to 15 residents. She said she administered 2 to 3 breathing treatments during her shift. She said she often ran out of wound care and insulin supplies and had to wait until someone could deliver supplies to them. She said admissions took approximately 4 hours to complete and she had 4 admissions on [DATE]. She said she usually worked over her 12-hour shift to finish admitting residents and completing her documentation for the day because it was impossible to complete everything when she was the only nurse on the positive hall for the shift. During an interview on [DATE] at 1:14 p.m., CNA J said she worked the day shift on the COVID-19 positive unit. She said there was 1 or 2 CNAs scheduled during the day shift on the COVID-19 positive hall. She said most of the time she worked the positive hall as the only CNA. She said today CNA K was scheduled on the hall, but it was her first day on the hall. She said she spoke to the staffing coordinator within the last few weeks regarding adding more CNA staff to the COVID-19 positive hall but nothing had changed. She said 29 of the 33 residents on the COVID-19 positive hall required ADL assistance of some kind. She said she made rounds and provided incontinent care and repositioned residents. She said the day shift CNAs passed and picked up all 3 meal trays which took about an hour for each meal. She said she assisted residents with getting dressed and answered call lights throughout the shift. She said showers took about 15 minutes each but were difficult to complete when there was only 1 CNA on the hall. She said they were not able to complete all the showers that were scheduled. During an interview on [DATE] at 1:21 p.m., CNA K said today was her first day to work on the COVID-19 positive hall. She said CNA J came in to work on her day off because she (CNA J) did not want to her (CNA K) to be the only CNA for the day shift. CNA K said approximately 30 of the 33 residents on the COVID-19 positive hall needed assistance with ADLs. She said she made rounds when she arrived and provided incontinent care. She said she assisted residents with getting dressed and answered call lights when they went off. She said the day shift CNA was responsible for passing out and picking up trays for all 3 meal every day. She said she repositioned and off-loaded dependent residents while making rounds. She said when she finished one round, it was time to start a new round. She said CNAs also had to document on ADLs and meal intake. She said scheduled showers were not getting completed. During an interview on [DATE] at 2:26 p.m., RN B said she was notified by the unit manager that that facility was moving 8 residents that tested positive for COVID-19 from the negative halls to the COVID-19 positive hall and she was also receiving 2 new admissions. She said she was still the only nurse on the COVID-19 hall with 1 MA and 1 CNA. She said CNA J worked today on her day off and went home at 2:00 p.m. She said currently there were 33 residents on the positive hall and she would have a total of 43 when all residents arrived. RN B said 1 of the new admissions was sitting in a car outside waiting to admit. She said herself, the MA, and the CNA were responsible for moving residents to different rooms to make space for the new residents because no management staff came to the COVID-19 positive hall to help. She said she begged the unit manager, DON, and staffing coordinator for 2 nurses to be scheduled per shift on the COVID-19 positive hall for months and they still just have 1 nurse per shift. During an observation on [DATE] at 2:38 p.m., RN B, MA E, and CNA K were going room to room preparing for the new residents that were moving onto the COVID-19 positive hall. There were no other staff on the COVID-19 positive hall. During an interview on [DATE] at 2:31 p.m., the unit manager said corporate decided to start taking admissions again on the COVID-19 positive hall. She said the COVID-19 positive unit would receive 8 new COVID-19 positive residents from the negative halls and they are accepting 2 new admissions from outside the facility. She said she was aware that there was 1 nurse, 1 MA, and 1 CNA working on the COVID-19 positive hall. During an interview on [DATE] at 6:14 p.m., RN F said she worked 12 hour shifts on the COVID-19 positive hall at night. She said there was only 1 nurse and usually 1 CNA scheduled on the COVID-19 positive hall on the night shift. She said the residents on the COVID-19 hall were weak, sick, and scared. She said the residents were not able to see their families and they had more needs. She said they needed at least 2 nurses on the hall to provide all the required care for the residents. She said she spoke to the DON about needing another nurse on the COVID-19 hall, but the DON told her that 1 nurse could have up to 35 residents on the night shift. She said she performed respiratory assessments on all the residents which took approximately 2 hours to complete. She said there were times when she had received 2 new admissions on the COVID-19 positive hall during a shift and admissions take more than 2 hours to complete. She said all new admissions required a functional ability assessment be completed every 8 hours for 3 days. She said all residents required a skilled note to be completed daily. She said the night nurse completed skin treatments for residents in odd rooms and the day nurse completed skin treatments for residents in even rooms. She said skin assessments were put off until the end of the shift. During an interview on [DATE] at 12:57 p.m., LVN H said she only worked on the COVID-19 positive hall 1 time. She said she worked on the negative halls but tested positive for COVID-19 on [DATE] and the staffing coordinator asked her if she wanted to work on the COVID-19 hall. LVN H said she worked on the positive hall on [DATE] from 7:30 a.m. to 7:30 p.m. She said it was horrible. She said there were 34 residents with 1 nurse, 1 MA, and 2 CNAs. She said the COVID-19 unit was unorganized. She said she did not have any cans of feeding tube formula for Resident #1, no blood sugar testing strips, and no wound care supplies. LVN H said she had to wait on supplies, but someone did drop off supplies during her shift. She said she got no break and no lunch. She said residents required assessments, medications, blood sugar checks and insulin coverage. She said she did not know who had wound care or what treatment orders were due. She said she completed 2 wound treatments. She said the COVID-19 unit absolutely needed 2 nurses for each shift. During an interview on [DATE] at 4:31 p.m., the DON said he was aware of the need for more staffing on the COVID-19 positive hall. He said the nurses that worked on the COVID-19 positive hall had told him over the last few weeks that they needed 2 nurses for the day and night shift. He said he notified corporate because corporate sets the number of staffing hours allowed. He said he contacted the CSD and told her they needed more staff on the COVID-19 positive hall. He said the CSD asked how many residents were on the hall and he told her the number of residents. He said the CSD's response was that 1 nurse was enough for 35 residents. He said 1 nurse, 1 MA, and 1 or 2 CNAs was not enough staff to provide care to residents on the COVID-19 positive unit. The DON said his hands were tied and he could not even go onto the positive hall because corporate would not allow it. He said they had their COVID-19 positive hall for about 8 months and he had never been on the hall. He said the unit manager asked the CSD if she could work on the COVID-19 positive hall. He said CSD would not let her work on the hall or go onto the positive hall. The DON said the unit manager of the COVID-19 positive hall had not been allowed to go on the hall since it opened. The DON said it was frustrating because he was the DON but corporate would not allow him to manage the facility. He said skin was important and he expected wound care, skin assessments, and showers to be completed as scheduled. He said skin assessments were due weekly. During an interview on [DATE] at 1:09 p.m., the treatment nurse said she was only allowed to go onto the COVID-19 positive hall to assess newly admitted resident's skin and complete wound assessments. She said she did not complete weekly skin assessments or daily wound treatments for the residents on the COVID-19 positive hall. She said the nurses on the COVID-19 positive hall were responsible for weekly skin assessments and daily wound care treatments. During an interview on [DATE] at 4:32 p.m., the wound physician said he went onto the COVID-19 positive hall on [DATE] because there were so many residents on the positive hall that had skin issues and he wanted to get a head start on treatment because some residents come off the positive hall with wounds that would have worsened. He said it was his first time on the COVID-19 positive hall and the first time to see several of the residents in the facility. He said the treatment nurse normally rounded with him, but she could not go onto the COVID-19 positive hall so he had a CNA working on the COVID-19 hall round with him. 1.A face sheet dated [DATE] indicated Resident #1 was [AGE] years old, admitted on [DATE], and died in the facility on [DATE]. Resident #1's [DIAGNOSES REDACTED]. A nursing note dated [DATE] at 10:42 a.m. indicated Resident #1's COVID-19 results from [DATE] were positive and resident would be moved to COVID-19 positive hall. Physician orders [REDACTED].