Every finding on record at University Health and Rehabilitation Center

Based on observations, staff interviews and manufacturer recommendations, the facility failed to date opened multi-dose vials of insulin medication in 2 of 4 medication administration carts (carts number 1 and 2) and failed to remove expired multi-dose insulin pens from the medication cart drawer for 3 of 4 medication administration carts reviewed (carts number 1, 2 and 3). Findings Included: A review of the manufacturer's recommendations, dated December 1st, 2021, indicated to discard Lantus insulin multi-dose vial 28 days after opening. A review of the manufacturer's recommendations, dated July 7th, 2023, indicated to discard Humalog insulin multi-dose vial 28 days after opening. On 4/13/26 at 10:35 AM, an observation of the medication administration cart #3 with Nurse #9 revealed one Humalog insulin pen, opened on 3/1/26 and one Lantus insulin pen, opened on 3/12/26.On 4/13/26 at 10:40 AM, during an interview, Nurse #9 indicated that the nurses who worked on the medication carts were responsible for discarding opened and undated or expired multi-dose vials and insulin pens. She mentioned that per training/competency, every nurse should put the date of opening on multi-dose medications. Nurse #9 stated that she had not checked the date of opening on insulin vials or pens in her medication administration cart at the beginning of her shift. Nurse #9 confirmed she had not administered the expired medications this shift.b. A review of the manufacturer's recommendations, dated July 7th, 2023, indicated to discard Humalog insulin multi-dose vial 28 days after opening. A review of the manufacturer's recommendations, dated December 1st, 2021, indicated to discard Lantus insulin multi-dose vial 28 days after opening. On 4/13/26 at 11:00 AM, an observation of the medication administration cart #2 with Nurse #3 revealed one opened and undated multi-dose vial of Lantus insulin, one opened and undated Lantus insulin pen, and one Humalog insulin pen, opened on 3/14/26.On 4/13/26 at 11:05 AM, during an interview, Nurse #3 indicated that the nurses who worked on the medication carts, were responsible for discarding opened and undated or expired multi-dose vials and insulin pens. She mentioned that per training/competency, every nurse should put the date of opening on multi-dose medications. Nurse #3 stated that she had not checked the date of opening on insulin vials or pens in her medication administration cart at the beginning of her shift. Nurse #3 confirmed she had not administered expired medications this shift.c. A review of the manufacturer's recommendations, dated December 1st, 2021, indicated to discard Lantus insulin multi-dose vial 28 days after opening. On 4/13/26 at 11:10 AM, an observation of the medication administration cart #1 with Nurse #2 revealed one opened and undated multi-dose vial of Lantus insulin, one Lantus insulin pen, opened on 3/12/26, and one Lantus insulin pen, opened on 3/5/26.On 4/13/26 at 11:15 AM, during an interview, Nurse #2 indicated that the nurses who worked on the medication carts were responsible for discarding opened and undated or expired multi-dose vials and insulin pens. She mentioned that per training/competency, every nurse should put the date of opening on multi-dose medications. Nurse #2 stated that she had not checked the date of opening on insulin vials or pens in her medication administration cart at the beginning of her shift. Nurse #2 confirmed she had not administered expired medication this shift.On 4/14/26 at 11:25 AM, during an interview, the Director of Nursing indicated that all the nurses were responsible for checking all the medications in their assigned medication administration carts for expiration dates and remove expired medications every shift. She expected that no expired or undated items be left in the medication carts.On 4/14/25 at 12:30 PM, during an interview, the Administrator expected no expired items to be left in the medication carts.

Based on observations and staff interviews, the facility failed to label and date leftover frozen food that had been removed from its original packaging and failed to properly seal leftover frozen food stored in 1 of 1 reach in freezer. The facility also failed to clean food debris from under the steam table, black buildup substance around wall edges around kitchen wall perimeter and within floor tile grout lines. In addition, the facility failed to repair open holes under sinks, broken wall tile, damaged door molding, accumulated debris from an air duct vent, and a leaking water pipe under the sink located at the back of the kitchen. The deficient practice had the potential to affect food served to the residents and the cleaning and sanitation practices pose a potential risk for pests and contamination.The findings included:a. Observations during the initial tour of the main kitchen with Dietary Manager (DM) on 04/13/26 at 10:21 AM revealed the following: -One small clear bag with 8-10 breaded chicken strips with no open date labeled on bag. The item was discarded by the DM.-One medium sized clear plastic bag 1/4 full of diced chicken with no open date labeled on the bag. The item was discarded by the DM.-One 15 pound box of sliced bacon was observed stored inside a plastic bag. The bacon was not fully covered on the left side, and the box itself was missing a portion of the top left corner, leaving part of the bacon exposed. The box was positioned on a shelf directly beneath the freezer condenser. The condenser had several frozen icicles hanging from it above the bacon. Clear, frozen liquid was observed on top of the box and on the exposed bacon inside the box. The item was discarded by the DM.An interview was conducted on 04/13/26 at 10:28 AM with the Dietary Manager (DM). She stated that she was responsible for monitoring the freezer and coolers to ensure food items were properly dated and labeled. She also reported that she checked opened items and their discard by dates daily. The DM stated she had not observed any issues with staff failing to date items. She did not provide a reason for why the undated food items found in the freezer were not labeled. She reiterated that all food and drink items should be dated when opened. The DM further stated she was unaware that liquid had dripped from the condenser onto the box of bacon. She explained that the plastic bag containing the bacon should have been closed to prevent outside elements from coming into contact with the product.An interview was conducted on 04/15/26 at 11:43 PM with Dietary Cook/Aide #1. He stated he dated food and drink items upon opening them. He also stated the food items should be stored in an airtight bowl, or a plastic bag/wrap. Cook/Aide #1 did not recall putting any food items back into the freezer without a date on it.An interview was conducted on 04/15/26 at 1:01 PM with Dietary Aide #2. He stated opened food items should be dated and stored in an airtight bowl, or a plastic bag/wrap and not open to air. Dietary Aide #2 did not recall putting any food items back into the freezer without a date on it.An interview was conducted on 04/15/26 at 1:02 PM with Dietary Aide #3 stated all opened food items should be stored in an airtight bowl, or a plastic bag/wrap and not open to air. She also stated she dated and initialed food and drink items upon opening them. Dietary Aide #3 explained she did not recall putting opened chicken strips or chicken cubes back into the freezer without a date on it.b. Observations during the follow-up tour of the main kitchen with Dietary Manager (DM) on 04/14/26 at 1:25 PM in the presence of the Dietary Manager (DM) revealed the following: -several open areas around plumbing pipes under 3 sinks- water leak under the sink located on back wall of kitchen-damaged trim at doorway entrances and around cooler and freezer areas-paint peeling from ceiling above racks at kitchen entrance door and in dish room area-damaged tile along corner of wall. -Overall dirt/black substance build-up on entire floor worse along walls, and under steam table, and under other equipment in kitchenAn interview was conducted with the Dietary Manager (DM) on 04/14/26 at 1:25 PM. She stated the Maintenance Director and Administrator #2 was aware of the observed concerns related to the open areas around plumbing pipes under 3 sinks, water leak under the sink located on back wall of kitchen, damaged trim at doorway entrances and around cooler and freezer areas, paint peeling from ceiling above racks at kitchen entrance door and in dish room area, the damaged tile along corner of wall, and the dirt/black substance build-up on entire floor that was worse along walls, and under steam table, and under other equipment in kitchen. She indicated the areas of concern had not been addressed yet. When asked if deep cleaning was on a routine schedule, the DM stated that spot deep cleanings were conducted, but full kitchen deep cleaning was not currently performed. She reported using a pressure washer on the floors and walls a couple of weeks ago and stated she does so periodically. The DM went on to say that she expected staff to follow the cleaning schedule and to clean as they were working.During a kitchen tour with the Dietary Manager (DM) on 04/15/2026 at 11:25 AM, the floor under the steam table was observed to contain visible layers of food debris, a dessert cup covered with plastic wrap containing an unidentified substance, disposable lids, a fork, dust, and dirt. The DM reported the area had been cleaned the previous day. Cook/Aide #1 began sweeping debris from under the steam table, while the DM stated, it's hard to get under there good, referring to a metal tube approximately 3 to 4 inches in diameter that houses wires/piping to the steam table. Additional observations revealed black buildup along the wall edges at the floor throughout the kitchen and dark residue within floor tile grout lines throughout the kitchen. When asked if deep cleaning was on a routine schedule, the DM stated that spot deep cleanings were conducted, but full kitchen deep cleaning was not currently performed. She reported using a pressure washer on the floors and walls a couple of weeks ago and stated she does so periodically. The DM went on to say that she expected staff to follow the cleaning schedule and to clean as they were working. An interview was conducted on 04/15/26 at 11:43 PM with Dietary Cook/Aide #1. He stated he always completed the scheduled cleaning during his shift. On 04/15/26 Dietary Cook/Aide #1 indicated he cleaned the prep tables and drawers. An interview was conducted on 04/15/26 at 1:01 PM with Dietary Aide #2. He stated there was a cleaning schedule for the dietary aides to follow daily and that he always did the scheduled cleaning that was required during his shift. On 04/15/26 Aide #2 indicated he washed the condiment containers in the dry storage area.An interview was conducted on 04/15/26 at 1:02 PM with Dietary Aide #3. She stated there was a cleaning schedule for the dietary aides to follow daily and that she did the scheduled cleaning that was required during her shift. On 04/15/26 Dietary Aide #3 indicated she cleaned and organized the walk-in cooler.During a kitchen tour with the Maintenance Director on 04/16/2026 at 09:33 AM he stated he was aware of multiple areas in the kitchen requiring repair, including holes, cracks, and damaged trim/molding, water leak under the sink located on back wall of kitchen, but had not yet completed the repairs. He reported he had been working at the facility since January and that numerous repairs were pending. He also noted he had two new helpers who began approximately two weeks prior. The Maintenance Director observed and verified several areas in need of repair during the tour, including large open areas around plumbing pipes under three sinks, damaged trim at doorway entrances and around the cooler and freezer areas, peeling paint on the ceiling above the racks at the kitchen entrance and in the dishwasher room, and damaged tile along the corner wall between the dish room and steam table. He stated these repairs would be addressed at some point. He also clarified that general kitchen cleanliness was the responsibility of the kitchen staff.During a kitchen tour with Administrator #2 on 04/16/2026 at 9:47 AM, he stated he was aware of several issues in the kitchen such as the cleanliness of the floors, open areas under sinks around pipes, and peeling paint on the ceiling. Administrator #2 observed and verified multiple areas in need of repair in the kitchen including several open areas around plumbing pipes under 3 sinks, water leak under the sink located on back wall of kitchen, damaged trim at doorway entrances and around cooler and freezer areas, paint peeling from ceiling above racks at kitchen entrance door and in dish washing room, broken tile along corner of wall, overall dirt/black substance build-up on entire floor worse along walls, and under steam table, and under other equipment in kitchen, and leaves hanging out of air duct on ceiling in back right hand side of kitchen. Administrator #2 also stated that he asks every day in the morning meeting if cleaning had been conducted. He indicated he expected the kitchen to be free of crumbs and debris throughout the day. The plan was to correct all areas of concerns. On 04/16/2026 at 2:54 PM, a follow up interview was conducted with Administrator #2. Administrator #2 stated he was aware of the repair needs and cleaning issues occurring in the kitchen, which the Dietary Manager (DM) had reported during morning stand up meetings. He stated that although the DM reported cleaning was being completed per the schedule, he did not verify that the work was being performed. Administrator #2 reported he did not conduct routine rounds in the kitchen. He stated the kitchen should remain as clean as possible throughout the day, be thoroughly cleaned at the end of each day, and that any holes, defects, or damage should be repaired promptly to minimize pest activity. He stated that he was uncertain why the Maintenance Director had not yet addressed the kitchen repairs. He indicated the facility hired two additional maintenance employees approximately two weeks ago to help manage the increased repair workload. Administrator #2 reported the plan was to correct all identified areas of concern.