#1 included Glucerna 1.2 at 50 cc/hr per gastrostomy tube for 22 hours, water at 40 cc/hr per gastrostomy tube for 22 hours, flush gastrostomy tube with 30 cc of water before and after medications and flush with 10 cc of water between medications. Resident #1's orders did not include orders for her left ankle wound. A Braden scale for predicting pressure sore risk dated [DATE] indicated Resident #1 was at high risk of developing pressure injuries. An MDS dated [DATE] indicated Resident #1 did not have intact cognition, did not make herself understood, and did not understand others. She required total assistance with ADLs. Resident #1 required total assistance with bathing. She was incontinent of bowel and bladder. Resident #1's MDS indicated she was at risk of developing pressure injuries but did not have unhealed pressure injuries. The MDS indicated Resident #1 had a [MEDICAL CONDITION]. A care plan dated [DATE] indicated Resident #1 was on isolation precautions due to COVID-19. She required tube feedings and was dependent on staff for tube feedings and flushes. Resident #1 had a left lateral ankle diabetic ulcer with the current treatment plan of Santyl and cover with a dry dressing daily. Interventions included to monitor and document wound size, periwound skin, exudate, granulation, infection necrosis, eschar, and provide treatment and skin assessments as per facility protocol. She required total assistance with ADLs including bathing/showering. An undated bathing schedule indicated Resident #1 was scheduled for baths on Tuesday, Thursday, and Saturday during the day shift. Bathing documentation for Resident #1 dated [DATE] indicated from [DATE] to [DATE], Resident #1 received 1 bath on [DATE]. A wound care evaluation completed by a wound care physician, dated [DATE] for Resident #1 indicated Resident #1's left ankle diabetic wound measured 2.3 x 2.8 x 0.2 cm with 80% slough and moderate serous drainage. The treatment order included to apply Santyl, calcium alginate, and cover daily. Resident #1's left ankle diabetic wound was surgically debrided. A wound care evaluation dated [DATE] (2 days before Resident #1 moved to the COVID-19 unit) indicated Resident #1's left ankle diabetic wound measured 2.0 x 3.0 x 0.2 cm with 5% slough and moderate serous drainage. The treatment order included to apply a collagen sheet, calcium alginate, and cover daily. Resident #1's left ankle diabetic wound was surgically debrided. A weekly skin assessment dated [DATE] indicated Resident #1 had a left lateral ankle diabetic wound measuring 3.0 x 4.0 x 0.2 cm. A telemedicine wound care evaluation dated [DATE] for Resident #1 indicated no in-person visit was possible due to COVID-19. The evaluation indicated Resident #1's left ankle diabetic wound measured 3.0 x 4.0 x 0.2 cm with 5% slough and moderate serous drainage. The treatment order included to apply a collagen sheet daily, apply calcium alginate and cover daily. The evaluation indicated Resident #1's left ankle wound had deteriorated. A weekly skin assessment dated [DATE] indicated Resident #1 had intact skin. The MAR for Resident #1 indicated a treatment order (start date of [DATE]) for her left lateral ankle that included to clean with normal saline, pat dry, apply Santyl (ointment that helps remove dead tissue and aids in wound healing) to the wound bed, and cover with a dry dressing daily (this was not the most recent treatment ordered by the wound care physician). The MAR indicated [REDACTED]. During an observation on [DATE] at 1:01 p.m., Resident #1 was lying in bed on her right side and her left foot was off-loaded with a pillow. Her hair appeared disheveled. RN B removed a sock from Resident #1's left foot. A dressing dated [DATE] was covering Resident #1's outer left ankle. There was a dark red ring visible on the dressing. RN B removed the dressing and the dressing had a dark reddish black ring that covered most of the dressing. Resident #1's left ankle had an open wound approximately the size of a half dollar. The wound bed was dark pink and slough (yellowish white dead tissue) covered approximately ½ of the wound. Resident #1's ankle wound had no drainage and no odor was noted (surveyor was wearing N95 and face shield). During an interview on [DATE] at 1:04 p.m., RN B said she was aware that Resident #1 had a wound to her left ankle and thought she was the last person to perform wound treatment to Resident #1's left ankle wound about a week ago. During an interview on [DATE] at 1:09 p.m., the treatment nurse said Resident #1 died during the night of [DATE]. She said Resident #1 acquired the wound to her left ankle after she was admitted to the facility. She said the Resident #1's left ankle wound was first noted on [DATE]. She said she last assessed Resident #1's left ankle wound on [DATE] and measured wounds. She said she did not know how Resident #1 had a dressing dated [DATE] when she saw her on [DATE] and removed the dressing. She said the wound physician did not go on the COVID-19 positive hall on [DATE]. A nursing note dated [DATE] at 1:00 a.m. indicated Resident #1 was noted with no blood pressure, pulse, or respirations. Resident #1's skin was cold to touch, and she was pronounced dead by 2 RNs. 2. A face sheet dated [DATE] indicated Resident #2 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED].#2 indicated there were no orders for wound care. An MDS dated [DATE] indicated Resident #2 had moderately impaired cognition, made her needs known, and was able to understand others. She required extensive and total assistance with ADLs and was incontinent of bowel. Bladder incontinence was not rated. Resident #2 required total assistance with bathing. The MDS indicated Resident #2 was at risk of developing pressure injuries and did not have unhealed pressure injuries. A care plan dated [DATE] for Resident #2 indicated she was at risk of psychosocial well-being alteration related to COVID-19. The care plan did not address skin assessments, wound care, ADLs, or bathing/showering. An undated bathing schedule indicated Resident #2 was to receive baths on Monday, Wednesday, and Friday during the day shift. A bathing documentation from [DATE] to [DATE] indicated Resident received 2 baths since [DATE]. Resident #2's bathing documentation indicated she received baths on [DATE] and [DATE]. A hospital wound care note dated [DATE] indicated Resident #2 had a stage 1 unhealed pressure injury to her coccyx. There were no measurements included in the hospital wound care note. An admission skin assessment dated [DATE] indicated Resident #2 had redness to her coccyx and both heels. The skin assessment did not include measurements. Resident #2's clinical record from [DATE] through [DATE] indicated the last weekly skin assessment was completed [DATE]. Resident #2's clinical record indicated a weekly skin assessment and Braden scale for predicting pressure sore risk should have been completed [DATE]. A nursing note dated [DATE] at 7:10 a.m. indicated Resident #2 was sent to the hospital for clotted blood in her indwelling catheter. A hospital discharge record dated [DATE] indicated Resident #2 was diagnosed with [REDACTED]. The records did not indicate she had a wound. A nursing note dated [DATE] at 9:06 p.m. indicated Resident #2 readmitted to the facility. A wound was noted to her buttock. The nursing note did not include wound measurements or a description of the wound. A nursing note dated [DATE] at 7:01 a.m. indicated Resident #2 had a stage 1 [MEDICATION NAME] dressing to her coccyx. The note did not incl (TRUNCATED)

Based on observation, interview, and record review, the facility failed to ensure necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new pressure injuries from developing was provided for 5 of 6 residents reviewed for pressure injuries. (Resident #s 1, 2, 3, 4, and 5) 1.The facility did not thoroughly assess or treat Resident #1's diabetic left ankle wound. 2. The facility did not thoroughly assess or treat Resident #2's unstageable pressure injury to her right buttock. 3. The facility did not thoroughly assess or treat Resident #3's stage 3 pressure injury to her sacrum. 4. The facility did not thoroughly assess or treat Resident #4's moisture associated skin damage. 5. The facility did not thoroughly assess or treat Resident #5's stage 2 pressure injury. This failure could place residents at risk for new development or worsening of existing pressure injuries, pain, and decreased quality of life. Findings included: 1. A face sheet dated [DATE] indicated Resident #1 was [AGE] years old, admitted on [DATE], and died in the facility on [DATE]. Resident #1's [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #1 did not have intact cognition, did not make herself understood, and did not understand others. She required total assistance with ADLs. She was incontinent of bowel and bladder. Resident #1's MDS indicated she was at risk of developing pressure injuries but did not have unhealed pressure injuries. Resident #1 had a [MEDICAL CONDITION]. A nursing note dated [DATE] at 4:51 p.m. indicated Resident #1 was evaluated by wound care for a diabetic wound to her left lateral ankle measuring 0.8x0.4x0.1 cm with light serous drainage and 30% slough. New treatment order to apply Leptospermum honey and cover with dressing daily. An evaluation of clinically unavoidable pressure injury dated [DATE] for Resident #1 indicated the evaluation did not include the location of Resident #1's pressure injury. The evaluation indicated Resident #1 had diabetes, was incontinent, and the head of bed required elevation most of the day. The evaluation included interventions that were in place before the development of Resident #1's pressure injury and included turning/repositioning, barrier cream, dietary supplements, and offloading of extremities. A nursing note dated [DATE] at 6:18 p.m. for Resident #1 indicated a technician was at the facility to perform a venous doppler. Preliminary impression from the technician appeared to be positive for a lower left extremity [MEDICAL CONDITION]. The technician said the final report would be done within 24 hours. The nurse practitioner was notified on the preliminary report. An ultrasound result dated [DATE] for Resident #1 indicated the ultrasound appeared positive for a [MEDICAL CONDITIONS] in her lower left extremity. Physician orders [REDACTED].#1 included Eliquis 10mg twice a day for 7 days then 5mg twice a day for 6 months for [MEDICAL CONDITION]. A nursing note dated [DATE] for Resident #1 indicated the radiology technician refused to complete an arterial ultrasound on Resident #1 because the resident was too contracted to get a good image. The nurse practitioner was made aware that arterial ultrasound was not completed and why it was not completed. A Braden scale for predicting pressure sore risk dated [DATE] indicated Resident #1 was at high risk of developing pressure injuries. A wound care evaluation dated [DATE] for Resident #1 indicated Resident #1's left ankle diabetic wound measured 2.3x2.8x0.2 cm with 80% slough and moderate serous drainage. The treatment order included to apply Santyl, calcium alginate, and cover daily. Resident #1's left ankle diabetic wound was surgically debrided. A wound care evaluation dated [DATE] for Resident #1 indicated Resident #1's left ankle diabetic wound measured 2.0x3.0x0.2 cm with 5% slough and moderate serous drainage. The treatment order indicated to apply calcium alginate daily and cover with a dressing and Santyl was discontinued. A wound care evaluation dated [DATE] for Resident #1 indicated Resident #1's left ankle diabetic wound measured 2.3x3.0x0.2 cm with 5% slough and moderate serous drainage. The treatment order indicated to apply calcium alginate daily and cover with a dressing. Resident #1's left ankle diabetic wound was surgically debrided. A wound care evaluation dated [DATE] for Resident #1 indicated Resident #1's left ankle diabetic wound measured 2.0x3.0x0.2 cm with 5% slough and moderate serous drainage. The treatment order included to apply calcium alginate and cover daily. Resident #1's left ankle diabetic wound was surgically debrided. A wound care evaluation dated [DATE] (two days before Resident #1 was moved to the COVID unit) indicated Resident #1's left ankle diabetic wound measured 2.0x3.0x0.2 cm with 5% slough and moderate serous drainage. The treatment order included to apply a collagen sheet, calcium alginate, and cover daily. Resident #1's left ankle diabetic wound was surgically debrided. A facility wound log dated [DATE] indicated Resident #1's left lateral ankle wound was first identified in the facility on [DATE], measured 3.0x4.0x0.2 cm with 5% slough and light drainage. A nursing note dated [DATE] at 10:42 a.m. indicated Resident #1's COVID-19 results from [DATE] were positive and resident would be moved to COVID-19 positive hall. A weekly skin assessment dated [DATE] indicated Resident #1 had a left lateral ankle diabetic wound measuring 3.0x4.0x0.2 cm. A care plan dated [DATE] indicated Resident #1 was on isolation precautions due to COVID-19. She required tube feedings and was dependent on staff for tube feedings and flushes. Resident #1 had a left lateral ankle diabetic ulcer with the current treatment plan of Santyl and cover with a dry dressing daily. Interventions included to monitor and document wound size, periwound skin, exudate, granulation, infection necrosis, eschar, and provide treatment and skin assessments as per facility protocol. She required total assistance with ADLs. A telemedicine wound care evaluation dated [DATE] for Resident #1 indicated no in-person visit was possible due to COVID-19. The evaluation indicated Resident #1's left ankle diabetic wound measured 3.0x4.0x0.2 cm with 5% slough and moderate serous drainage. The treatment order included to apply a collagen sheet daily, apply calcium alginate and cover daily. The evaluation indicated Resident #1's left ankle wound had deteriorated. An undated facility wound log indicated Resident #1's left lateral ankle wound was first identified in the facility on [DATE], measured 3.0x4.0x0.2 cm with 5% slough and light drainage. The treatment included collagen and calcium alginate. A weekly skin assessment dated [DATE] indicated Resident #1 had intact skin. During an observation on [DATE] at 1:01 p.m., Resident #1 was lying in bed on her right side and her left foot was off-loaded with a pillow. Resident #1 was wearing slipper socks. RN B removed the slipper sock from Resident #1's left foot. A dressing dated [DATE] was covering Resident #1's outer left ankle. There was a dark red ring that was visible on the dressing. RN B removed the dressing and the dressing had a dark reddish black ring that covered most of the dressing. Resident #1's left ankle had an open wound approximately the size of a half dollar. The wound bed was dark pink and slough (yellowish white dead tissue) covered approximately ½ of the wound. Resident #1's ankle wound had no drainage and no odor was noted (surveyor was wearing N95 and face shield). During an interview on [DATE] at 1:04 p.m., RN B said she was aware Resident #1 had a wound to her left ankle and thought she was the last person to perform wound treatment to Resident #1's left ankle wound. During an interview on [DATE] at 1:46 p.m., CNA J said Resident #1 had a dressing over her left outer ankle and she did not see the wound. A nursing note dated [DATE] at 1:00 a.m. indicated Resident #1 was noted with no blood pressure, pulse, or respirations. Resident #1's skin was cold to touch, and she was pronounced dead by 2 RNs. During an interview on [DATE] at 1:09 p.m., the treatment nurse said Resident #1 died during the night of [DATE]. She said Resident #1 acquired the wound to her left ankle after she was admitted to the facility. She said the Resident #1's left ankle wound was first noted on [DATE] and was noted to be a diabetic wound. She said she last assessed Resident #1's left ankle wound on [DATE] and measured her wound. She said she did not know how Resident #1 had a dressing dated [DATE] when she saw her on [DATE] and removed the dressing. She said the wound physician did not go on the COVID-19 positive hall on [DATE] but did complete a telemedicine visit. Medication administration records (MAR) dated [DATE] indicated Resident #1 had a treatment order (start date of [DATE]) to her left lateral ankle that included to clean with normal saline, pat dry, apply Santyl (ointment that helps remove dead tissue and aids in wound healing) to the wound bed, and cover with a dry dressing daily (this was not the most recent treatment ordered by the wound care physician). The MAR indicated [REDACTED]. 2. A face sheet dated [DATE] indicated Resident #2 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. A hospital wound care note dated [DATE] indicated Resident #2 had a stage 1 unhealed pressure injury to her coccyx. There were no measurements included in the hospital wound care note and the plan for Resident #2's pressure injury included preventative bundle and ongoing assessment. Resident #2's admission skin assessment dated [DATE] indicated she had redness to her coccyx and bilateral heels. The assessment did not include wound measurements. A nursing note dated [DATE] at 7:42 a.m. indicated Resident #2 had a stage 1 [MEDICATION NAME] dressing to her coccyx. The nursing note did not include wound measurements or a description of the wound. A MDS dated [DATE] indicated Resident #2 had moderately impaired cognition, made her needs known, and was able to understand others. She required extensive and total assistance with ADLs and was incontinent to bowel and bladder continence was not rated. The MDS indicated Resident #2 was at risk of developing pressure injuries and did not have unhealed pressure injuries. A nursing note dated [DATE] at 7:42 a.m. for Resident #2 indicated to continue wound care to buttock per order. The nursing note did not include wound measurements or a description of the wound. A care plan dated [DATE] for Resident #2 indicated she was at risk of psychosocial well-being altercation related to COVID-19. The care plan did not address skin assessments or wound care. A nursing note dated [DATE] at 6:59 a.m. indicated Resident #2 had a stage 1 [MEDICATION NAME] dressing to her coccyx. A nursing note dated [DATE] at 7:12 a.m. indicated Resident #2 had a stage 1 [MEDICATION NAME] dressing to her coccyx. A nursing note dated [DATE] at 7:10 a.m. indicated Resident #2 was sent to the hospital for clotted blood in her indwelling catheter. Hospital discharge records dated [DATE] indicated Resident #2 was diagnosed with [REDACTED]. The records did not indicate she had a wound. A nursing note dated [DATE] at 9:06 p.m. indicated Resident #2 readmitted to the facility. A wound was noted to her buttock. The nursing note did not describe the wound or include measurements. A nursing note dated [DATE] at 7:01 a.m. indicated Resident #2 had a stage 1 [MEDICATION NAME] dressing to her coccyx. The note did not include measurements or description of the wound. A nursing note dated [DATE] at 6:57 a.m. indicated Resident #2 had a stage 1 [MEDICATION NAME] dressing to her coccyx. The note did not include measurements or description of the wound. During an observation on [DATE] at 1:58 p.m., Resident #2 was lying in her bed and was awake. CNA J and CNA K rolled Resident #2 onto her side and removed her brief. Resident #2 had a dressing on coccyx dated [DATE]. RN B was providing care to another resident during the observation of Resident #2's wound and not available to remove the dressing. The CNAs pulled back the dressing reveal a wound approximately 2.5 cm by 6.5 cm to her right buttocks with slough covering the wound bed. The skin surrounding Resident #2's right buttock wound was dark pink. During an interview on [DATE] at 2:01 p.m., Resident #2 said she was not aware of the wound to her bottom and she had no pain to her bottom. During an interview on [DATE] at 2:00 p.m., CNA J said she had not seen Resident #2's wound because she had a dressing on her bottom since she admitted . Resident #2's clinical record dated [DATE] to [DATE] indicated there was no weekly skin assessment completed since [DATE]. Resident #2's clinical record indicated a weekly skin assessment and Braden scale for predicting pressure sore risk was due [DATE]. Resident #2's weekly skin assessment, after surveyor intervention, dated [DATE] indicated Resident #2 had an unstageable open area to her coccyx measuring 3.0x6.5 cm with a large amount of slough and a dark center, unable to measure depth. A Braden scale for predicting pressure sore risk dated [DATE] for Resident #2 indicated she was at moderate risk of developing pressure injuries. During an interview on [DATE] at 1:09 p.m., the treatment nurse said she assessed Resident #2's skin when she admitted on [DATE] and she had no open areas, but her buttocks was excoriated. The treatment nurse said she did not assess Resident #2 when she returned to the facility on [DATE] because she was off that day. She said the charge nurse was responsible for performing skin assessments for readmitted residents. During an interview on [DATE] at 6:16 p.m., RN F said Resident #2 had redness to her bottom at admission on [DATE], but she did not think she had any open areas. A wound evaluation for Resident #2 dated [DATE] indicated she had an unstageable pressure injury to her right buttock measuring 2.0x6.7x0.1 cm with 90% slough and light serous drainage. The wound physician surgically debrided Resident #2's right buttock wound. Treatment orders for Resident #2's wound included to apply leptospermum honey and cover with dressing daily. During an observation on [DATE] at 11:38 a.m., Resident #2 was sitting up in her bed. The treatment nurse assisted the resident onto her side and removed her brief. Resident #2 had a dressing on her coccyx dated [DATE]. The treatment nurse pulled back the dressing and Resident #2's wound was approximately 2.5 cm by 6.5 cm to her right buttocks with slough covering the wound bed. The skin surrounding Resident #2's right buttock wound was dark pinkish red. The drainage on the dressing was yellowish brown. A treatment administration record dated [DATE] for Resident #2 indicated no treatments were completed to Resident #1's right buttock wound. During an interview on [DATE] at 4:32 p.m., the wound physician said the treatment nurse normally rounded with him, but she could not go onto the COVID-19 positive hall so he had a CNA working on the COVID-19 hall round with him on [DATE]. He said normally he would assess the wound and the treatment nurse would change the dressing after he assessed the wound. He said he expected staff to change the dressing after he assessed the wound. A wound evaluation for Resident #2 dated [DATE] indicated she had an unstageable pressure injury to her right buttock measuring 2.0x6.0x0.1 cm with 90% slough and light serous drainage. The wound physician surgically debrided Resident #2's right buttock wound. Treatment orders for Resident #2's wound included to apply leptospermum honey and cover with dressing daily. 3. A face sheet dated [DATE] indicated Resident #3 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #3's admission skin assessment dated [DATE] indicated she had excoriation to her sacral/coccyx area. A nursing note dated [DATE] at 1:55 p.m. indicated Resident #3 was noted with small open areas with minimal amount of serous drainage. Resident #3's coccyx was cleaned with normal saline, patted dry, and dressing applied. Physician orders [REDACTED].