Based on observations, record review, and staff and Pest Control Technician interviews, the facility failed to maintain an effective pest control program as evidenced by the presence of roaches for 1 of 3 observations in the kitchen. Findings included:Pest control summary of services from the pest control service were reviewed for the following dates of 09/09/25, 09/16/25, 09/30/25, 10/07/25, 10/14/25, 10/21/25, 11/05/25, 11/21/25, 11/25/25, 12/02/25, 12/10/25, 12/17/25, 12/30/25, 01/06/26, 01/13/26, 01/20/26, 01/28/26, 02/04/26, 02/17/26, 02/25/26, 03/03/26, 03/11/26, 03/24/26, 03/31/26, and 04/09/26.The following general comments/instructions were documented on the summary of services:-09/09/25- Spot treated kitchen, underneath cooking equipment, dishwasher area, restrooms, dining area, and office for general pest control. German roach activity was found in the electrical box in the dishwasher, near the coffee station, and the heating warmer for the food. Cracks in the wall, floor, and ceiling tiles need to be repaired, this is causing a harboring site for roaches. Roach gel bait was applied to the cracks and crevices of broken tiles. Treated room [ROOM NUMBER], human resource office, and soiled linen room. Target pests: German roaches, and general pest control in cracks and crevices and spot inside treatment.-09/16/25- Spot treated kitchen, underneath cooking equipment, dishwasher area, restrooms, dining area, and office for general pest control. German roach activity. Target pests: German roaches and general pest control, spot inside treatment.-09/30/25- Spot treated kitchen, underneath cooking equipment, dishwasher area, restrooms, dining area, and office for general pest control and German roaches. Repairs are needed, cracks, broken floor tiles and base boards, standing water due to drains not working properly, and greasy cooking equipment should be degreased, these issues are providing harboring sites for German roaches and causing control methods to fail. room [ROOM NUMBER] was fogged per the manager and maintenance technicians request for german roaches. Maintenance Director was informed to put a DO NOT ENTER sign on the door so that staff and residents would not enter. Treated room [ROOM NUMBER] and the activity room for general pest control. Target pests: German roaches and general pest control, spot inside treatment and space treatment.-10/07/25- General pest control roaches interior and exterior doorways. Treated business office, social worker office, sunshine room, conference room, activity room, nursing stations, laundry room, central supply room, soiled linen room, unit manager office, dayroom, administrative office, transportation office, human resource office, receptionist office, and admissions office for general pest control. Treated rooms 49, 47, 41, 40, 37, 35, 29, 30, 15, 72, 63, 64, 69, 70, 10, 7, 5, 4, and 3 for general pest control. Spot treated kitchen, underneath cooking equipment, dishwashing era, restrooms, dining room area, and office for general pest control.-10/14/25 and10/21/25- Spot treated kitchen, underneath cooking equipment, dishwashing era, restrooms, dining room area, and office for general pest control.-11/05/25- General pest control roaches-interior and exterior doorways. Technician spot treated the interior foundation of the building with insecticide including bathrooms, kitchen, laundry room, bedrooms, brick room, offices, and doorways.-11/21/25 and 03/31/26- General pest control. Target pests: Cockroach other than American-11/25/25- General pest control. Target pests: Rat and Mice-12/02/25 and 02/04/26- General pest control roaches-interior and exterior doorways-12/23/25, 01/06/26 and 01/20/26- General pest control.-12/17/25 and 12/30/25- General pest control. Target pests: Bed bugs-01/13/26 and 01/28/26- General pest control. Target pests: Rats-02/17/26- General pest control. Technician spot treated the interior foundation of the building with insecticide including kitchen, common areas, multipurpose room, and doorways. Technician also replaced bait in rodent stations where needed throughout the building.-02/25/26- General pest control. Technician spot treated the interior foundation of the kitchen with insecticide including storage rooms, dish area, and office.-03/03/26- General pest control roaches-interior and exterior doorways. (Please contact Maintenance Director on each visit, he will need to walk the technician through-no exceptions). Technician spot treated the interior foundation of the building with insecticide including bathrooms, kitchen, rehabilitation room, activities room, nurse's stations, and offices in multipurpose room.-03/11/26 and 03/24/26- General pest control roaches-interior and exterior doorways. (Please contact Maintenance Director on each visit, he will need to walk the technician through-no exceptions). Technician spot treated the interior foundation of the kitchen with insecticide including storage room and doorways.-04/09/26- General pest control roaches-interior and exterior doorways. Target Pests: ants and bed bug (Please contact Maintenance Director on each visit, he will need to walk the technician through-no exceptions). Technician spot treated the interior foundation of the building with insecticide including bathrooms, kitchen, rehabilitation room, doorways, nurse's stations, and offices in multipurpose room.Review of Dietary Stand-up Meeting Reports documented by the Dietary Manager revealed Pest Sightings: some for the following dates: 02/28/26, 03/02/26, 03/03/26, 03/04/26, 03/09/26, 03/10/26, 03/12/26, 03/16/26, 03/26/26, 03/30/26, 04/01/26, 04/06/26, 04/07/26, 04/08/26, and 04/09/26.During a kitchen observation with the Dietary Manager (DM) on 04/15/2026 at 11:25 AM, a live roach was on the floor in front of the dry storage doorway in the kitchen. The roach proceeded into the dry storage area. This was observed by both the surveyor and the DM. An interview and concurrent observation were conducted with the DM regarding the live roach activity. She stated that they do have ongoing live roach activity and that she typically sees roaches under the steam table and in other warm areas. An inspection of the area beneath the steam bar revealed multiple layers of food debris, a dessert cup covered with plastic wrap containing food, disposable lids, a fork, dust, and dirt. The area appeared not to have been cleaned. The DM explained that she kept a log of pest sightings in her office and would also complete a The DM explained that she had reported the roach sitings when they were observed to Administrator #2. The DM indicated the pest control technician was on sight on the evening of 04/14/26 and did treat the kitchen area for roaches.Review of Pest Control Logs provided by the Dietary Manager revealed the following: 03/31/26-Bottom of gas oven and dish room. 04/09/26-Door at front, spray for flies, cart area, ants around steamtable, and gas stove. Pest control came on 04/14/26.On 04/16/26 at 9:23 AM, a follow up interview was conducted with the Dietary Manager (DM). The DM stated she did not have a formal deep cleaning schedule for the kitchen and that she had staff perform deep cleaning periodically. She explained that she expected staff to clean as they worked in order to keep areas tidy. The DM indicated the Pest Control Logs she had provided was in reference to roach sightings unless otherwise specified.On 04/15/26 at 11:43 AM, an interview was conducted with Cook/Aide #1. He stated that he sees live roaches regularly but ignores them. He also reported that the roach activity had improved slightly over the past few months.On 04/15/26 at 1:01 PM, an interview was conducted with Dietary Aide #2. He stated that he had seen live roaches regularly; however, he noted that the activity was not as severe as it had been before December 2025 when the new facility owners took over.On 04/15/26 at 1:02 PM, an interview was conducted with Dietary Aide #3. She stated that she had seen live roaches regularly; however, she noted that the activity was not as severe as it had been before December 2025 when the new facility owners took over. Dietary Aide #3 also reported that there was a notebook in the Dietary Manager's (DM's) office where staff document the date and location of any live roach activity observed.On 04/15/26 at 1:14 PM, a phone interview was conducted with the Pest Control Technician. He stated that he treats the facility weekly according to a structured schedule. During the first week of each month, he treats the common areas of the facility, which include personal offices, nurses' stations, common bathrooms, and breakrooms, as well as any specific resident rooms identified by the Maintenance Manager. He stated that every other week he treats the kitchen in addition to any resident rooms requested by the Maintenance Manager. The Technician reported that he has seen improvement in the live roach activity but stated that active infestation remains. The Pest Control Technician then stated he normally sees at least one (1) live roach when he was conducting the pest control treatment. He explained that the ongoing issue was due to sanitation problems in the kitchen and the facility's failure to address his recommended repairs. These concerns include holes in walls, cracked tiles and crevices, and open areas around pipes. He described that the open areas around the pipes lacked insulation or caulking, and the cracks and holes have not been repaired. He further stated that there were consistently food crumbs, flour, dough, and other food debris on the floor, which provided a food source for roaches. He emphasized that if these areas were not kept clean, roaches would choose the actual food over the bait every time. The Pest Control Technician noted that while some areas of the kitchen were clean at times, no sustained deep cleaning had been maintained. Areas behind equipment, under shelves, and beneath the steam bar had layers of food debris, dust, and dirt that appeared not to have been cleaned for a very long time. The Technician reported that no repairs have been completed, except for a border placed around the freezer, which does not fully seal or touch the freezer. He stated that he had communicated these concerns to the Maintenance Director during every visit and had spoken to Administrator #2 in the past (did not recall exact date) related to above the concerns. The Pest Control Technician added that the Maintenance Director accompanied him during the pest control treatments.On 04/15/26 at 9:33 AM, an observation and interview were conducted with the Maintenance Director during a tour of the kitchen. The Maintenance Director stated that he did accompany the Pest Control Technician during the pest control treatments. The Maintenance Director also stated he was aware of issues in the kitchen, including holes, cracks, and damaged trim or molding that required repair; however, he had not yet completed the repairs. He stated he had been employed at the facility since January and that several areas throughout the facility required attention. He also reported that two new maintenance helpers had started approximately two weeks ago. During the tour, the Maintenance Director identified multiple areas in the kitchen needing repair and stated, it will be addressed at some point. He verified the presence of large open areas around plumbing pipes under three sinks, a water leak under the sink on the back wall of the kitchen, damaged trim and molding at doorway entrances and around the cooler and freezer, peeling paint on the ceiling above the racks near the kitchen entrance door, and damaged tile along the wall corners. He stated that maintaining cleanliness in the kitchen was the responsibility of the kitchen staff.On 04/16/26 at 2:54 PM, an interview was conducted with Administrator #2. Administrator #2 stated he was aware that repairs, cleaning issues, and pest sightings had been occurring in the kitchen, and that the Dietary Manager (DM) reported these concerns during morning stand up meetings. He explained that while the DM reported that cleaning was being completed, he did not verify that the work was being done. Administrator #2 indicated he did not make routine rounds in the kitchen. He went on to say he reviewed the pest service summaries and that he was comparing prices with other pest control companies for a possible change of pest control companies. Administrator #2 explained that the kitchen should be kept as clean as possible throughout the day, thoroughly cleaned at the end of the day, and that any holes, defects, or damages should be repaired as soon as possible to reduce pest activity. He stated he expected the kitchen to remain free of crumbs and debris throughout the day and for staff to clean as they worked. Administrator #2 reported that the plan was to correct and repair all identified areas of concern.

Based on record reviews, and resident, family member, and staff interviews, the facility failed to honor a resident's choice related to shower time for 1 of 5 residents reviewed for choices (Resident #53). Findings include:Resident #53 was admitted to the facility on [DATE] with diagnoses that included contractures of right hand, left and right knees, and chronic kidney disease. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #53's cognition was intact. He had a range of motion impairment on both sides of his lower extremities and utilized an electric wheelchair for mobility. Resident #53 was dependent on staff with toilet hygiene, shower/baths, dressing, personal hygiene, bed mobility, and transfers. Resident #53 had an external catheter and was always incontinent with bowels. Resident #53 was not coded for rejection of care during the look back period.A review of Resident #53's active care plan, last revised 03/20/26, included a focus area for activities of daily living (ADL) self-care performance deficit related to spastic diplegic cerebral palsy.A review of the Shower Schedule located in a binder at the nurse's station was conducted. The shower schedule had a list that included the room number and shift the shower was to be given on. The schedule revealed Resident #53 was to receive a shower every Tuesday and Thursday on second shift (3:00 PM to 11:00 PM).An interview was conducted on 04/13/26 at 2:14 PM with Resident #53. He reported that a new company purchased the facility in December 2025, and in January 2026 his shower times were changed from 7:00 AM to 3:00 PM (1st shift) to 3:00 PM to11:00 PM (2nd shift). He stated he had always received his showers on Tuesdays and Thursdays during 1st shift. Resident #53 explained that no one informed him that his shower times would be changed, nor did anyone ask whether he wanted to change his established schedule. He stated that when he learned of the change (he did not recall who notified him), he informed several staff members on multiple occasions that he did not want his showers on 2nd shift and wanted his original 1st shift schedule restored. He reported being told by several staff that the schedule could not be changed. Resident #53 stated that his family visited approximately three weeks ago. He told them the facility would not change his shower times back to 1st shift, and his family then requested to speak with the Director of Nursing (DON). According to Resident #53, the DON told him and his family she would look into the matter and see what could be done. He reported that he had not received any follow up in almost three weeks. Resident #53 stated that the situation had been frustrating and that he simply wanted his request honored, as he believed it was his right.An interview was conducted on 04/15/26 at 9:23 AM with Nurse #9. She stated that Resident #53 was dependent on staff for his activities of daily living. Nurse #9 explained that Resident #53's showers had previously been scheduled for Tuesdays and Thursdays during 1st shift (7:00 AM to 3:00 PM), but the new owners changed his shower times to 2nd shift (3:00 PM to 11:00 PM). She reported that Resident #53 became upset when he learned of the change and expressed that he wanted his shower schedule returned to 1st shift. Nurse #9 stated this issue had been ongoing since January and that Resident #53's preferences had been communicated to the administrative staff. Nurse #9 did not know why the change had occurred.An interview was conducted on 04/15/26 at 9:31 AM with Nursing Aide (NA) #2. She stated that she was very familiar with Resident #53 and was assigned to his hall on the days she worked. NA #2 reported that the new Director of Nursing (DON) changed Resident #53's shower schedule in January from every Tuesday and Thursday on 1st shift (7:00 AM to 3:00 PM) to 2nd shift (3:00 PM to 11:00 PM). She stated that Resident #53 had been requesting to have his showers changed back to 1st shift since the change occurred. NA #2 explained that Resident #53 had always received his showers during 1st shift. She also stated that she had been informed by the DON the time could not be changed.An interview was conducted on 04/15/26 at 10:02 AM with Unit Manager (UM) #1. She verified she started working at the facility in December 2025 when the new owners started at the facility. The UM explained in January 2026 the Director of Nursing (DON) had initiated a new shower schedule for the staff to follow. UM #1 stated she had been the UM on Resident #53's hall for approximately 2 to 3 weeks when the DON asked her to re-evaluate the shower schedule assignments for the entire building to see if any residents had day or time preferences due to concerns that had been brought to the DON. UM #1 indicated the DON explained that some residents were alert and oriented and might not want their shower times changed. The UM reported that the DON did not direct her to review or speak with any specific resident. She also stated the DON never informed her that Resident #53 wanted to change his shower times. UM #1 indicated she did not start the process of reevaluating the shower schedule that had been put in place in January. The UM emphasized that it was the residents' right to choose their preferred shower days and shifts. UM #1 explained that her approach was to ask both the nursing assistants and the residents about their preferences and to accommodate them to the best of her ability.A phone interview was conducted on 04/16/2026 at 10:33 AM Resident #53's Family Member. She stated that Resident #53 had been requesting to have his showers changed back to 1st shift since January, after the new company assumed ownership and altered his schedule. She reported that he had made several requests, but the shower time was never returned to 1st shift. The family member stated that she requested to speak with the Director of Nursing (DON) approximately three weeks ago to ask why Resident #53's request had not been addressed. She reported that the DON told her she would evaluate the schedule and determine whether changes could be made. The Family Member indicated that the DON said she wanted the schedule to be convenient and provide structure. The Family Member emphasized that resident rights should be the priority.An interview was conducted on 04/15/26 at 9:40 AM with the Director of Nursing (DON). The DON confirmed that she created a new shower schedule in January to establish more structure and improve workflow. She acknowledged that she did not speak with residents prior to making the changes and stated her intent was to balance the number of showers scheduled between first and second shifts. The DON reported that approximately two weeks ago, Resident #53's family requested a meeting with her. During the meeting, the resident and his family asked that his showers be returned to 1st shift because it was his preference. The DON stated she told them she would look into the matter and see what could be done. Instead, she delegated the task to Unit Manager (UM) #1, instructing her to review the shower schedule and determine whether Resident #53's preference could be accommodated. The DON indicated resident rights should be honored.A phone interview was conducted on 04/19/26 at 4:39 PM with the Administrator. He stated that he expected resident rights to always be considered. He indicated that if a resident was alert and oriented and requested a change in their shower schedule, that request should be evaluated and granted whenever possible.

Based on record review, observations, resident and staff interviews, the facility failed to provide maintenance services necessary to ensure resident bathrooms were in good repair and maintained in a safe, homelike manner. Damaged sheetrock, damaged floor tile, shower tile with visible blackish-brown substance present, and a broken ceramic toilet tank lid were observed for 1 of 4 sampled residents (Resident #15) on 1 of 4 halls (Hall #1).Findings included: A review of the census showed Resident #15 was transferred from room [ROOM NUMBER] to room [ROOM NUMBER] on 1/28/2026.Resident #15's quarterly Minimum Data Set, dated [DATE] documented that he was cognitively intact.A review of facility work orders from 1/1/26 through 4/15/26 revealed one completed work order for room [ROOM NUMBER] on 3/20/26 (installation of a grab bar in the bathroom). No work orders were found for room [ROOM NUMBER]. No work orders were available prior to January of 2026.During an interview on 4/13/26 at 3:26 PM, Resident #15 stated he was admitted to room [ROOM NUMBER] in 2025 and recently moved to room [ROOM NUMBER] following a hospitalization. He described the bathroom in room [ROOM NUMBER] as being in poor condition, with dirty shower tile, no grab bar near the toilet, wall damage on the left wall by the toilet and shower, and a broken toilet tank lid. He stated he had not used the shower and did not know how long the bathroom had been in this condition. He recalled reporting these issues in the past but could not remember to whom. He added that the bathroom in room [ROOM NUMBER] was also in poor condition, with visible sheetrock patching on the walls and large spots on the painted tile floor.An observation of the bathroom in room [ROOM NUMBER] on 4/13/26 at 3:35 PM identified a tile shower with a blackish brown substance covering approximately a 2 foot (ft) by 2.5 ft area on the shower floor and up the left wall. The wall between the toilet and shower had sheetrock damage at the base. A 2 ft by 4 ft piece of 1/4 inch wood had been screwed to the wall on the right side of the toilet. The ceramic toilet tank lid was broken, missing the bottom left corner.An observation of the bathroom in room [ROOM NUMBER] on 4/13/26 at 3:40 PM revealed sheetrock damage extending approximately 2.5 ft up the left wall beside the toilet. The door frame was damaged, with missing paint and rust visible from the floor up to 2.5 ft. The bathroom floor appeared to be tile that had been painted with a green layer and then a blue layer, with multiple areas of chipping paint exposing different colors beneath.During an interview and observation with the Maintenance Director on 4/16/26 at 10:16 AM, he stated that many rooms and bathrooms were already in this condition when the company assumed operations in January and appeared to have been this way for a long time. He acknowledged awareness of the condition of room [ROOM NUMBER]'s bathroom, explaining that water damage caused the tile and wall deterioration. He stated the toilet lid had not been broken during his last visit to the room and was unsure when it occurred. The Maintenance Director reported that since the new ownership assumed operations, maintenance projects had to be prioritized based on severity, and he stated they began addressing the highest priority concerns first.During a second interview and observation with the Maintenance Director on 4/16/26 at 10:23 AM, he also acknowledged awareness of the condition of the bathroom in room [ROOM NUMBER] and stated that both the walls and floors needed significant repair.During an interview with Administrator #2 on 4/16/26 at 2:57 PM, he stated the facility was under new leadership and actively working to address ongoing repair needs. Administrator #2 stated he was aware that there were several rooms throughout the facility that needed repair and that the maintenance team was actively working on addressing them. He stated his expectation was for all rooms and bathrooms to be maintained in good repair and to provide a safe, homelike environment.

Based on observations, record review, and interviews with staff and the Nurse Practitioner (NP), the facility failed to provide an ongoing activity program that met the individual interests and needs to enhance the quality of life for 1 of 1 resident reviewed for activities (Resident #13). Findings included:Resident #13 was readmitted on [DATE] with diagnoses including hemiplegia (complete or near-complete paralysis on one side of the body) and hemiparesis (partial weakness on one side of the body) following cerebral infarction (stroke) affecting the left nondominant side, speech and language deficits following cerebral infarction, aphasia (disorder that affects language abilities due to brain damage, usually from a stroke or injuries), schizoaffective disorder, and a cognitive communication deficit.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] showed Resident #13 had adequate hearing, unclear speech, and was assessed as cognitively intact. The assessment showed the resident required moderate assistance to dependence on staff for activities of daily living (ADL). Activities preference was indicated as very important for the resident to go outside in good weather and participate in his favorite activities. It was somewhat important to have books, newspapers, magazines, listen to music, keep up with the news, and participate in group activities.The activity participation quarterly assessment dated [DATE] showed Resident #13 fully engaged in preferred activities and preferred room/bedside activities, independent activities, and one on one sessions. Staff were encouraged to continue offering activities based on his personal preferences.The quarterly MDS assessment dated [DATE] showed Resident #13 was assessed as having adequate hearing, unclear but understandable speech, and was cognitively intact. The resident had bilateral upper- and lower extremity impairments and required partial to moderate assistance with most ADL.Review of the care plan revised on 3/17/26 showed the resident was dependent on staff for activities, cognitive stimulation, and social interaction. The goal was for the resident to attend and participate in activities of choice. Interventions directed staff to converse with the resident during care, assist in arranging community activities, ensure activities matched the resident's abilities and interests, invite him to scheduled activities, and provide materials for independent activities such as painting.Observations on 4/13/26 at 10:22 AM and 1:21 PM, on 4/15/26 at 11:32 AM, and on 4/16/26 at 10:41 AM showed the resident lying in bed with a sheet pulled to his shoulders. The television was on, but the resident did not watch it and did not appear interested. During the observations there was no music playing in the room and the surveyor did not observe anything that could play music. The television in the room was shared between the resident and his roommate. On 4/13/26 at 2:52 PM, Resident #13's roommate was observed watching TV, while the resident lay in the bed with his eyes closed and sheet pulled to his shoulder. Resident #13 had his back to the television, and the Activity Calendar was posted on the wall near the television.Attempts were made to interview Resident #13 on 4/13/26 at 10:25 AM, at 1:21 PM and 3:00 PM, on 4/15/26 at 11:32 AM and at 3:00 PM, and on 4/16/26 at 10:30 AM; however, Resident #13 did not to speak and covered his face or closed his eyes when approached. On 4/15/26 at 3:00 PM, an attempt was made to communicate with the resident using the communication board and the resident did not respond.During an interview on 4/15/26 at 3:00 PM, Nurse Aide (NA) #3 stated he frequently cared for the resident. NA #3 reported the resident had schizophrenia and hallucinated at times, spoke minimally, and responded best using a communication board. NA #3 indicated he tried to communicate with the resident during care and used the communication board. The resident previously attended some activities but had not gone for some time, stayed in bed, and avoided communication. During a follow up on 4/16/26 at 10:30 AM, NA #3 stated that Resident #13 had left side paralysis, was highly educated, and had previously worked for a computer company. NA #3 stated the resident liked reading the newspaper, and he provided one when he was able. He stated he tried to read to the resident and engage him whenever possible. NA #3 stated Resident #13 was dependent on staff for ADL care and required encouragement to get out of bed or attend activities. NA #3 reported he had not observed activity staff performing one to one activities with the resident. NA #3 stated Resident #13 did not like to watch television in his room, which he shared with his roommate. According to NA #3, when the roommate was in the room, the roommate changed the channel and watched television programs of his choice.During an interview on 4/16/26 at 9:20 AM, Nurse #10 stated the resident was dependent on staff for most ADL care and communicated with single word responses. The resident previously attended activities but recently had not participated. Nurse #10 did not know whether staff encouraged the resident to attend activities or whether he received 1:1 sessions.During an interview on 4/16/26 at 10:10 AM, the Activity Director stated she conducted one to one activities with Resident #13, such as having conversations with him; however, she stated the resident did not participate and only stared. She indicated the resident had a communication board and that she sometimes used it to communicate with him. The Activity Director stated one to one sessions for residents were usually 15 to 20 minutes in duration. She was unable to state the duration of the one to one sessions provided to Resident #13, was unable to state the frequency of the one to one visits and could not identify specific activities the resident preferred. She indicated she had magnetic stones available as a sensory activity but stated the resident did not participate in that activity. When asked to provide documentation of one to one sessions, the Activity Director produced the most recent record dated April 2025.During an interview on 4/16/26 at 11:20 AM, Nurse Practitioner (NP) #1 stated Resident #13 had diagnoses of schizophrenia and might hallucinate at times but had no behaviors. NP #1 indicated the resident responded better with his communication board. NP #1 stated the resident would benefit from leaving his room or from 1:1 activities even if he showed limited interest.During an interview on 4/16/26 at 3:57 PM, the Director of Nursing (DON) stated she expected staff to encourage Resident #13 to get out of bed and attend activities of choice. She stated the activity calendar should be posted in the resident's room, so he could read it and choose activities. The DON indicated staff should communicate using the communication board, and activity staff should perform 1:1 sessions when the resident declined group activities. The DON further stated the Resident's choice of activities per his assessment were to be honored.