#3 indicated there were no wound treatment orders. A MDS dated [DATE] indicated Resident #3 had intact cognition, made her needs known, and was able to understand others. She required extensive assistance with ADLs and was incontinent to bowel and bladder. The MDS indicated Resident #3 was not at risk of developing pressure injuries and did not have unhealed pressure injuries. A care plan dated [DATE] for Resident #3 indicated she was at risk of psychosocial well-being altercation related to COVID-19. The care plan did not address skin assessments or wound care. A nursing note dated [DATE] at 7:42 a.m. indicated Resident #3 had a coccyx wound with treatment in process. The note did not include measurements, description of the wound, or type of treatment. A nursing note dated [DATE] at 7:59 a.m. indicated Resident #3 had a coccyx wound with treatment in process. The note did not include measurements, description of the wound, or type of treatment. A nursing note dated [DATE] at 7:28 a.m. indicated Resident #3 had a coccyx wound with treatment in process. The note did not include measurements, description of the wound, or type of treatment. A nursing note dated [DATE] at 8:00 a.m. indicated Resident #3 had a coccyx wound with treatment in process. The note did not include measurements, description of the wound, or type of treatment. A nursing note dated [DATE] at 8:06 a.m. indicated Resident #3 had a coccyx wound with treatment in process. The note did not include measurements, description of the wound, or type of treatment. Physician orders [REDACTED].#3 indicated there were no wound treatment orders. The note did not include measurements, description of the wound, or type of treatment. Treatment administration records dated [DATE] for Resident #3 indicated there was no documentation for wound care treatment. During an observation on [DATE] at 1:16 p.m., Resident #3 was awake and sitting up in her bed. RN B assisted Resident #3 onto her side and removed her brief. Resident #3 had an open area to her coccyx approximately the size of a quarter (2.4x2.4 cm). The wound bed was dark pink with dark tissue in the center of the wound bed. Resident #3 had an open area to her right buttock approximately the size of a quarter. The wound bed was pink. Resident #3 had 2 open areas to her left buttock. One open area on Resident #3's left buttock was approximately the size of a penny (1.6x1.6 cm) with a pink wound bed. Another open area to Resident #3's left buttock was approximately the size of a nickel (1.8x1.8) and the wound bed was pink. Resident #3 did not have a dressing cover any of her wounds. Resident #3's brief had 3 areas of dark pink drainage that matched the location of Resident #3's open wounds. During an interview on [DATE] at 1:19 p.m., Resident #3 said she was not getting good care at the facility but would not elaborate. She said she did not have pain to her bottom. Resident #3's clinical record indicated there was no weekly skin assessment completed since [DATE]. Resident #3's clinical record indicated a weekly skin assessment and a Braden scale for predicting pressure sore risk were due [DATE]. A Braden scale for predicting pressure sore risk with an effective date of [DATE] but completed on [DATE] for Resident #3 indicated she was at very high risk of developing pressure injuries. Resident #3's weekly skin assessment, after surveyor intervention, dated [DATE] indicated Resident #3 had an open area to her coccyx measuring 3.5x1.5x1.0 cm, an open area to her left buttock measuring 1.5x3.2 cm, an open area to her right buttock measuring 3.0x2.5 cm, and an open area to her sacrum measuring 2.5x2.2 cm. Physician orders [REDACTED].#3 included a wound care consult. A wound evaluation for Resident #3 dated [DATE] indicated she had a stage 3 pressure injury to her sacrum measuring 3.0x1.0x0.2 cm with light serous drainage and 10% slough. The wound physician surgically debrided Resident #3's sacrum wound. Treatment orders for Resident #3's sacrum wound included to apply barrier cream daily. Resident #3 had moisture associated skin damage to her right buttock measuring 3.0x2.5x0.1 cm with light serous drainage. Treatment orders for Resident #3's moisture associated skin damage to her right buttock included to apply barrier cream daily. Resident #3 had moisture associated skin damage to her left buttock measuring 8.0x5.6x0.1 cm with light serous drainage. Treatment orders for Resident #3's moisture associated skin damage to her right buttock included to apply barrier cream daily. During an interview on [DATE] at 10:53 a.m., the treatment nurse said she would call the wound physician regarding Resident #3's wound drainage and ask about adding a dressing because there should be a dressing. A wound evaluation for Resident #3 dated [DATE] indicated she had a stage 4 pressure injury to her sacrum measuring 4.0x3.0x0.3 cm with light serous drainage and 70% slough. The wound physician surgically debrided Resident #3's sacrum wound. Treatment orders for Resident #3's sacrum wound included to apply Leptospermum honey and cover daily and discontinue barrier cream. Resident #3's sacrum wound was surgically debrided. Resident #3 had moisture associated skin damage to her right buttock measuring 3.0x1.4x0.1 cm with light serous drainage. Treatment orders for Resident #3's moisture associated skin damage to her right buttock included to apply barrier cream daily. Resident #3 had moisture associated skin damage to her left buttock measuring 6.0x4.4x0.1 cm with light serous drainage. Treatment orders for Resident #3's moisture associated skin damage to her right buttock included to apply barrier cream daily. During an interview on [DATE] at 4:32 p.m., the wound physician said if he ordered barrier cream as treatment for [REDACTED]. 4. A face sheet dated [DATE] indicated Resident #4 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. An admission skin assessment dated [DATE] for Resident #4 indicated she had open areas to her buttocks included an open area to her right buttock measuring 1.7x0.9 cm and left buttock measuring 3.0x1.0 cm. Physician orders [REDACTED].#4 included to clean the area to buttock with wound cleanser, pat dry, apply barrier cream and cover with border gauze every night. A MDS dated [DATE] indicated Resident #4 had intact cognition, made her needs known, and understood others. She required extensive assistance with most ADLs. She was incontinent of bladder and bowel continence was not rated. The MDS indicated Resident #4 was not at risk of developing pressure injuries and did not have unhealed pressure injuries. A care plan dated [DATE] for Resident #4 indicated she was at risk of psychosocial well-being altercation related to COVID-19. The care plan did not address skin assessments or wound care. During an observation on [DATE] at 1:09 p.m., Resident #4 was awake and sitting up in her bed. RN B assisted Resident #4 onto her side and removed her brief. Resident #4 had excoriation to her left and right buttocks. There was an open area to Resident #4's left buttock approximately the size of a standard paperclip (2.8x0.5 cm) that appeared to be a stage 2 pressure injury. The wound bed was pink and there was no drainage or slough. There was an open area to Resident #4's right buttock approximately the size of a pencil top eraser (0.6x0.6 cm) that appeared to be a stage 2 pressure injury. The wound bed was pink and there was no drainage or slough. There was no barrier cream and dressings covering Resident #4's wounds. During an interview on [DATE] at 1:11 p.m., Resident #4 said she was unaware she had wounds and denied being in pain. She said she did not receive showers every other day. During an interview on [DATE] at 1:48 p.m., CNA K said Resident #4 did not have a dressing covering her wound this morning when she made rounds. Medication administration records (MAR) dated [DATE] for Resident #4 indicated wound care that included to clean area to buttock with wound cleanser, pat dry, apply barrier cream and cover every night was completed nightly from [DATE] to [DATE]. Resident #4's clinical record indicated there was no weekly skin assessment completed since [DATE]. Resident #4's clinical record indicated a Braden scale for predicting pressure sore risk was due on [DATE] and a weekly skin assessment was due on [DATE]. A Braden scale for predicting pressure sore risk with the effective date of [DATE] but completed on [DATE] for Resident #4 indicated she was at moderate risk of developing pressure injuries. Resident #4's weekly skin assessment, after surveyor intervention, dated [DATE] indicated she had various shades of discoloration noted to the back of her left hand, right hand, and thumb. There was a small scabbed area noted to Resident #4's right hip and MASD noted to her coccyx. A wound evaluation for Resident #4 dated [DATE] indicated she had moisture associated skin damage (MASD) to her left buttock measuring 3.0x0.4x0.1 cm with 5% slough and light serous drainage. The wound physician debrided Resident #4's MASD to her left buttock. Treatment orders for Resident #4's MASD to her left buttock included to apply barrier cream daily. Resident #4 had MASD to her right buttock measuring 0.6x0.5x0.1 cm with light serous drainage. Treatment orders for Resident #4's MASD to her right buttock included to apply barrier cream daily. A nursing note dated [DATE] at 6:02 a.m. indicated Resident #4 was found unresponsive at 3:50 a.m. with no respirations and weak to absent pulse. Compressions and rescue breaths provided until emergency medical personnel arrived. Rescue efforts terminated at 4:51 a.m. 5. A face sheet dated [DATE] indicated Resident #5 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. A nursing note dated [DATE] at 8:51 p.m. indicated Resident #5 was admitted with shearing noted to right buttock measuring 0.6x0.4 cm and another shearing area to right buttock measuring 1.0x1.0 cm. The treatment nurse was notified. An admission skin assessment dated [DATE] for Resident #5 indicated she had 2 open areas to her right buttock measuring 0.6x0.4 cm and 1.0x1.0 cm. Physician orders [REDACTED]. A care plan dated [DATE] indicated Resident #5 required isolation precautions due to COVID-19 and she was at risk of psychosocial well being altercation related to COVID-19. The care plan did not address skin assessments or wound care. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #5 had moderately impaired cognition, made her needs known, and understood others. She required extensive assistance with ADLs. She was incontinent of bladder and bowel continence was not rated. The MDS indicated Resident #5 was not at risk of developing pressure injuries and had no unhealed pressure injuries. During an observation on [DATE] at 12:55 p.m., Resident #5 was awake and sitting up in her bed. RN B assisted the resident on her side and removed her brief. Resident #5 had an indwelling urinary catheter. Resident #5 had shearing to her right buttock approximately the size of a quarter (2.4x2.4 cm). Resident #5 had scattered dark purple discoloration on her right buttock and to the right of the shearing that was approximately the size of standard round door knob (4.4x4.4 cm). During an interview on [DATE] at 12:58 p.m., Resident #5 said she was not in pain and did not know if she had skin impairments to her bottom. She said she did not know when she last received a shower or bath. Resident #5's weekly skin assessment, after surveyor intervention, dated [DATE] indicated Resident #5 had scattered discoloration and noted dark purple area to her right sacrum and buttocks. A wound evaluation for Resident #5 dated [DATE] indicated she had an unstageable deep tissue injury to her right buttock measuring 3.0x3.0 cm. There was no drainage. Treatment orders for Resident #5's unstageable deep tissue injury to her right buttock included to apply barrier cream daily. A Braden scale for predicting pressure sore risk dated [DATE] indicated Resident #5 was at low risk of developing pressure injuries. During an interview on [DATE] at 5:50 p.m., the unit manager said she assessed Resident #5's skin on [DATE] and she had an open area to her sacrum. She said she notified the nurse practitioner of the pencil top eraser size pressure injury to her sacrum. A wound evaluation for Resident #5 dated [DATE] indicated Resident #5's right buttock wound was a stage 2 and measured 3.0x15.0x0.1 cm with no drainage. Resident #5's wound deteriorated, and treatment orders were updated to apply collagen powder and cover with a dressing daily and to discontinue barrier cream. During an interview on [DATE] at 5:41 p.m., LVN A said 1(one) nurse on the COVID-19 hall was not enough. She said she begged the unit manager for help but she did not get help. She said she had not seen the treatment nurse on the hall and there were probably 6 or 7 daily wound treatments that the nurses were expected to perform but there was not enough time to complete wound care. She said wound care was sometimes not completed during the shift. She said the nurse on the COVID-19 positive hall also was expected to complete skin assessments. She said she prioritized her duties and skin was left for the end of the day and skin assessments were sometimes not completed during the shift. During an interview on [DATE] at 6:21 p.m., CNA M said she worked 12 hour shifts at night and had been the only CNA working on the night shift on the COVID-19 positive hall until tonight ([DATE]). She said she tried to get all her tasks completed during the shift and she would notify the next shift if she was unable to complete resident care. During an interview on [DATE] at 12:17 p.m., RN B said she worked the day shift on the COVID-19 hall. RN B said there were a lot of late skin assessments that were past due. She said wound treatments and skin assessments were not always completed during the shift. She said there were 3 residents with wound treatments that she was aware of and weekly skin assessments were due when they popped up in red on the computer. She said she told the unit manager, DON, and staff coordinator for months that a second nurse was needed on the COVID-19 positive hall. She said when she prioritized her duties, skin assessments and treatments were last to be done. During an interview on [DATE] at 1:14 p.m., CNA J said she spoke to the staffing coordinator regarding adding more CNA staff to the COVID-19 positive hall but nothing had changed. She said 29 of the 33 re(TRUNCATED)

Based on observation, interview, and record review, the facility failed to ensure residents were free of neglect for 1 of 32 residents reviewed for neglect. (Resident #3) The facility did not assess and provide treatment when Resident #3 complained of excruciating pain and when she exhibited signs/symptoms of a [MEDICAL CONDITION]. After surveyor intervention, Resident #3 was transferred to a local hospital where she was diagnosed with [REDACTED]. She received a blood transfusion and was placed in the ICU. An Immediate Jeopardy situation was identified on 01/12/17. The Immediate Jeopardy was removed on 01/13/17; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the 32 residents on a pain management program from not receiving needed care and pain alleviation. Findings included: Physician orders [REDACTED].#3 was [AGE] years old and admitted on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Physician orders [REDACTED].#3 received an order for [REDACTED]. The Medication Administration Record (MAR) dated January 2017 indicated Resident #3 received [MEDICATION NAME] and aspirin daily while in the facility. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #3 understood others and made her needs known. The MDS indicated Resident #3 did not exhibit behaviors and did not reject care. She required extensive assistance with bed mobility, dressing, bathing, toilet use, and personal hygiene. She was incontinent of bowel and bladder. The MDS indicated Resident #3 rarely experienced pain and the worst pain in the last 5 days was 3 on a 0-10 scale with 10 being the worst pain. A nursing note dated 01/04/17 at 12:13 a.m. indicated Resident #3 requested to go to the hospital because she was dying. She was given a Tylenol #4 and sent to ER (emergency room ). ([DIAGNOSES REDACTED].>A pain risk assessment dated [DATE] indicated Resident #3 had low back pain at an intensity of an 8 on a 0-10 scale with 10 being the worst pain. The assessment indicated Resident #3's pain was shooting and constant. A nursing note dated 01/06/17 at 5:20 p.m. indicated Resident #3 complained of pain. The resident hollered down the hall that she was in pain and pain medication was administered. There was no description of the pain. A nursing note dated 01/06/17 at 11:04 p.m., indicated Resident #3 said she did not feel good, was hurting badly, and continued to say that she wanted to die to get rid of the pain. There was no pain level or location noted. The MAR dated 01/06/17 indicated Resident #3 had a pain level of 0 on a 0-10 pain scale for the day, evening, and night shift. A MAR dated January 2017 indicated on 01/07/17 Resident #3 had generalized pain at a level 4 on a 0-10 pain scale and on 01/10/17 at a level 6 on a 0-10 pain scale. The MAR indicated that Resident #3 also received Tylenol as needed for pain on 01/08/17. There was no pain level indicated on the MAR. Resident #3 received Tylenol #4 on 01/08/17 for pain at a level of 7 on a 0-10 pain scale. A care plan printed 01/12/17 indicated Resident #3 was receiving a platelet inhibitor, [MEDICATION NAME], since 1/13/16 and aspirin, which was added to this care plan on 01/12/17 (after surveyor intervention). Interventions included monitoring for adverse consequences, which included [MEDICAL CONDITION] and increased risk for bleeding. Resident #3 had constipation and interventions included monitoring bowel movements every shift. The care plan indicated Resident #3 had gastrointestinal discomfort and interventions included checking stools for occult blood if bleeding was suspected. At <https://www.drugs.com/ accessed on 1/19/16> indicated .Aspirin Low Strength (aspirin) and [MEDICATION NAME] (prasugrel) Using prasugrel together with aspirin may increase the risk of bleeding, especially [MEDICAL CONDITION]. Talk to your doctor if you have any questions or concerns. Your doctor may already be aware of the risks, but has determined that this is the best course of treatment for [REDACTED]. You should seek immediate medical attention if you experience potential signs and symptoms of gastrointestinal injury such as abdominal pain, bloating, dizziness, lightheadedness, loss of appetite, nausea, vomiting (especially with fresh or dried blood that looks like coffee grounds), and red or black, tarry stools. It is important to tell your doctor about all other medications you use, including vitamins and herbs. Do not stop using any medications without first talking to your doctor . A nursing note dated 01/11/17 at 11:19 a.m., indicated Resident #3's abdomen was bloated and swollen, and she complained of pain when palpated. A new order for a KUB (kidney/ureter/bladder x-ray) was received. During an observation and interview on 01/11/17 at 2:45 p.m., Resident #3 was sitting up in bed. Her skin was pale and her face was flushed. MA T brought Resident #3 her scheduled pain medication (Tylenol #4) and left the room. MA T did not ask Resident #3 if she was in pain or where her pain was located. Resident #3 said she wanted to go somewhere else that could help her with her pain. She said the facility did not help her with her pain. Resident #3 said her pain started at her neck, went down her body, and up her back. She said her pain was 13 on the 0-10 scale. During an interview on 01/11/17 at 3:03 p.m., LVN Q was notified by the surveyor that Resident #3 complained of pain at 13 on the 0-10 scale. LVN Q did not leave the medication cart to assess Resident #3. LVN Q said Resident #3 had an order for [REDACTED].#4 twenty minutes prior. During an observation and interview on 01/11/17 at 3:20 p.m., ADON E intervened before LVN Q gave Resident #3 a dose of regular Tylenol. ADON E said LVN Q called Resident #3's physician to notify him of Resident #3's pain and had received an order to give an additional dose of Tylenol #4. During an observation on 1/11/17 at 6:00 p.m., Resident #3 said no medication helped her pain and she said she had pain everywhere and was praying for death. She also complained that it burned to urinate and grimaced when interviewed. She said she had been to the hospital last time for pneumonia and she requested this investigator to take me with you to get some help. During an observation and interview at 1/11/17 at 6:11 p.m., LVN Q, charge nurse, said Resident #3 had not reported burning on urination to him and he recalled his last assessment of her was at 3:15 p.m. when he medicated her with Tylenol #4 for pain. He said Resident #3 always complained of pain all over. He said he planned to call the doctor and see what he could do to, pipe her down. A nursing note dated 01/11/17 at 6:50 p.m., indicated that Resident #3 told surveyors that her pain was so bad that she was praying to die, the nurse went to assess the resident after surveyors talked to the resident, the resident said her pain was at a 9.9 on a 0-10 scale that started in her back and went down her legs, the nurse called the physician who gave an order for [REDACTED].