Based on record review, observations, and interviews with the Nurse Practitioner, resident and staff, the facility failed to schedule a follow-up appointment with dermatology for 1 of 3 residents reviewed for non-pressure related skin conditions (Resident #35). The findings included: Resident #35 was admitted to the facility on [DATE] with diagnoses that included diabetes and a history of basal cell carcinoma of the skin. A Nurse Practitioner (NP) progress note dated 12/9/25 indicated Resident #35 had a sore on top of the head. The NP documented a dermatology appointment was to be made by nursing. A NP progress note dated 1/27/26 read that Resident #35 was being seen for a wound to the top of his head. Wound was present from scratching and was the size of a nickel. New orders were provided for treatment of the healing wound to the top of his head. Resident #35 had a history of basal cell carcinoma to the head, neck and skin. Consults: dermatology consultation as needed for possible basal cell carcinoma on top of the head. Per Resident #35's physician orders, an order dated 1/27/26 indicated to wash the wound on top of his head with normal saline. Apply antibiotic ointment to the wound bed then Triamcinolone (an ointment that reduces itching, redness and swelling) cream to the surrounding skin daily and as needed. A review of the January 2026 Treatment Administration Record (TAR) revealed Resident #35 received the treatment as ordered to the wound on his scalp. A review of Resident #35's physician orders included an order dated 1/30/26 for a dermatology consult as needed for possible basal cell carcinoma on top of head. He had a history of basal carcinoma to head, neck and skin. The order was signed off as completed by Nurse #14. Multiple attempts to interview Nurse #14 by phone on 4/15/26 and 4/16/26 were not successful. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #35 was cognitively intact and received application of ointments/medications other than to his feet. An NP progress note dated 2/9/26 indicated Resident #35 was being seen that day by the NP for the wound to the top of his head. The NP documented the wound had healed and redness and swelling had decreased around the wound. The note indicated that an order was placed on 1/30/26 for a dermatology appointment. Plan: schedule a dermatology appointment to evaluate and treat the wound to the top of the head. History of basal cell carcinoma. A NP progress note dated 3/6/26 read that Resident #35 was being seen that day by the NP for a wound to the top of his head. The NP documented the wound to the top of his head remained healed; however, the wound bed and surrounding skin were red, inflamed and irritated. An NP progress note dated 3/30/26 indicated that Resident #35 was inquiring about the dermatology consultation for possible basal cell carcinoma or squamous cell carcinoma to the top of his head. The NP documented the wound had redness, inflammation and irritation surrounding the scabbed over wound to the top of the head and sometimes itched. An interview and observation occurred with Resident #35 on 4/13/26 at 10:41 AM. A scabbed area was noted to the top of his scalp. Resident #35 explained that he had a history of skin cancer and that he was told he needed to see the dermatologist a few months ago but wasn't sure if the appointment had been made yet. He indicated that he had an established dermatologist due to his history of skin cancer but had not had the need to go back to the clinic for a while. He explained that he developed an itchy spot to his scalp back in the winter which was made worse by scratching it. Resident #35 stated that he received a cream to the area that relieved the itching and caused the area to scab over when it first started in December 2025. Resident #35 stated that he had discussed the lack of his dermatology appointment with the NP many times and felt it had been forgotten about. Resident #35 stated that he had not reached out to the dermatology clinic on his own. On 4/15/26 at 9:00 AM, an interview occurred with the Resident Transportation staff member. She indicated that there was a staff member (former Resident Appointment Scheduler) that made all the resident appointments but had not worked at the facility since the beginning of 2026. The Resident Transportation staff member stated that she had been making resident appointments since January 2026 and was not aware that Resident #35 needed a dermatology appointment. She explained that if a resident needed an appointment the nurse would print out the referral or NP order and provide it to the appointment scheduler, which was the Resident Transportation staff member at the time of the interview. She was unable to locate a referral for Resident #35 to be seen by dermatology. Multiple attempts to interview the former Resident Appointment Scheduler by phone on 4/15/26 and 4/16/26 were not successful. Another interview occurred with the Resident Transportation staff member on 4/15/26 at 10:06 AM, who indicated she called the dermatology clinic and was told they had received a referral (date unknown) and had called the previous staff member that was responsible for making resident appointments requesting further information. The dermatology clinic stated they had never heard back from that staff member. The Resident Transportation staff member stated she would collect the needed information to make the appointment for Resident #35. The NP was interviewed on 4/15/26 at 9:27 AM and stated she had been assessing Resident #35's wound on the top of his head since December 2025 and had requested a dermatology appointment due to his history of basal cell carcinoma. She stated she was not sure if the appointment had been made but would still like Resident #35 to follow up with dermatology. She explained she would have let the Unit Manager know if someone needed an appointment with a specialist and the nursing staff should have ensured this appointment was made. The NP did not feel this was an urgent matter as the area to the scalp had healed but would have liked for him to follow-up with dermatology due to his history of basal cell carcinoma. Unit Manager #1 was interviewed on 4/15/26 at 9:42 AM and explained if a resident needed an appointment made with a specialist, the referral or order would have been printed out and provided to the resident appointment scheduler. Unit Manager #1 was unsure if a dermatology appointment had been made for Resident #35 and could not recall if she had been made aware at the time the order was written on 1/30/26. The Director of Nursing (DON) was interviewed on 4/16/26 at 9:49 AM and explained she started working at the facility towards the end of January 2026. She stated referrals or orders should have been printed out and provided to the resident appointment scheduler for Resident #35 to have a scheduled dermatology appointment. She stated there was a change in the staff member scheduling resident appointments prior to her becoming the DON and was unaware that Resident #35 had not been scheduled to see the dermatology clinic or that there was an order written on 1/30/26 for him to be seen by dermatology. The DON indicated that currently the Resident Transportation staff member was responsible for making resident appointments, but this would be transitioned to the Medical Records staff member in the next few months. She stated this person had only been at the facility for a few weeks and that was the reason for the delay in transferring responsibilities. The Administrator was interviewed on 4/16/26 at 12:15 PM and indicated that it was his expectation for resident appointments to be scheduled in a timely manner.

Based on record review, Nurse Practitioner and staff interviews, the facility failed to assess and obtain treatment orders for a resident admitted from the hospital with a pressure ulcer for 1 of 8 residents reviewed for pressure ulcers (Resident #125).The findings included: A review of the hospital records for Resident #125 from 12/31/25 to 1/23/26 indicated a hospital-acquired unstageable pressure injury was present to the sacrum. The discharge summary did not contain any type of wound care orders for the sacral pressure injury. Resident #125 was admitted to the facility on [DATE] (Friday) with diagnoses that included end stage renal disease on hemodialysis and pressure ulcer of the sacral region. Review of the admission assessment and nursing progress note dated 1/23/26, completed by Nurse #13, indicated skin impairment to the coccyx was present on admission to the facility and was marked as unstageable. There were no other details in the progress note describing the skin impairment. Attempts to contact Nurse #13 via the phone were unsuccessful from 4/15/26 to 4/16/26. A review of Resident #125's care plan included a focus area dated 1/23/26 for having skin impairment. The interventions included treatment as ordered. A phone interview was conducted with Nurse #7 on 4/16/26 at 1:36 PM, who was assigned to care for Resident #125 from 7:00 AM to 7:00 PM on 1/24/26. She stated that she couldn't recall providing wound care to Resident #125 on that day. She indicated if there was an order she would have completed the wound care, if there was no order present, she would not have known to complete any wound care. Attempts to contact Nurse #8 via the phone from 4/15/26 to 4/16/26 were unsuccessful. Nurse #8 was scheduled to care for Resident #125 from 7:00 AM to 7:00 PM on 1/25/26. A phone interview occurred with Nurse #3 on 4/16/26 at 1:13 PM. She was assigned to care for Resident #125 from 7:00 AM to 7:00 PM on 1/26/26. She indicated that she did not provide wound care to Resident #125 on that day. An admission skin assessment dated [DATE] was completed by Nurse #5 who was the wound care nurse. The assessment documented a pressure ulcer was present to the sacrum measuring 2 centimeters (cm) in length and 2 cm in width. A phone interview was conducted with Nurse #5 on 4/15/26 at 1:25 PM, who was also the wound care nurse in January 2026. She explained that when a resident was admitted to the facility the nurse would do an initial assessment and transcribe any wound care orders present on the hospital discharge summary. If wound care orders were not present the nurse should have reached out to the NP or on-call provider to obtain wound care orders. She went on to say that as the wound care nurse she completed a skin assessment within 24 hours of admission during the week or on Monday if the admission occurred late on Friday or the weekend and ensured that treatment orders were appropriate and transcribed correctly. Nurse #5 could not recall why she completed the skin assessment on Tuesday 1/27/26 rather than Monday but stated she reviewed the hospital discharge summary for Resident #125 who had a sacral pressure ulcer on admission. Nurse #5 stated that when she completed the skin assessment, she recalled the bandage to Resident #125's sacral wound was from the hospital and there were no wound care orders on her Treatment Administration Record (TAR). Nurse #5 could not recall if she had reported this to anyone. A review of Resident #125's physician's orders included an order dated 1/27/26 to cleanse the sacral pressure ulcer with 1/4 strength Dakin's solution (a highly diluted, antiseptic bleach solution used to clean skin wounds to treat or prevent infection) and pat dry. Apply calcium alginate (a highly absorbent wound dressing to promote healing) to the wound bed and cover with super absorbent foam daily and as needed. This order was entered by Nurse #5 who was wound care nurse at that time. A review of Resident #125's January 2026 Treatment Administration Record (TAR) revealed the first documented treatment provided to the sacral pressure ulcer was on 1/27/26. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #125 had severely impaired cognition and was coded with one unstageable pressure ulcer that was present on admission. Resident #125 transferred to the hospital on 2/11/26 from dialysis due to respiratory concerns. On 4/15/26 at 9:27 AM, an interview occurred with the Nurse Practitioner (NP). She recalled Resident #125 was admitted to the facility with a sacral wound but was unaware an order for treatment was not present from 1/23/26 to 1/26/26. She indicated that if a resident was admitted to the facility with a wound and did not have any treatment orders, she would have expected the nursing staff to contact her or the on-call provider and obtain wound care orders. Nurse #1/Unit Manager #1 was interviewed on 4/15/26 at 9:42 AM. Unit Manager #1 stated that the admitting nurse should have taken wound care orders from the hospital discharge summary and if wound care orders were not present, they should have called the NP or on-call provider for wound care orders. She further stated the wound care nurse assessed all new admissions within 24 hours during the week and on Monday if residents were admitted late on Friday or the weekend. The wound care nurse would have completed a skin assessment and ensured wound care orders were present. The Director of Nursing (DON) was interviewed on 4/16/26 at 9:49 AM, who stated that she had been at the facility since the end of January 2026, and that since she had been the DON, the admitting nurse would do the overall assessment to include observing the skin. Any orders present on the hospital discharge summary would be transcribed and if a resident did not have wound care orders, the admitting nurse would reach out to the NP or on-call provider for wound care orders. The wound care nurse assessed all new admissions and readmissions, within 24 hours or on Monday if they were admitted late on Friday or on the weekend. The wound care nurse ensured that all orders were transcribed correctly for wound care or had been obtained from the NP or on-call provider if not present on the hospital orders. The DON stated she was unaware Resident #125 did not have wound care orders for the treatment of the sacral pressure ulcer from 1/23/26 to 1/26/26.