#4. During an interview on 1/12/17 at 3:32 p.m., MA R said Resident #3 complained of pain at maybe an 8. She said she did a follow up to check for pain relief about an hour later, but she did not document the follow up. During an interview on 1/12/17 at 4:05 p.m., CNA U said Resident #3 yelled when she hurt and nurses knew that she needed pain medication when she yelled. She said Resident #3's stools were dark and soft and was told by the nurses that it was because she drank chocolate supplements. She said Resident #3's abdomen had a little roundness, but looked the same as it always did. A nursing note dated 01/12/17 at 12:09 a.m. indicated Resident #3 was sent to theER on [DATE] at 7:35 p.m. The hospital records dated 01/11/17 indicated Resident #3 present to the ER (emergency room ) with complaints of pain all over. Resident #3 was found to be significantly anemic with hemoglobin of 5.5 (normal hemoglobin 12.0-15.5). Resident #3's abdomen was distended, protuberant (bulging), with abdominal tenderness in all 4 quadrants. Resident #3 was having dark hemoccult-positive (blood in stools) melanotic (black pigmentation) stools. Resident #3's was placed in the ICU (intensive care unit). Resident #3 received 2 units of blood on 01/11/17. A hospital discharge summary dated 01/15/17 indicated Resident #3 was admitted to the hospital with [REDACTED]. Resident #3 also presented with an abnormal urinalysis concerning for a urinary tract infection [MEDICAL CONDITION]. Resident #3 was treated with [MEDICATION NAME] (antibiotic) and discharged with [MEDICATION NAME] (antibiotic) for 7 additional days. Resident #3 was treated with [MEDICATION NAME] (medication to treat erosive esophagitis) and underwent an EGD (upper endoscopy). The summary indicated severe esophagitis was the source of bleeding. Resident #3's order for [MEDICATION NAME] was discontinued, but aspirin was maintained. During an interview on 01/12/17 at 9:27 a.m., LVN P said Resident #3 went to the hospital in the evening of 01/11/17 because she was hollering out in pain. During an interview on 1/11/17 at 6:31 p.m., the corporate RN said residents were assessed every shift for pain and documented on the electronic medication record. She said residents should be reassessed for pain relief and if it was not effective, then the doctor was to be called and the registered nurse on duty should assess the resident. She said she did not know if this protocol had been followed for Resident #3. She said Resident #3 had a documented history of attention seeking behavior and that was considered in her pain control protocol. A care plan revised 01/12/17 indicated Resident #3 had chronic pain and interventions included assessing characteristics of pain using the pain assessment for and notifying the physician of any changes in the level or frequency of pain. The care plan indicated Resident # 3's acceptable pain level was 2, 3, and 4 on the 0-10 pain scale. The care plan did not address Resident #3's attention seeking behavior with pain. The Abuse/Neglect Policy dated 9/1/2005 indicated the definition of neglect was, .the failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury, or harm, or death to a resident . (sic) The administrator was notified on 01/12/17 at 2:42 p.m., an Immediate Jeopardy situation was identified due to the above failures. The facility's revised Plan of Removal was accepted on 01/12/17 at 6:13 p.m. and included: Quality of Care - Assessments Action 1.Patient (proper name) was seen by MD on 1/3/17, 1/7/17 & 1/10/17. Additionally, patient was assessed by LVN and RN on 1/11/17 and convinced to transport to hospital on eve of 1/11/17. Patient is currently in hospital. Person Responsible: DON DOC: 1/11/17 2. A report from EMAR and ETAR will be reviewed and crossed referenced with narcotic records for all patients. Any resident with documented complaints of pain will be reviewed to determine effectiveness of current pain management and treatment protocols. If relief is not being obtained a change of condition assessment will be completed and MD notified. RNC and DON 1/12/17 3. In-service initiated with nursing staff on 1/12/17 and staff will be inserviced prior to start of next scheduled shift on recognizing change in condition and importance of change in condition assessment and pain management to ensure appropriate action. Routine Pain Meds effectiveness is evaluated q shift on MAR. PRN Pain Medications are triggered in EMR for effectiveness within 45 minutes and Nurses are responsible for following up and documenting effectiveness in EMR. Regional Nurse Consultant will conduct In-Service per Surveyor request. Nursing Mgmt. will conduct 24 hour report review daily. 01/13/17 4. Medical Director has reviewed and approved plan of correction. Compliance will be monitored weekly through Standards of Care and reported monthly in QA Committee x3 months to ensure ongoing compliance or changes as needed NHA 24 hour report will be reviewed daily during morning meeting to ensure residents with changes have change in condition assessment completed and appropriate follow-through has occurred. (sic) On 01/12/17 at the surveyors confirmed the Plan of Removal was implemented sufficiently to remove the Immediate Jeopardy by: Five LVNs, 4 CNAs, 1 PT, and 1 MA were interviewed and said they were in-serviced on pain assessments, following up after pain medication administration, and stop and watch for residents with a change in condition. On 01/13/17 at 11:21 a.m., the administrator and DON were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 indicated there were 32 residents on a pain management program.

Based on observation, interview, and record review, the facility failed to implement their policies and procedures to prohibit mistreatment, neglect, or abuse for 2 of 8 residents reviewed for abuse. (Resident #s 3 and 6) The facility did not assess and provide treatment when Resident #3 complained of excruciating pain and when she exhibited signs/symptoms of a [MEDICAL CONDITION]. After surveyor intervention, Resident #3 was transferred to a local hospital where she was diagnosed with [REDACTED]. She received a blood transfusion and was placed in the ICU. An Immediate Jeopardy situation was identified on 01/12/17. The Immediate Jeopardy was removed on 01/13/17; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Resident #6 reported to the DON that CNA M was rough with her and made her use a bed pan. The facility did not investigate the allegation of abuse/neglect or report it to the State agency. These failures could place the 32 residents on a pain management program (s/s K) and the census of 93 residents (s/s F) at risk of abuse or neglect. Findings included: The Abuse/Neglect Policy dated 9/1/2005 indicated the definition of neglect was, .the failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury, or harm, or death to a resident . (sic) The Abuse/Neglect Prohibition Policy date 9/1/15 required the staff to .investigate the alleged incident should an allegation of suspected incident of resident abuse, neglect or injury of an unknown source be reported . The definition of neglect was .the failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury, or harm, or death to a resident . 1.Physician orders [REDACTED].#3 was [AGE] years old and admitted on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Physician orders [REDACTED].#3 received an order for [REDACTED]. The Medication Administration Record (MAR) dated January 2017 indicated Resident #3 received [MEDICATION NAME] and aspirin daily while in the facility. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #3 understood others and made her needs known. The MDS indicated Resident #3 did not exhibit behaviors and did not reject care. She required extensive assistance with bed mobility, dressing, bathing, toilet use, and personal hygiene. She was incontinent of bowel and bladder. The MDS indicated Resident #3 rarely experienced pain and the worst pain in the last 5 days was 3 on a 0-10 scale with 10 being the worst pain. A nursing note dated 01/04/17 at 12:13 a.m. indicated Resident #3 requested to go to the hospital because she was dying. She was given a Tylenol #4 and sent to ER (emergency room ). ([DIAGNOSES REDACTED].>A pain risk assessment dated [DATE] indicated Resident #3 had low back pain at an intensity of an 8 on a 0-10 scale with 10 being the worst pain. The assessment indicated Resident #3's pain was shooting and constant. A nursing note dated 01/06/17 at 5:20 p.m. indicated Resident #3 complained of pain. The resident hollered down the hall that she was in pain and pain medication was administered. There was no description of the pain. A nursing note dated 01/06/17 at 11:04 p.m., indicated Resident #3 said she did not feel good, was hurting badly, and continued to say that she wanted to die to get rid of the pain. There was no pain level or location noted. The MAR dated 01/06/17 indicated Resident #3 had a pain level of 0 on a 0-10 pain scale for the day, evening, and night shift. A MAR dated January 2017 indicated on 01/07/17 Resident #3 had generalized pain at a level 4 on a 0-10 pain scale and on 01/10/17 at a level 6 on a 0-10 pain scale. The MAR indicated that Resident #3 also received Tylenol as needed for pain on 01/08/17. There was no pain level indicated on the MAR. Resident #3 received Tylenol #4 on 01/08/17 for pain at a level of 7 on a 0-10 pain scale. A care plan printed 01/12/17 indicated Resident #3 was receiving a platelet inhibitor, [MEDICATION NAME], since 1/13/16 and aspirin, which was added to this care plan on 01/12/17 (after surveyor intervention). Interventions included monitoring for adverse consequences, which included [MEDICAL CONDITION] and increased risk for bleeding. Resident #3 had constipation and interventions included monitoring bowel movements every shift. The care plan indicated Resident #3 had gastrointestinal discomfort and interventions included checking stools for occult blood if bleeding was suspected. At <https://www.drugs.com/ accessed on 1/19/16> indicated .Aspirin Low Strength (aspirin) and [MEDICATION NAME] (prasugrel) Using prasugrel together with aspirin may increase the risk of bleeding, especially [MEDICAL CONDITION]. Talk to your doctor if you have any questions or concerns. Your doctor may already be aware of the risks, but has determined that this is the best course of treatment for [REDACTED]. You should seek immediate medical attention if you experience potential signs and symptoms of gastrointestinal injury such as abdominal pain, bloating, dizziness, lightheadedness, loss of appetite, nausea, vomiting (especially with fresh or dried blood that looks like coffee grounds), and red or black, tarry stools. It is important to tell your doctor about all other medications you use, including vitamins and herbs. Do not stop using any medications without first talking to your doctor . A nursing note dated 01/11/17 at 11:19 a.m., indicated Resident #3's abdomen was bloated and swollen, and she complained of pain when palpated. A new order for a KUB (kidney/ureter/bladder x-ray) was received. During an observation and interview on 01/11/17 at 2:45 p.m., Resident #3 was sitting up in bed. Her skin was pale and her face was flushed. MA T brought Resident #3 her scheduled pain medication (Tylenol #4) and left the room. MA T did not ask Resident #3 if she was in pain or where her pain was located. Resident #3 said she wanted to go somewhere else that could help her with her pain. She said the facility did not help her with her pain. Resident #3 said her pain started at her neck, went down her body, and up her back. She said her pain was 13 on the 0-10 scale. During an interview on 01/11/17 at 3:03 p.m., LVN Q was notified by the surveyor that Resident #3 complained of pain at 13 on the 0-10 scale. LVN Q did not leave the medication cart to assess Resident #3. LVN Q said Resident #3 had an order for [REDACTED].#4 twenty minutes prior. During an observation and interview on 01/11/17 at 3:20 p.m., ADON E intervened before LVN Q gave Resident #3 a dose of regular Tylenol. ADON E said LVN Q called Resident #3's physician to notify him of Resident #3's pain and had received an order to give an additional dose of Tylenol #4. During an observation on 1/11/17 at 6:00 p.m., Resident #3 said no medication helped her pain and she said she had pain everywhere and was praying for death. She also complained that it burned to urinate and grimaced when interviewed. She said she had been to the hospital last time for pneumonia and she requested this investigator to take me with you to get some help. During an observation and interview at 1/11/17 at 6:11 p.m., LVN Q, charge nurse, said Resident #3 had not reported burning on urination to him and he recalled his last assessment of her was at 3:15 p.m. when he medicated her with Tylenol #4 for pain. He said Resident #3 always complained of pain all over. He said he planned to call the doctor and see what he could do to, pipe her down. A nursing note dated 01/11/17 at 6:50 p.m., indicated that Resident #3 told surveyors that her pain was so bad that she was praying to die, the nurse went to assess the resident after surveyors talked to the resident, the resident said her pain was at a 9.9 on a 0-10 scale that started in her back and went down her legs, the nurse called the physician who gave an order for [REDACTED].#4. During an interview on 1/12/17 at 3:32 p.m., MA R said Resident #3 complained of pain at maybe an 8. She said she did a follow up to check for pain relief about an hour later, but she did not document the follow up. During an interview on 1/12/17 at 4:05 p.m., CNA U said Resident #3 yelled when she hurt and nurses knew that she needed pain medication when she yelled. She said Resident #3's stools were dark and soft and was told by the nurses that it was because she drank chocolate supplements. She said Resident #3's abdomen had a little roundness, but looked the same as it always did. A nursing note dated 01/12/17 at 12:09 a.m. indicated Resident #3 was sent to theER on [DATE] at 7:35 p.m. The hospital records dated 01/11/17 indicated Resident #3 present to the ER (emergency room ) with complaints of pain all over. Resident #3 was found to be significantly anemic with hemoglobin of 5.5 (normal hemoglobin 12.0-15.5). Resident #3's abdomen was distended, protuberant (bulging), with abdominal tenderness in all 4 quadrants. Resident #3 was having dark hemoccult-positive (blood in stools) melanotic (black pigmentation) stools. Resident #3's was placed in the ICU (intensive care unit). Resident #3 received 2 units of blood on 01/11/17. A hospital discharge summary dated 01/15/17 indicated Resident #3 was admitted to the hospital with [REDACTED]. Resident #3 also presented with an abnormal urinalysis concerning for a urinary tract infection [MEDICAL CONDITION]. Resident #3 was treated with [MEDICATION NAME] (antibiotic) and discharged with [MEDICATION NAME] (antibiotic) for 7 additional days. Resident #3 was treated with [MEDICATION NAME] (medication to treat erosive esophagitis) and underwent an EGD (upper endoscopy). The summary indicated severe esophagitis was the source of bleeding. Resident #3's order for [MEDICATION NAME] was discontinued, but aspirin was maintained. During an interview on 01/12/17 at 9:27 a.m., LVN P said Resident #3 went to the hospital in the evening of 01/11/17 because she was hollering out in pain. During an interview on 1/11/17 at 6:31 p.m., the corporate RN said residents were assessed every shift for pain and documented on the electronic medication record. She said residents should be reassessed for pain relief and if it was not effective, then the doctor was to be called and the registered nurse on duty should assess the resident. She said she did not know if this protocol had been followed for Resident #3. She said Resident #3 had a documented history of attention seeking behavior and that was considered in her pain control protocol. A care plan revised 01/12/17 indicated Resident #3 had chronic pain and interventions included assessing characteristics of pain using the pain assessment for and notifying the physician of any changes in the level or frequency of pain. The care plan indicated Resident # 3's acceptable pain level was 2, 3, and 4 on the 0-10 pain scale. The care plan did not address Resident #3's attention seeking behavior with pain. The administrator was notified on 01/12/17 at 2:42 p.m., an Immediate Jeopardy situation was identified due to the above failures. The facility's revised Plan of Removal was accepted on 01/12/17 at 6:13 p.m. and included: Quality of Care - Assessments Action 1.Patient (proper name) was seen by MD on 1/3/17, 1/7/17 & 1/10/17. Additionally, patient was assessed by LVN and RN on 1/11/17 and convinced to transport to hospital on eve of 1/11/17. Patient is currently in hospital. Person Responsible: DON DOC: 1/11/17 2. A report from EMAR and ETAR will be reviewed and crossed referenced with narcotic records for all patients. Any resident with documented complaints of pain will be reviewed to determine effectiveness of current pain management and treatment protocols. If relief is not being obtained a change of condition assessment will be completed and MD notified. RNC and DON 1/12/17 3. In-service initiated with nursing staff on 1/12/17 and staff will be inserviced prior to start of next scheduled shift on recognizing change in condition and importance of change in condition assessment and pain management to ensure appropriate action. Routine Pain Meds effectiveness is evaluated q shift on MAR. PRN Pain Medications are triggered in EMR for effectiveness within 45 minutes and Nurses are responsible for following up and documenting effectiveness in EMR. Regional Nurse Consultant will conduct In-Service per Surveyor request. Nursing Mgmt. will conduct 24 hour report review daily. 01/13/17 4. Medical Director has reviewed and approved plan of correction. Compliance will be monitored weekly through Standards of Care and reported monthly in QA Committee x3 months to ensure ongoing compliance or changes as needed NHA 24 hour report will be reviewed daily during morning meeting to ensure residents with changes have change in condition assessment completed and appropriate follow-through has occurred. (sic) On 01/12/17 at the surveyors confirmed the Plan of Removal was implemented sufficiently to remove the Immediate Jeopardy by: Five LVNs, 4 CNAs, 1 PT, and 1 MA were interviewed and said they were in-serviced on pain assessments, following up after pain medication administration, and stop and watch for residents with a change in condition. On 01/13/17 at 11:21 a.m., the administrator and DON were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 indicated there were 32 residents on a pain management program. 2. A face Sheet dated 01/12/2017 indicated Resident #6, admitted [DATE] was [AGE] years old with [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #6 had intact cognitive skills for decision making and required extensive assistance of two staff for bed mobility, transfers, to walk in room, locomotion on unit, and toileting. The MDS also indicated Resident #6 was impaired on one side of her upper extremity and both sides of her lower extremities and continent of her bowel and bladder. A nursing care plan dated 01/02/17 indicated Resident # 6 had a problem with balance and required extensive assist to transfer due to partial weight bearing status. During an interview on 1/11/17 at 4:03 p.m., CNA DD said Resident #6 complained to her that a CNA on the nightshift put her on the bedpan against her wishes. She said Resident #6 reported it to the DON and the CNA was not allowed to care for Resident #6 any longer. During an observation and interview on 1/11/17 at 4:03 p.m., Resident #6 was sitting up in her wheelchair in her room. She had a soft cast to her left lower leg. Resident #6 said when she asked CNAs M and O to assist her to the bathroom, on the night shift, CNA M treated her rough. Resident #6 was tearful and said CNA M told her she had to use a bed pan and refused to assist her to go to the bathroom. Resident #6 said she explained to the CNAs that she did not want to use the bed pan and had been going to the bathroom with assistance. Resident #6 said she reported the incident to the DON at a care plan meeting that week and the DON had told her CNA M would not be allowed to provide care for her anymore. She said she felt better knowing CNA M would not be in her room anymore. During a phone interview on 1/12/17 at 10:35 a.m., CNA M said the DON spoke to her about a resident, but did not recall the woman's name on 600 hall. She said she recalled the resident's family requested the bedpan be used at night. CNA M said she was scheduled to work that night and had not been told she was restricted from providing care to any resident. During an interview on 1/12/17 at 10:16 a.m., CNA L said Resident #6 complained on Monday 1/9/17 that a night CNA made her use the bedpan and was rude to her. She said Resident #6's complaint was reported to ADON F and they spoke with Resident #6 about her concern. She said Resident #6 was upset. CNA L said Resident #6 required two staff to assist her to the bathroom. She said the resident did not use a bedpan. During an interview on 1/11/17 at 4:57 p.m., the DON said Resident #6 told her she did not want CNA M back in her room because she made her use the bedpan instead of assisting her to the bathroom. She said she did not write up the concern, but handled it by re-assigning CNA M to another unit. She said CNA M was re-assigned, but not told she was not allowed to provide Resident #6 ' s care. She said resident concerns were usually written and resolved in a grievance process that the administrator signed off on, but she did not consider this a formal concern or abuse and resolved it verbally. During an interview on 1/11/17 at 5:05 p.m., the SW said resident concerns were written on a concern form, discussed in daily interdisciplinary team meeting in the mornings and given to the appropriate department manager to resolve the issue. She said she was not aware of any staff re-assignments or any concerns regarding Resident #6. During an interview on 1/12/17 at 9:22 a.m., the administrator said he was aware of the incident , but Resident #6 denied feeling abused. He said the incident was not investigated or reported to State agency. The facility 802 dated 1/11/17 indicated the census was 93 residents.