Based on observations and staff interviews, the facility failed to: 1) Label medications (meds) with the minimum information required, including the name of the resident, on 1 of 2 medication (med) carts observed (Med Cart #1); 2) Discard expired medications on 2 of 2 medication carts observed (Med Cart #1 and Med Cart #4) and in 1 of 1 Medication Storeroom (Nurse Station #2 Medication Storeroom); and 3) Store medications in accordance with the manufacturer's storage instructions on 1 of 2 med carts (Med Cart #1). The findings included: 1. An observation was conducted on 1/14/25 at 3:50 PM of Medication (Med) Cart #1 in the presence of Nurse #1. The observation revealed the following medications were stored on the med cart: a. According to the manufacturer, in-use prefilled pens of Insulin Glargine-yfgn should be stored at room temperature and used within 28 days. An opened and in-use prefilled pen of Insulin Glargine-yfgn was stored on the med cart without a resident's name on the label to indicate who the insulin pen belonged to. An auxiliary sticker placed on the pen included a blank space entitled, Expiration Date. A handwritten date written on the blank indicated the insulin pen expired on 1/3/25 (11 days prior to the date of the observation). There was no date on the labeling to indicate when this insulin pen was dispensed from the pharmacy or when it had been put into use. An interview was conducted with Nurse #1 on 1/14/25 at 3:50 PM. When asked, Nurse #1 confirmed the insulin pen was not labeled with a resident's name. She did not know who the insulin pen belonged to. b. According to the manufacturer, in-use prefilled pens of Insulin Lispro should be stored at room temperature and used within 28 days. An opened and in-use prefilled pen of Insulin Lispro dispensed from the pharmacy for Resident #15 had an auxiliary sticker placed on the pen which included a blank space entitled, Expiration Date. A handwritten date on this blank indicated the insulin pen expired on 12/28/24 (17 days prior to the date of the observation). There was no date on the labeling to indicate when this insulin pen was dispensed from the pharmacy or when it had been put into use. An interview was conducted with Nurse #1 on 1/14/25 at 3:50 PM. Upon review of the insulin pen, Nurse #1 confirmed the expiration date written on the insulin pen indicated the medication was expired. c. According to the manufacturer, intact (unopened) bottles of latanoprost eye drops should be stored under refrigeration at 36 degrees Fahrenheit (o F) to 46 o F. An unopened bottle of 0.005% latanoprost eye drops dispensed from the pharmacy on 1/7/25 for Resident #15 was stored on the med cart. A pharmacy auxiliary sticker placed on the bottle read, Keep in Refrigerator Do Not Freeze. An interview was conducted with Nurse #1 on 1/14/25 at 3:50 PM. When asked, the nurse confirmed the auxiliary sticker placed on the container of latanoprost indicated the eye drops should be stored in the refrigerator. An interview was conducted on 1/16/25 at 11:17 AM with the facility's Director of Nursing (DON). During the interview, the medication storage observations were discussed. When asked, the DON reported medications needed to be labeled with the minimum information required, including the name of the resident. She confirmed the insulin pen that was observed to be stored on the med cart without a resident's name needed to be discarded. Additionally, the DON stated the nursing staff should read the medication labels and store items as instructed and appropriate. Expired medications should be identified and discarded by placing them in the Drug Buster (a solution that dissolves and deactivates oral tablets/capsules) or returning them to the pharmacy. Upon further inquiry, the DON reported the facility's unit managers were expected to perform a second check by inspecting the med carts and storerooms weekly to ensure all medications were within date and stored properly. 2. An observation was conducted on 1/15/25 at 11:25 AM of the Nursing Station #2 Medication Storage Room. The observation revealed the following medications were stored on the med cart: a. According to the manufacturer, in-use vials of Novolin R insulin should be stored at room temperature and used within 42 days. An opened vial of Novolin R insulin dispensed from the pharmacy on 9/27/24 for Resident #9 was observed to be stored in the refrigerator. Neither the insulin vial nor the plastic container it was stored in were dated as to when the vial was opened or its shortened expiration date. The label on the insulin vial indicated it was dispensed from the pharmacy 111 days prior to the date of the observation. b. A bottle containing 8 ounces of a compounded drug product (2 milligrams/milliliter of omeprazole suspension) dispensed from the pharmacy for Resident #65 on 12/3/24 was stored in the Med Room refrigerator. Omeprazole is a medication which may be used for the treatment of gastroesophageal reflux disease (GERD). The pharmacy labeling on the omeprazole suspension indicated this medication had an expiration date of 12/9/24 (37 days prior to the date of the observation). c. A bottle containing 6 ounces of a compounded drug product (2 milligrams/milliliter of omeprazole suspension) dispensed from the pharmacy for Resident #65 on 12/30/24 was stored in the Med Room refrigerator. The pharmacy labeling on the omeprazole suspension indicated this medication had an expiration date of 1/13/25 (2 days prior to the date of the observation). On 1/15/25 at 2:55 PM, Nurse #2 was shown the expired medications stored in the med room refrigerator. As the nurse reviewed these medications, Nurse #2 confirmed they were expired and stated she would need to pull them from the refrigerator for disposal. An interview was conducted on 1/16/25 at 11:17 AM with the facility's Director of Nursing (DON). During the interview, the medication storage observations were discussed. When asked, the DON reported expired medications should be identified and discarded by placing them in the Drug Buster (a solution that dissolves and deactivates oral tablets/capsules) or returning them to the pharmacy. Upon further inquiry, the DON reported the facility's unit managers were expected to perform a second check by inspecting the med carts and storerooms weekly to ensure all medications were within date and stored properly. 3. An observation was conducted on 1/15/25 at 2:40 PM of Medication (Med) Cart #4 in the presence of Nurse #3. The observation revealed the following medications were stored on the med cart: a. One stock bottle of Poly-Iron 150 capsules (originally containing 100 capsules) with approximately 80 capsules remaining in the bottle was observed to have a manufacturer expiration date of December 2024. Poly-Iron 150 is an iron supplement used to treat iron-deficiency anemia. b. One stock bottle of 100 milligram (mg) Thiamine B-1 (originally containing 100 tabs) with approximately 60 tablets remaining in the bottle was observed to have a manufacturer expiration date of December 2024. Thiamine B-1 is a B-vitamin supplement used to treat a vitamin deficiency. An interview was conducted on 1/15/25 at 2:50 PM with Nurse #3. During the interview, the nurse examined the labeling on the stock medications identified with a concern. Upon review, Nurse #3 confirmed these medications were expired and needed to be pulled off the medication cart. An interview was conducted on 1/16/25 at 11:17 AM with the facility's Director of Nursing (DON). During the interview, the medication storage observations were discussed. When asked, the DON reported expired medications should be identified and discarded by placing them in the Drug Buster (a solution that dissolves and deactivates oral tablets/capsules) or returning them to the pharmacy. Upon further inquiry, the DON reported the facility's unit managers were expected to perform a second check by inspecting the med carts and storerooms weekly to ensure all medications were within date and stored properly.

Based on observation, record review and staff interviews, the facility failed to place a resident's call light within reach to allow for the resident to request staff assistance if needed for 1 of 1 resident reviewed for accommodation of needs (Resident #78). Findings included: Resident #78 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated 11/ 5/24 revealed the resident was assessed as moderately cognitively impaired. The assessment indicated Resident #78 had clear speech, could make herself understood and had the ability to understand others. Resident #78 was assessed with impairment on both sides related to functional limitation in range of motion for upper and lower extremities. The resident was dependent on staff for all activities of daily living (ADL) and needed substantial to maximum assistance to roll left or right. An observation of Resident #78 on 1/13/25 at 12:02 PM, revealed the resident's call bell was tied to the bed rail on her right side. It was noted to be on the floor beside the bed and out of reach of the resident. The resident was observed to be lying on her bed and did not speak with the surveyor when asked about her call bell and if she could use it. During an observation on 1/14/25 at 8:09 AM, the resident's call bell was observed lying on the floor. When the resident was asked where her call bell was, she pointed to the bed rail and when asked if she could reach it and use it, the resident demonstrated that she could not reach it, but nodded her head indicating she could use it. During an observation on 1/15/25 at 8:44 AM, Nurse #3 was observed leaving the resident's room. The resident was observed lying in her bed. The call bell was wrapped to the bed rail and was hanging off the bed on the right side. The call bell was out of reach of the resident. When the resident was asked if she knew where her call bell was, she looked at the surveyor and shook her head indicating NO. During an observation and interview with the Director of Nursing (DON) on 1/15/25 at 8:50 AM in Resident # 78's room, the DON acknowledged the call bell was hanging to the side of the bed, and not within the reach of resident. The DON stated Resident #78 could use the call bell and was able communicate her needs to the staff. The DON placed the call bell within the reach of the resident by clipping it to the bed linen near the resident's chest. During an interview on 1/15/25 at 8:52 AM, Nurse #3 indicated Resident #78 was alert and oriented and was able to communicate her needs. The Nurse stated that the resident could use the call bell if she needed to. Nurse #3 stated she was in the resident's room earlier that morning administering medication. Nurse #3 indicated the resident could not turn or reposition independently and needed staff assistance with her ADL care. She indicated she was not paying attention and had not noticed the call bell hanging to the side of the bed and not within the reach of the resident. During an interview on 1/15/25 at 2:27 PM, Nurse Aide (NA) #1 verified she was the direct care NA for Resident #78 for the past 3 days (1/13/25 through 1/15/25) from 7:00 AM - 3:00 PM. NA #1 stated Resident #78 needed total assistance with ADL care and needed assistance with turning and repositioning. NA #1 indicated Resident #78 was alert and oriented, able to communicate her needs and only spoke to people she was familiar with. NA #1 further indicated the resident was able to use the call bell and would use it as needed. NA #1 stated she usually checked on Resident #78 first thing in the morning between 7:00 -7:30 AM and later after breakfast (between 8:30 -9:30 AM) to provide her morning care as the resident would like to be out of bed around 10 AM. NA #1 indicated she had not noticed the call bell hanging to the side of the bed. NA #1 stated she usually placed the call bell wrapped to the bed rail and within reach of the resident. NA #1 indicated the resident could not turn to reach her call bell if it was hanging to the side of the bed. During an interview on 1/15/25 at 3:30 PM, the DON reiterated Resident #78 was alert and oriented and was able to use her call bell. The DON indicated the resident only spoke with people she was familiar with and could not move or roll over side to side and needed total assistance from staff for her care. The DON stated Resident # 78 could not reach the call bell if it was hanging to the side of her bed. The DON indicated nursing staff should always ensure that the resident's call bell was within reach of the resident after care was provided.