Based on observation, interview, and record review, the facility failed to ensure 1 of 32 residents reviewed for pain received the care and services necessary to attain or maintain the highest practicable well-being and pain management. (Resident #3) The facility did not assess and provide adequate pain relief interventions when Resident #3 complained of excruciating pain and when she exhibited signs/symptoms of a [MEDICAL CONDITION]. After surveyor intervention, Resident #3 was transferred to a local hospital where she was diagnosed with [REDACTED]. She received a blood transfusion and was placed in the ICU. An Immediate Jeopardy situation was identified on 01/12/17. The Immediate Jeopardy was removed on 01/13/17; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the 32 residents on a pain management program from not receiving needed care and pain alleviation. Findings included: Physician orders [REDACTED].#3 was [AGE] years old and admitted on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Physician orders [REDACTED].#3 received an order for [REDACTED]. The Medication Administration Record (MAR) dated January 2017 indicated Resident #3 received [MEDICATION NAME] and aspirin daily while in the facility. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #3 understood others and made her needs known. The MDS indicated Resident #3 did not exhibit behaviors and did not reject care. She required extensive assistance with bed mobility, dressing, bathing, toilet use, and personal hygiene. She was incontinent of bowel and bladder. The MDS indicated Resident #3 rarely experienced pain and the worst pain in the last 5 days was 3 on a 0-10 scale with 10 being the worst pain. A nursing note dated 01/04/17 at 12:13 a.m. indicated Resident #3 requested to go to the hospital because she was dying. She was given a Tylenol #4 and sent to ER (emergency room ). ([DIAGNOSES REDACTED].>A pain risk assessment dated [DATE] indicated Resident #3 had low back pain at an intensity of an 8 on a 0-10 scale with 10 being the worst pain. The assessment indicated Resident #3's pain was shooting and constant. A nursing note dated 01/06/17 at 5:20 p.m. indicated Resident #3 complained of pain. The resident hollered down the hall that she was in pain and pain medication was administered. There was no description of the pain. A nursing note dated 01/06/17 at 11:04 p.m., indicated Resident #3 said she did not feel good, was hurting badly, and continued to say that she wanted to die to get rid of the pain. There was no pain level or location noted. The MAR dated 01/06/17 indicated Resident #3 had a pain level of 0 on a 0-10 pain scale for the day, evening, and night shift. A MAR dated January 2017 indicated on 01/07/17 Resident #3 had generalized pain at a level 4 on a 0-10 pain scale and on 01/10/17 at a level 6 on a 0-10 pain scale. The MAR indicated that Resident #3 also received Tylenol as needed for pain on 01/08/17. There was no pain level indicated on the MAR. Resident #3 received Tylenol #4 on 01/08/17 for pain at a level of 7 on a 0-10 pain scale. A care plan printed 01/12/17 indicated Resident #3 was receiving a platelet inhibitor, [MEDICATION NAME], since 1/13/16 and aspirin, which was added to this care plan on 01/12/17 (after surveyor intervention). Interventions included monitoring for adverse consequences, which included [MEDICAL CONDITION] and increased risk for bleeding. Resident #3 had constipation and interventions included monitoring bowel movements every shift. The care plan indicated Resident #3 had gastrointestinal discomfort and interventions included checking stools for occult blood if bleeding was suspected. At <https://www.drugs.com/ accessed on 1/19/16> indicated .Aspirin Low Strength (aspirin) and [MEDICATION NAME] (prasugrel) Using prasugrel together with aspirin may increase the risk of bleeding, especially [MEDICAL CONDITION]. Talk to your doctor if you have any questions or concerns. Your doctor may already be aware of the risks, but has determined that this is the best course of treatment for [REDACTED]. You should seek immediate medical attention if you experience potential signs and symptoms of gastrointestinal injury such as abdominal pain, bloating, dizziness, lightheadedness, loss of appetite, nausea, vomiting (especially with fresh or dried blood that looks like coffee grounds), and red or black, tarry stools. It is important to tell your doctor about all other medications you use, including vitamins and herbs. Do not stop using any medications without first talking to your doctor . A nursing note dated 01/11/17 at 11:19 a.m., indicated Resident #3's abdomen was bloated and swollen, and she complained of pain when palpated. A new order for a KUB (kidney/ureter/bladder x-ray) was received. During an observation and interview on 01/11/17 at 2:45 p.m., Resident #3 was sitting up in bed. Her skin was pale and her face was flushed. MA T brought Resident #3 her scheduled pain medication (Tylenol #4) and left the room. MA T did not ask Resident #3 if she was in pain or where her pain was located. Resident #3 said she wanted to go somewhere else that could help her with her pain. She said the facility did not help her with her pain. Resident #3 said her pain started at her neck, went down her body, and up her back. She said her pain was 13 on the 0-10 scale. During an interview on 01/11/17 at 3:03 p.m., LVN Q was notified by the surveyor that Resident #3 complained of pain at 13 on the 0-10 scale. LVN Q did not leave the medication cart to assess Resident #3. LVN Q said Resident #3 had an order for [REDACTED].#4 twenty minutes prior. During an observation and interview on 01/11/17 at 3:20 p.m., ADON E intervened before LVN Q gave Resident #3 a dose of regular Tylenol. ADON E said LVN Q called Resident #3's physician to notify him of Resident #3's pain and had received an order to give an additional dose of Tylenol #4. During an observation on 1/11/17 at 6:00 p.m., Resident #3 said no medication helped her pain and she said she had pain everywhere and was praying for death. She also complained that it burned to urinate and grimaced when interviewed. She said she had been to the hospital last time for pneumonia and she requested this investigator to take me with you to get some help. During an observation and interview at 1/11/17 at 6:11 p.m., LVN Q, charge nurse, said Resident #3 had not reported burning on urination to him and he recalled his last assessment of her was at 3:15 p.m. when he medicated her with Tylenol #4 for pain. He said Resident #3 always complained of pain all over. He said he planned to call the doctor and see what he could do to, pipe her down. A nursing note dated 01/11/17 at 6:50 p.m., indicated that Resident #3 told surveyors that her pain was so bad that she was praying to die, the nurse went to assess the resident after surveyors talked to the resident, the resident said her pain was at a 9.9 on a 0-10 scale that started in her back and went down her legs, the nurse called the physician who gave an order for [REDACTED].#4. During an interview on 1/12/17 at 3:32 p.m., MA R said Resident #3 complained of pain at maybe an 8. She said she did a follow up to check for pain relief about an hour later, but she did not document the follow up. During an interview on 1/12/17 at 4:05 p.m., CNA U said Resident #3 yelled when she hurt and nurses knew that she needed pain medication when she yelled. She said Resident #3's stools were dark and soft and was told by the nurses that it was because she drank chocolate supplements. She said Resident #3's abdomen had a little roundness, but looked the same as it always did. A nursing note dated 01/12/17 at 12:09 a.m. indicated Resident #3 was sent to theER on [DATE] at 7:35 p.m. The hospital records dated 01/11/17 indicated Resident #3 present to the ER (emergency room ) with complaints of pain all over. Resident #3 was found to be significantly anemic with hemoglobin of 5.5 (normal hemoglobin 12.0-15.5). Resident #3's abdomen was distended, protuberant (bulging), with abdominal tenderness in all 4 quadrants. Resident #3 was having dark hemoccult-positive (blood in stools) melanotic (black pigmentation) stools. Resident #3's was placed in the ICU (intensive care unit). Resident #3 received 2 units of blood on 01/11/17. A hospital discharge summary dated 01/15/17 indicated Resident #3 was admitted to the hospital with [REDACTED]. Resident #3 also presented with an abnormal urinalysis concerning for a urinary tract infection [MEDICAL CONDITION]. Resident #3 was treated with [MEDICATION NAME] (antibiotic) and discharged with [MEDICATION NAME] (antibiotic) for 7 additional days. Resident #3 was treated with [MEDICATION NAME] (medication to treat erosive esophagitis) and underwent an EGD (upper endoscopy). The summary indicated severe esophagitis was the source of bleeding. Resident #3's order for [MEDICATION NAME] was discontinued, but aspirin was maintained. During an interview on 01/12/17 at 9:27 a.m., LVN P said Resident #3 went to the hospital in the evening of 01/11/17 because she was hollering out in pain. During an interview on 1/11/17 at 6:31 p.m., the corporate RN said residents were assessed every shift for pain and documented on the electronic medication record. She said residents should be reassessed for pain relief and if it was not effective, then the doctor was to be called and the registered nurse on duty should assess the resident. She said she did not know if this protocol had been followed for Resident #3. She said Resident #3 had a documented history of attention seeking behavior and that was considered in her pain control protocol. A care plan revised 01/12/17 indicated Resident #3 had chronic pain and interventions included assessing characteristics of pain using the pain assessment for and notifying the physician of any changes in the level or frequency of pain. The care plan indicated Resident # 3's acceptable pain level was 2, 3, and 4 on the 0-10 pain scale. The care plan did not address Resident #3's attention seeking behavior with pain. The Abuse/Neglect Policy dated 9/1/2005 indicated the definition of neglect was, .the failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury, or harm, or death to a resident . (sic) The administrator was notified on 01/12/17 at 2:42 p.m., an Immediate Jeopardy situation was identified due to the above failures. The facility's revised Plan of Removal was accepted on 01/12/17 at 6:13 p.m. and included: Quality of Care - Assessments Action 1.Patient (proper name) was seen by MD on 1/3/17, 1/7/17 & 1/10/17. Additionally, patient was assessed by LVN and RN on 1/11/17 and convinced to transport to hospital on eve of 1/11/17. Patient is currently in hospital. Person Responsible: DON DOC: 1/11/17 2. A report from EMAR and ETAR will be reviewed and crossed referenced with narcotic records for all patients. Any resident with documented complaints of pain will be reviewed to determine effectiveness of current pain management and treatment protocols. If relief is not being obtained a change of condition assessment will be completed and MD notified. RNC and DON 1/12/17 3. In-service initiated with nursing staff on 1/12/17 and staff will be inserviced prior to start of next scheduled shift on recognizing change in condition and importance of change in condition assessment and pain management to ensure appropriate action. Routine Pain Meds effectiveness is evaluated q shift on MAR. PRN Pain Medications are triggered in EMR for effectiveness within 45 minutes and Nurses are responsible for following up and documenting effectiveness in EMR. Regional Nurse Consultant will conduct In-Service per Surveyor request. Nursing Mgmt. will conduct 24 hour report review daily. 01/13/17 4. Medical Director has reviewed and approved plan of correction. Compliance will be monitored weekly through Standards of Care and reported monthly in QA Committee x3 months to ensure ongoing compliance or changes as needed NHA 24 hour report will be reviewed daily during morning meeting to ensure residents with changes have change in condition assessment completed and appropriate follow-through has occurred. (sic) On 01/12/17 at the surveyors confirmed the Plan of Removal was implemented sufficiently to remove the Immediate Jeopardy by: Five LVNs, 4 CNAs, 1 PT, and 1 MA were interviewed and said they were in-serviced on pain assessments, following up after pain medication administration, and stop and watch for residents with a change in condition. On 01/13/17 at 11:21 a.m., the administrator and DON were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 indicated there were 32 residents on a pain management program.