Based on staff interviews and record reviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of Preadmission Screening and Resident Review (PASRR) Level II status (Resident #23), use of a hypoglycemic medication (a medication that helps to lower blood sugar levels in people diagnosed with diabetes) (Resident #23), use of an antianxiety medication (Resident #52) and hypoglycemic medication was inaccurately coded as insulin (Resident #4) for 3 of 21 residents whose MDS assessments were reviewed. The findings included: 1a. Resident #23 was admitted to the facility on [DATE] with a cumulative diagnosis which included major depressive disorder and schizophrenia. The resident's care plan included the following area of focus, in part: I have a level two PASRR dx [diagnosis]: Schizophrenia (Revised on: 5/27/19). Resident #23's most recent comprehensive Minimum Data Set (MDS) was an annual assessment dated [DATE]. The Identification Information section of this MDS assessment did not report Resident #23 had a PASRR Level II determination. On the date of the review (1/15/25), Resident #23's profile in her electronic medical record (EMR) revealed she had a PASRR number ending with the letter B, which was indicative of a PASRR Level II determination with no limitation on the timeframe. The results of the evaluation, including the determination of a PASRR Level II status, were used for formulating a determination of need, an appropriate care setting, and a set of recommendations for services to help develop an individual's plan of care. An interview was conducted on 1/16/25 at 9:50 AM with MDS Nurse #2 related to Resident #23's annual assessment dated [DATE]. MDS Nurse #1 joined the interview on 1/16/25 at 9:55 AM as the resident's PASRR determination was discussed. Upon review of Resident #23's 2/2/24 MDS assessment, MDS Nurse #2 confirmed the assessment inaccurately indicated this resident had a PASRR Level I status when it should have noted she had a PASRR Level II status. MDS Nurse #1 acknowledged the MDS assessment was incorrect, but noted Resident #23 was care planned for a PASRR Level II (which was correct). An interview was conducted on 1/16/25 at 11:17 AM with the facility's Director of Nursing (DON). During the interview, concerns identified during the review of Resident #23's MDS assessments were discussed. Upon inquiry, the DON reported she would expect the MDS assessments to be coded accurately. 1b. The resident's care plan included the following area of focus, in part: The resident has potential for uncontrolled hypo/hyperglycemia [low and high blood sugar levels] r/t [related to] Diabetes Mellitus (Revised on: 5/24/21). Resident #23's November 2024 Physician's Orders and Medication Administration Record (MAR) revealed the following medications were used to manage the resident's diabetes between 11/3/24 and 11/9/24: -- 2 mg/3 milliliters (ml) Ozempic (an injectable antidiabetic agent that helps to lower blood sugar and is considered a hypoglycemic medication) to be given as 1 mg injected subcutaneously (under the skin) one time a day every Monday for diabetes (ordered on 11/6/23). -- 5 milligram (mg) glipizide Extended Release (ER) Tablet (an oral antidiabetic agent that helps to lower blood sugar and is considered a hypoglycemic medication) to be given as one tablet by mouth once a day for diabetes (ordered on 12/14/22). Based on the documentation provided by Resident #23's November 2024 Physician Orders and MAR, the resident did not receive an insulin injection between 11/3/24 and 11/9/24. Resident #23's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The Medications section of this MDS assessment indicated the resident received an insulin injection on one (1) day during the 7-day lookback period. Meanwhile, this MDS did not indicate Resident #23 received a hypoglycemic medication. An interview was conducted on 1/16/25 at 9:50 AM with MDS Nurse #2. MDS Nurse #1 joined the interview on 1/16/25 at 9:55 AM as Resident #23's MDS assessments were discussed. Upon review of the medications classified on her quarterly MDS dated [DATE], the MDS nurses reported they were aware the Ozempic was inaccurately coded and needed to be corrected on the MDS. An interview was conducted on 1/16/25 at 11:17 AM with the facility's Director of Nursing (DON). During the interview, concerns identified during the review of the Resident #23's MDS assessments were discussed. Upon inquiry, the DON reported she would expect the MDS assessments to be coded accurately and to ensure the medications were classified appropriately. 2. Resident #52 was admitted to the facility on [DATE] with reentry on 12/2/24 from a hospital. The resident's cumulative diagnoses included schizoaffective disorder. The resident's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The Medications section of the 12/10/24 MDS assessment indicated Resident #52 received an antianxiety medication during the 7-day look back period. Resident #52's December 2024 Physician Orders and Medication Administration Record (MAR) provided documentation which indicated the resident did not receive an antianxiety medication during the 7-day look back period from 12/4/24 to 12/10/24. An interview was conducted on 1/16/25 at 9:50 AM with MDS Nurse #2. MDS Nurse #1 joined the interview on 1/16/25 at 9:55 AM as Resident #52's MDS assessments and electronic medical record (EMR) were reviewed. Upon review of the resident's Medications section of the quarterly MDS dated [DATE], MDS Nurse #1 reported he may have incorrectly coded this section to indicate the resident received an antianxiety medication. When asked if Resident #52 received an antianxiety medication during the 7-day lookback period, the MDS nurse stated he did not. An interview was conducted on 1/16/25 at 11:17 AM with the facility's Director of Nursing (DON). During the interview, concerns identified during the review of the sample resident's MDS assessments were discussed. Upon inquiry, the DON reported she would expect the MDS assessments to be coded accurately and to ensure the medications were classified appropriately. 38077 3. Resident #4 was admitted on [DATE] and readmitted to the facility on [DATE] with diagnosis that included type 2 diabetes mellitus with diabetic peripheral angiopathy. Review of the physician orders dated 10/22/24 revealed the following : Ozempic (an injectable, anti-diabetic medication used for the treatment of type 2 diabetes and an anti-obesity medication used for weight management) inject 0.75 milliliter subcutaneously in the morning every Friday for weight management. Review of the Medication Administration Record (MAR) for November 2024 revealed Ozempic (1 milligram (mg)/dose) Subcutaneous Solution Pen-injector Inject 0.75 ml subcutaneously in the morning every Friday for weight management was marked as administered to the resident on Fridays (11/1/24; 11/8/24; 11/15/24; 11/22/24; and on 11/29/24.). Review of the Admission/5-day Minimum Data Set (MDS) assessment dated [DATE] indicated she received one insulin injection during the seven day look back period. During an interview on 1/13/25 at 10:44 AM, Resident #4 indicated she was diabetic and does not receive any insulin. She indicated she was on Ozempic for weight loss. During an interview 1/14/25 at 1:53 PM, Nurse #4 indicated she was assigned to Resident #4. Nurse #4 stated Resident #4 was diabetic and received oral medication to manage the diabetes. Nurse #4 indicated the resident was not on any insulin and received injectable Ozempic for weight loss. During an interview on 1/15/25 at 9:22 AM, MDS Coordinator #1 indicated Resident #4 was on Ozempic and per the MDS 3.0 Drug Class Index reference sheet that the MDS nurses utilize for medication classification, Ozempic was indicted as INS. MDS Coordinator #1 indicated he had assumed INS was insulin and hence had marked as receiving insulin during the look back period. Review of the MDS 3.0 Drug Class Index sheet revealed drug class INS was classified as a hypoglycemic medication which included insulin. During an interview on 1/15/25 at 3:26 PM, the Administrator indicated the MDS Nurse had made an error. The Administrator stated Ozempic was a new medication and was used to lower blood sugar levels for diabetic residents, and the staff would be educated on this medication.

Based on observations, record review, and staff interviews, the facility failed to post cautionary signage outside the resident's room to indicate supplemental oxygen was in use for 1 of 3 residents reviewed for respiratory care (Resident #85). The findings included: Resident #85 was admitted to the facility on [DATE] with diagnoses which included hypoxia. Review of Resident #85's physician's orders revealed she had an oxygen order dated 12/24/24 for oxygen supplementation at 2L (liters) every shift via nasal cannula (a device that delivers extra oxygen through a tube and into the nose) for hypoxia (low levels of oxygen in your body tissues). Resident #85's admission Minimum Data Set, dated dated dated [DATE] revealed Resident #85 was assessed as cognitively intact and was coded for oxygen use. An observation on 1/13/25 at 12:05 PM revealed Resident #85 was lying on her bed in her room wearing a nasal cannula for supplemental oxygen. The oxygen concentrator indicated oxygen was flowing at 2 L/minute. There was no signage outside Resident #85's room indicating supplemental oxygen was in use. An observation on 1/14/25 at 8:37 AM revealed Resident #85 was in her room wearing a nasal cannula for supplemental oxygen. There was no signage outside Resident #63's room indicating supplemental oxygen was in use. An observation was conducted in conjunction with an interview on 1/14/25 at 9:00 AM. Resident #85 indicated she was receiving continuous oxygen for her health issues. The oxygen concentrator indicated oxygen was flowing at 2 L/minute. An observation on 1/14/25 at 2:00 PM revealed Resident #85 was in her room wearing a nasal cannula for supplemental oxygen. There was no signage outside Resident #63's room indicating supplemental oxygen was in use. An interview was conducted on 1/14/25 at 2:05 PM with Nurse #4. She stated Resident #85 was on 2 L/min continuous oxygen therapy via nasal cannula for hypoxia since admission. She stated the admitting nurse was responsible for placing the oxygen signage on a resident's door. She added if the signage was not posted or missed by the admitting nurse then the assigned nurse would place the signage near the resident's room door. An interview was conducted on 1/14/25 at 2:43 PM with the Director of Nursing (DON). She stated nursing were responsible for putting oxygen signage on a resident's door. The DON indicated when any resident was on oxygen therapy, the admitting nurse or the Unit Manager was responsible to put the signage on the door. The DON further indicated the resident was on oxygen and the signage must have been missed by the nurses.

Based on record reviews, and staff, Nurse Practitioner (NP), responsible party, and Resident interviews, the facility failed to notify the physician and responsible party of changes in condition for of 1 of 1 resident (Resident #7). Resident #7 had intact cognition and a history of stroke and on 10/21/24 at approximately 9:00 PM he reported to a nurse aide (NA) he had pain and numbness in his left arm and leg. The NA aide reported this to the nurse. On the next shift at approximately 6:00 AM Resident #7 informed another NA he could not feel his left side. The NA reported this to the nurse. On 10/22/24 between 7:00 and 7:15 AM Unit Manager (UM) #1 was called to the room by an NA and assessed Resident #7 and found his speech was slurred, his left arm and leg did not have any feeling, and they did not have any muscle tone. The Nurse Practitioner was in the facility and assessed Resident #7 and had him transferred to the Emergency Department (ED) for evaluation of stroke symptoms. There were no nursing progress notes entered on 10/21/24 or 10/22/24 regarding notification of the physician or responsible party regarding the change in Resident #7's condition until the note entered by UM #1 on 10/22/24 at 8:25 AM. Resident #7 presented to the Emergency Department (ED) with new onset vision changes and inability to use his left upper and lower extremities. Diagnoses included cerebral vascular accident (CVA- ischemic stroke) with following cognitive deficits and dysphagia (difficulty swallowing) post CVA. It was noted Resident #7 was outside of the window for the administration of Alteplase (tPA) which is a medicine that dissolves blood clots used to treat ischemic strokes. Resident #7 was admitted to the critical care stroke unit and was discharged on [DATE]. Immediate jeopardy began on 10/21/24 for Resident #7 he reported his left arm and leg were numb and a medical provider and responsible party were not notified. Immediate jeopardy was removed on 11/02/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a scope and severity of D (no actual harm with potential for more than minimal harm that is immediate jeopardy) to ensure education is completed and monitoring systems are in place and are effective. Findings included: Resident #7 was admitted to the facility on [DATE], with diagnoses of history of right hemiparesis/hemiplegia (partial or complete paralysis of one side) with right side weakness related to a stroke and Type 1 diabetes mellitus. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #7's cognition was intact. An interview with NA # 5 at 10/29/24 4:33 PM revealed she worked the 3:00 pm to 11:00 PM shift on 10/21/24 and did first rounds with Resident #7 at 6:30 PM and he did not have any concerns. When she did her second round at 9:00 PM, the resident told her he had pain and numbness in his left arm and leg. NA #5 indicated she went to tell Nurse #5 Resident #7 had numbness and pain, and Nurse #5 nodded to NA #5. NA #5 stated Nurse #5 did not go in to check on Resident #7, that she was aware of. An interview with Nurse # 5 on 10/29/24 at 6:06 PM revealed she worked the 3:00 PM to 11:00 PM shift on 10/21/24. Nurse #5 went to Resident #7's bedside to take his blood sugar at 5:00 PM. The Resident did not mention he was having any issues. Nurse #5 did not recall NA #5 telling her Resident #7 was having any change in condition. An interview with NA #4 on 10/29/24 at 5:05 pm revealed at 6:00 AM (on 10/22/24) Resident #7 stated, I can't feel my left side. NA #4 went to tell Nurse #6 and Nurse #6 wrote something down but did not come with NA #4. NA #4 further stated she went back to the room and told Resident #7 she reported his symptoms to Nurse #6 and went on with her assignment. An interview with Nurse #6 on 10/30/24 at 12:47 PM revealed on 10/21/24 at around 6:00 AM NA #4 reported to her that Resident #7's left side wasn't feeling right. Nurse #6 stated that she did an assessment when she gave Resident #7 his medication and checked his blood sugar at around 6:00 AM. She stated she briefly spoke with him while doing the blood sugar and Resident #7 did not indicate anything was wrong at that time. Nurse #7 stated she had not been given any kind of report from the prior shift that anything was going on with Resident #7. An interview with NA #8 on 10/29/24 at 4:25 PM revealed she worked the 7:00 AM to 3:00 PM shift on 10/22/24 and had taken breakfast to the resident around 7:15 am and asked Resident #7 how he was doing. He said, I am not well and I haven't felt well since last night and he couldn't feel his left side, and this had started after dinner. Resident #7 further revealed that his vision was blurred on the left side, and he was numb and could not feel anything on the left side. NA #8 stated she noticed his speech was slurred too. A review of the medical record revealed there were no nursing progress notes entered on 10/21/24 notification to the family or physician regarding a change in Resident #7's change in condition. An interview with Unit Manager (UM) #1 on 10/29/24 at 11:40 AM revealed she was requested by NA #8 to come to Resident #7's room as soon as possible at 7:15 AM (on 10/22/24). Upon arrival, she found Resident #7 with left-sided paralysis, including the left arm and left leg. UM #1 further revealed Resident #7 stated he had been unable to move his left side since last night after dinner. UM #1 stated she began her assessment and called for the Nurse Practitioner (NP). UM #1 stated Resident #7's left arm and leg were flaccid, dropping to the bed when she raised them up. The NP arrived, assessed Resident #7 and asked for EMS to be called because Resident #7 had had a stroke. A phone interview on 10/29/24 at 4:48 PM with the family member/responsible party revealed she was called by NA #8 around 8:15 AM (on 10/22/24) and was told that Resident #7 had been sent to the hospital for a stroke. A phone interview with Resident #7 on 10/30/24 at 5:30 PM revealed after dinner on 10/21/24 he could not feel his left arm and left side when the nurse aide was trying to change him. He could not help due to the lack of movement. NA #5 and NA #9 (3:00 pm to 11:00 pm shift) helped him because one person couldn't do it. He further stated he usually could position himself on his side with the use of the bed rails and a push on his hip to the turning side. This was when he noticed he couldn't move his left side. Nurse #5 came in and he told her he couldn't move his left arm or left leg, and he did not know what was going on. Resident #7 further stated Nurse #5 did not respond. Resident #7 indicated Nurse #5 should have checked him and called the doctor. Resident #7 explained his condition stayed the same until NA #4 came in on third shift and he told NA #4 he could not feel his left side and she went and told Nurse #6. Nurse #6 came into his room around 6:00 am or so and gave him his medicine. Resident #7 indicated Nurse #6 did not assess him or ask if anything was wrong. When the first shift NA (NA #8) came in with breakfast at 7:15 AM, Resident #7 told her he was not himself and she asked what was going on. Resident #7 told her he could not move his left side, and NA #8 immediately called Unit Manager #1. NP #1 came in and assessed him then sent him to the local hospital. An interview with the NP on 10/29/24 at 4:40 pm revealed she was called by the Unit Manager #1 on 10/22/24 because Unit Manager #1 thought Resident #7 had a stroke, and that UM #1 called EMS. NP #1 stated neuro-checks should have been done when his symptoms started on the evening of 10/21/24 and he should have been sent out to the ED on 10/21/24. She further indicated if Resident #7 had been assessed when he first was having numbness (after dinner), and nursing staff had called our on-call provider, we would have instructed them to send Resident #7 to the hospital where his condition could have been managed. NP #1 confirmed Resident #7 had been admitted to the local hospital with a left side stroke. An interview with DON 10/29/24 4:07 PM revealed that when the NA tells the nurse that something was wrong with a Resident, the nurse goes in and does an assessment and notifies the provider, she then notifies the party responsible. The Emergency Department (ED) note dated 10/22/24 indicated Resident #7 had a medical history significant for congested heart failure, chronic renal insufficiency, coronary artery disease, and prior stroke with left-sided deficits. Resident #7 presented to the Emergency Department with new onset vision changes and inability to use his left upper and lower extremities. Stroke code was called upon arrival. A National Institute of Health Stroke Scale (NIH) was documented as an 8 which indicated a mild to moderately severe stroke. Resident #7 reported he was unable to move his arm or leg at 6:00 PM on 10/21/24, which was new for him. The computed tomography (CT) scan showed a right posterior frontal lobe hypodensity concerning edema which could be related to an acute/subacute infarct. It was noted Resident #7 was outside of the window for the administration of Alteplase (tPA) which is a medicine that dissolves blood clots used to treat ischemic strokes. Resident #7 was admitted to neurology stroke service. Resident #7's vitals were blood pressure 162/59, pulse rate 60, temperature 98.5, and oxygen saturation 90%. The clinical impression after evaluation findings were Cerebral vascular accident (CVA) with following cognitive deficits and dysphagia (oropharyngeal phase) post CVA. Resident #7 was released to a skilled nursing facility on 10/29/24. The Administrator was notified of the immediate jeopardy 10/29/24 at 2:15 PM. The facility provided the following credible allegation of IJ removal: (1) Identify those recipients who have suffered, or are likely to suffer a serious adverse outcome as a result of the noncompliance: Resident #7, who has a history of a prior stroke with left sided weakness, reported to Nursing Assistant (NA) #7 on 10/21/24 at 9:00 PM he was experiencing pain and numbness to his left side. Nursing assistant #7 reported to the nurse who did not identify any acute changes, did not complete a neurological assessment, obtain vital signs, did not notify healthcare provider or, initiate emergency medical services. On 10/21/24 at 11:30 PM the resident reported to NA #4 he was moving slowly and could not move his left arm. Nursing assistant #4 reported to the nurse who did not identify any acute changes, did not complete a neurological assessment, obtain vital signs, did not notify healthcare provider, or initiate emergency medical services. The resident reported further symptoms to NA #4 on 10/22/24 at 6:00 AM about being unable to move his left side who then reported to the nurse who did not identify any acute changes, did not complete a neurological assessment, obtain vital signs, did not notify healthcare provider, or initiate emergency medical services. NA took Resident #7 his breakfast tray on 10/22/24 between 7 and 7:15 AM, the resident had slurred speech and was unable to move his left side. The CNA immediately reported the change in condition to Unit Manager #1. Unit Manager #1 assessed the resident and found his left side to be flaccid. The Resident was also complaining of blurry vision. Resident stated that he had been able to move his left side since last night after dinner. The Nurse Practitioner then assessed the resident and directed the resident to be sent out to the hospital via Emergency Medical Services because he had had a stroke. The resident was admitted to the hospital with an acute stroke on 10/22/24. An audit to determine if any residents had reported any new change in condition that was not reported to the healthcare provider by a licensed nurse of residents with a brief interview for mental status (BIMS) score of 13 or higher was completed by the Administrator on 10/25/2024. The Audit revealed that no other residents were noted to be affected. An audit was completed on 10/25/24 by the Director of Nursing of progress notes for the past 7 days to ensure that anyone reporting a change of condition had provider notification. The audit revealed that no one else was affected. As part of the staff education from 10/25/24-10/28/24, the Director of Nursing also questioned all of the licensed nurses regarding knowledge of any residents having had a change in condition that deviated from their baseline and did not have healthcare provider notification. Signatures accounted for both the education and the questionnaire. No residents were noted to be affected. From 10/31/24-11/1/24 the Director of Nursing or Staff Development Coordinator interviewed all nursing assistants regarding knowledge of any residents having change of conditions in the last 7 days that were not reported to the healthcare provider. No negative findings were noted. (2) Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: On 10/25/2024 the Director of Nursing initiated education to all licensed nurses to complete a clinical assessment of a minimum vital signs and pertinent body systems once notified of a change in condition to include accident or incident, injuries of unknown source, significant change in residents physical, emotional, or mental condition which can include elevated vital signs, altered mental status, blurred vision, headaches, numbness or tingling to body parts, uncontrolled pain, etc., to notify the healthcare provider immediately of findings once the assessment is complete. Education also included any changes reported by nursing assistants. Any licensed nurse that has not been educated by 10/28/2024 will be taken off the schedule until the educated has been received. All new hires will be educated by the Director of Nursing during orientation. The Director of Nursing will ensure all licensed nurses are in-serviced. On 11/1/2024, the Regional Director of Clinical Services educated the Administrator, The Director of Nursing, Staff Development Coordinator, and The Human Resource Director on the orientation process for nursing staff that will include education on recognizing change in condition, timely assessment and monitoring of change in condition, effective communication during a medical emergency, importance of notifying the healthcare provider, and effective communication during a medical emergency. On 11/1/2024, the Director of Nursing/Staff Development Coordinator re-educated all nursing assistants on change in condition of residents to include recognizing signs and symptoms of a stroke such as blurred vision, slurred speech, weakness to one side of the body, and facial drooping. Education also included the importance of reporting any change in condition or any of these symptoms to their nurse Any nursing assistant that has not received the education on 11/1/2024 will be taken off the schedule until the education has been received. The Director of Nursing will ensure all nursing assistant educated. The facility alleges removal of immediate jeopardy on 11/02/2024. An on-site validation of the facility's implementation of their credible allegation of immediate jeopardy removal was conducted on 11/4/24. Review of the completed facility audits included daily 24-hour resident report, resident clinical assessments to include neurological, pain and vital signs were documented in the record. Multiple interviews were conducted with nurse aides and licensed nurses to ensure the in-service/ education was provided prior to working their shift. The nurse aides and licensed nurses consistently reported they received in-service education, which included ensuring the medical team and Resident Representative was notified of the resident's change of condition assessment and verifying any new orders with a facility provider prior to initiating the orders. All nursing staff were educated on the reporting and documentation process of any signs of change of condition on the daily 24-hour report and in the resident record. An interview with the Director of Nursing and Staff Development Coordinator on 11/4/24 at 3:00 PM confirmed that re-education was done for all nurse aides and licensed nurses on the change of condition of residents including signs/symptoms of stroke, the importance of reporting any change of condition and documentation of notifying healthcare providers of a medical emergency. The Director of Nursing stated daily record reviews and monthly monitoring will be done to ensure the assessments and notification process was maintained. The immediate jeopardy removal date of 11/02/24 was validated.

Based on observation, record review, resident, family member, staff, Emergency Medical Technician (EMT), Physician, and Nurse Practitioner (NP) interviews, the facility failed to comprehensively assess a resident (Resident #1) who had untreated obstructive sleep apnea (a condition that causes the upper airway to become blocked during sleep, reducing or stopping airflow) to determine the root cause of periodic abdominal pain, change in mental status, and migraines that occurred intermittently over the last 6 months in conjunction with Carbon Dioxide (CO2) levels near the upper limit of the reference range (a set of numbers that are the high and low ends of the range of results that's considered to be normal) in August 2024 and October 2024. When breathing is reduced due to sleep apnea it can lead to a decrease in oxygen and an increase in CO2 in the blood. The facility also failed to implement Physician's orders for Resident #1 for a Continuous positive Airway Pressure (CPAP) machine (used to treat sleep apnea by keeping the airways open while sleeping) ordered on 4/13/24, pulmonary consultation (insurance requirement for obtaining the CPAP) ordered on 5/10/24, neurology consultation (ordered for constant migraines) ordered on 8/24/24, and an x-ray (ordered for abdominal pain) ordered on 8/24/24. On 10/6/24 Resident #1 was excessively sleeping, difficult to rouse, and had no oral intake. On 10/7/24 Emergency Medical Service (EMS) were contacted for altered mental status changes and upon EMS assessment Resident #1 was confused and hypoxic (low oxygen saturation) with an oxygen (O2) saturation of 60% (normal 90-100%) and a CO2 level in the 90's (normal 22-31). The resident's Glasgow Coma Scale (scale used to measure a person's level of consciousness) showed she was in a comatose state, and she was assessed at the hospital with hypercapnia (CO2 retention with elevated CO2 levels), prolonged systemic hypoxemia/severe respiratory failure, acute kidney injury, and transaminitis (high level of liver enzymes in the blood) suspected due to the prolonged systemic hypoxemia/severe respiratory failure. The contributing factors included untreated obstructive sleep apnea. Resident #1 was admitted to the Intensive Care Unit (ICU) on 10/7/24 and spent 10 days in the hospital. In addition, the facility failed to identify the seriousness of a change in condition, complete ongoing comprehensive assessments and identify the urgent need for medical attention for a resident with a history of a stroke. Resident #7 had intact cognition and on 10/21/24 at approximately 9:00 PM he reported to a nurse aide (NA) he had pain and numbness in his left arm and leg. The NA aide reported this to the nurse. On the next shift at approximately 6:00 AM Resident #7 informed another NA he could not feel his left side. The NA reported this to the nurse. There were no documented comprehensive assessments for Resident #7 by either nurse. On 10/22/24 between 7:00 and 7:15 AM a NA took Resident #7 his breakfast and Resident #7 stated he was not well, couldn't feel his left side, and his vision was blurred on the left side, and this had all started after dinner (on 10/21/24). Unit Manager #1 was called to the room and assessed Resident #7 and found his speech was slurred, his left arm and leg did not have any feeling, and they did not have any muscle tone. The Nurse Practitioner was in the facility and assessed Resident #7 and had him transferred to the Emergency Department (ED) for evaluation of stroke symptoms. Resident #7 presented to the ED with new onset vision changes and inability to use his left upper and lower extremities. Diagnoses included cerebral vascular accident (CVA- ischemic stroke) with following cognitive deficits and dysphagia (difficulty swallowing) post CVA. It was noted Resident #7 was outside of the window for the administration of Alteplase (tPA) which is a medicine that dissolves blood clots used to treat ischemic strokes. Resident #7 was admitted to the critical care stroke unit and was discharged on [DATE]. This deficient practice occurred for 2 of 3 residents reviewed for professional standards of care. Immediate jeopardy for Resident #1 began on 10/7/24 when Resident #1 had a significant change in condition and was assessed by EMS with an O2 saturation of 60% and a CO2 level in the 90s and immediate jeopardy ended on 10/25/24. Immediate jeopardy began on 10/21/24 for Resident #7 when he reported his left arm and leg were numb and a comprehensive assessment was not completed to determine if medical interventions were necessary. Immediate jeopardy ended for Resident #7 on 11/02/24. Immediate jeopardy was removed on 11/02/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a scope and severity of D (no actual harm with potential for more than minimal harm that is immediate jeopardy) to ensure education is completed and monitoring systems are in place and are effective. The findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included tachycardia (increased heart rate), asthma, and obstructive sleep apnea. The resident did not have a diagnosis of migraines on admission. A Physician order dated 3/28/23 revealed Resident #1 was to receive Fioricet 50-300-40 milligrams (mg) every 6 hours as needed for headache. A Physician order for Resident #1 dated 7/11/23 indicated Protonix (acid reflux medication) 40 milligrams (mg) twice a day. A Physician order for Resident #1 dated 11/8/23 indicated Propranolol (beta blocker) 20mg three times a day for headaches and migraines. A Physician order for Resident #1 dated 1/6/24 indicated Topamax 25mg daily for migraine headache. A Physician order dated 4/13/24 revealed an order for Resident #1 to receive a CPAP machine for obstructive sleep apnea. Another Physician order dated 5/10/24 revealed Resident #1 was to receive a pulmonology consult for her obstructive sleep apnea and CPAP machine. The Physician order dated 4/12/24 revealed an order for Acetaminophen 325mg give 2 tablets 3 times a day for pain. A phone interview occurred with Physician #1 on 10/22/24 at 3:52pm. Physician #1 verified he had written the order for Resident #1 to receive a CPAP machine and a Pulmonology consultation. He stated he had ordered the CPAP machine in April 2024 first because he understood Resident #1 already had a CPAP machine. Physician #1 stated Resident #1 required a CPAP machine for her obstructive sleep apnea. The Physician stated about a month later he learned (could not remember from who) that Resident #1 did not have a CPAP machine and needed a Pulmonology appointment to obtain a CPAP machine, so he wrote an order for a Pulmonology consultation in May 2024. He stated he did not know if Resident #1 ever attended the Pulmonology consultation but said he knew Resident #1 never had a CPAP machine. During a telephone interview with Physician #2 on 10/22/24 at 3:36pm, the Physician stated Resident #1 was required by insurance to receive a Pulmonary consultation prior to receiving a CPAP machine. He explained that the insurance company needed proof and severity of Resident #1's obstructive sleep apnea before they would approve Resident #1 for a CPAP machine. The Physician stated Resident #1 required a CPAP machine due to her obstructive sleep apnea. Physician #2 stated Resident #1 was never able to receive the consultation due to transportation difficulties. An interview with Transport Staff occurred on 10/22/24 at 4:54pm. Transport Staff confirmed she was responsible for making residents' appointments. She also discussed being responsible for securing alternate transportation if a resident did not fit in the facility's van. Transport Staff discussed Resident #1 being too large to transport in a wheelchair van and would need non-emergency stretcher transport. She stated the facility had a contract with a non-emergency transport company but said they are always booked up. Transport Staff discussed not receiving the consultation request for Pulmonology until 7/30/24. She stated since 7/30/24 she had been periodically trying to schedule the appointment with Pulmonology that would also meet the non-emergency transportation schedule. She stated she had been unsuccessful in getting Resident #1 to the Pulmonologist. A review of a Physicians note dated 6/19/24 written by Physician #1 revealed Resident #1 had episodic altered awareness, ongoing chronic headaches that were being treated with Topamax (migraine medication) daily and Fioricet (migraine medication) as needed, and insomnia with tiredness during the day which was documented as being treated with a CPAP machine and follow up with a Pulmonologist. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact, no rejection of care, and no shortness of breath. The MDS also documented Resident #1 did not have a CPAP machine. Resident #1 was documented as having a weight of 430 pounds. The MDS documented the resident also had pain that occasionally interfered with her daily routine and that she received pain medication. The physician order dated 8/18/24 revealed an order for lab work that included a complete blood count (CBC), comprehensive metabolic panel (CMP), lipid panel (for cholesterol), and an A1C (for diabetes). Resident #1's lab work dated 8/20/24 revealed her CO2 level was 30. On 8/24/24 there was a physician order for Resident #1 to receive a neurology consultation for constant migraines. There was an order on 8/24/24 for Resident #1 to receive an x-ray for abdominal pain. A nurses note dated 8/25/24 written by Nurse #3 revealed the x-ray technician told her the x-ray was unable to be performed because Resident #1 weighed more than the machine can hold. The care plan dated 8/26/24 for Resident #1 revealed no goals or interventions related to her diagnosis of sleep apnea. The resident's care plan also did not include information on migraines, abdominal pain, or refusals of care. A Physician's order revealed Resident #1's Fioricet 50-300-40 milligrams (mg) every 6 hours as needed for headache was discontinued on 9/8/24. Nursing documentation on 9/11/24 written by Unit Manager #1 revealed Resident #1 did not want to get out of bed due to not feeling well and having a headache. A Physician order for Resident #1 dated 9/14/24 indicated Fioricet 50-300-40 milligrams (mg) every 6 hours as needed for headache. On 9/14/24 a nursing note written by the Director of Nursing (DON) revealed Resident #1 requested Fioricet be re-started as needed for the resident's headaches. Review of Resident #1's Medication Administration Record (MAR) from October 2023 through August 2024 revealed Resident #1 received as needed (PRN) Fioricet 39 times and in September 2024 Resident #1 received Fioricet on 9/3, 9/7, 9/25, 9/26, and 9/30/24 for complaints of a headache. The resident's medical record revealed no evidence the orders were implemented for the CPAP ordered on 4/13/24, pulmonology consultation ordered on 5/10/24, or the neurology consultation and x-ray ordered on 8/24/24. On 10/1/24 Resident #1 was administered PRN Fioricet for complaints of a headache. A Physician order dated 10/4/24 for Resident #1 indicated Protonix 40mg once a day. This Protonix order indicated Resident #1's medication was lowered from the initial order dated 7/11/23 of Protonix 40mg twice a day. The Nurse Practitioner (NP) note dated 10/4/24 revealed Resident #1 had continued to complain of headaches that were not responding to the current treatment. The NP documented she was seeing Resident #1 today (10/4/24) for complaints of stomach pain rating a 9 out of 10 (10 being the worst pain). She documented due to the resident's size, imaging such as x-rays could not be completed, so no imaging had been done. The NP noted that Resident #1 had refused to go to the emergency room but that the resident told her she would go if the pain became intolerable. She documented Resident #1's stomach pain was due to eating but then documented Resident #1 has stomach pain when she is not eating. The NP noted that Resident #1 expressed that her migraines were returning daily without other neurological deficits. The NP's plan for stomach pain was to order lab work. There was no documented plan for Resident #1's increased migraines. The NP was interviewed on 10/23/24 at 8:18am. The NP discussed 10/4/24 was the first time she had ever seen Resident #1. She stated she saw Resident #1 on 10/4/24 for complaints of abdominal pain. The NP explained that was why she had ordered the lab work. She explained by doing lab work it would let her know if Resident #1 had an abdominal infection that maybe caused her pain. She stated Resident #1 had told her that x-rays had been ordered for her abdominal pain but had not been completed. The NP said when she asked Unit Manager #1 why the x-ray had not been completed, the nursing supervisor told her it was because Resident #1 did not fit into the facility van. She stated she offered to send Resident #1 to the hospital to have the x-rays completed on 10/4/24 but the resident refused. The NP discussed being aware that Resident #1's CO2 levels had been in the high range since August 2024 but stated Resident #1 did not show any signs of respiratory distress. Resident #1's lab work dated 10/5/24 revealed her CO2 level was 31. On 10/5/24 Resident #1 was provided with PRN Fioricet for complaints of a headache. Review of Resident #1's intake for 10/6/24 revealed she did not have any intake. Review of Resident #1's medical record revealed no nursing documentation for 10/6/24. Nursing Assistant (NA) #1 was interviewed on 10/23/24 at 8:55am. NA #1 stated she worked 11:00pm to 7:00am the night of 10/6/24 to the morning of 10/7/24 with Resident #1. She explained at the start of her shift Resident #1 was talkative and oriented, which NA #1 stated was Resident #1's baseline, but then said Resident #1 usually asked for food to be warmed between 1:00-2:00am and stated the resident did not request for any food to be warmed up. NA #1 stated the next time she saw Resident #1 was between 5:00-6:00am. She said at that time the resident was a little groggy but interacting with the NA. The NA stated she did not notice anything alarming or she would have told the nurse. During a telephone interview with Nurse #1 on 10/23/24 at 10:40am, the nurse discussed being familiar with Resident #1 and confirmed she worked with the resident on 10/6/24 from 7:00am to 3:00pm shift. Nurse #1 stated on 10/6/24 Resident #1 was talkative, but her speech was quiet and slow. She stated she could not remember if the resident ate or appeared sleepy but said Resident #1 took all her medications. NA #2 was interviewed on 10/23/24 at 11:35am. The NA confirmed she worked with Resident #1 on 10/6/24 on the 3:00pm to 11:00pm shift and stated she had been familiar with the resident. NA #2 discussed resident being usually very talkative, alert, and oriented but said on 10/6/24 Resident #1 was very sleepy and difficult to wake up. The NA stated she had to shake the resident to arouse her and then the resident would say I'm awake but the NA stated Resident #1 would fall right back to sleep. She discussed telling the nurse on shift (could not remember the nurses name) and the nurse performing vital signs then telling her Resident #1 was ok and I just gave her an Ativan. NA #2 stated Resident #1 would become very sleepy after receiving medication, so she stated she did not think anything was wrong. The NA stated Resident #1 did not eat or drink anything during her shift. Review of Resident #1's MAR for 10/6/24 revealed, the resident had not received any Ativan (antianxiety medication). There were no vital signs documented for Resident #1 on 10/6/24. During an interview with NA #3 on 10/23/24 at 11:45am, the NA confirmed she had worked with Resident #1 on 10/6/24 and 10/7/24 during the 7:00am to 3:00pm shift. NA #3 discussed not being very familiar with Resident #1 but said she had been assigned to her a few times before 10/6/24. She stated on 10/7/24 Resident #1 was very sleepy and had refused care which the NA stated had not happened before when she was assigned to her. The NA said she could not remember if Resident #1 had anything to eat or drink. NA #3 stated she informed Nurse #1 of Resident #1 refusing care. Review of Resident #1's intake for 10/7/24 revealed she did not have any intake. The NP note dated 10/7/24 documented Resident #1 was sleeping, would open her eyes, and respond to questions but remained very sleepy. She documented that Resident #1 was still reporting abdominal pain and that she checked with nursing to ensure Resident #1 was still receiving medication for her continued headaches. The NP documented her plan for the continued abdominal pain was to order further testing to rule out an infection. There was no plan noted related to Resident #1's headaches or documentation/plan for the resident's increased CO2 level. There was no documentation that the NP offered for Resident #1 to go to the hospital. A nursing progress note written by Nurse #1 dated 10/7/24 documented at 2:16pm revealed that Resident #1 was alert and able to answer, simple questions. The note documented Resident #1 was hard to arouse and the Medical Doctor (MD) was at the bedside. Nurse #1 documented Resident #1 refused care and refused her 2:00pm medication. During a telephone interview with Nurse #1 on 10/23/24 at 10:40am the Nurse discussed when she returned to work at 7:00am on 10/7/24, she saw a difference in Resident #1. She explained the resident was not talking, excessively sleepy, and difficult to arouse. The nurse stated she went and got the NP to assess Resident #1, and that the NP offered Resident #1 to go to the hospital, but the resident refused. Questioned Nurse #1 about her documentation and what she met by would only answer simple questions. Nurse #1 explained Resident #1 would usually provide long answers but on 10/7/24 Resident #1 would only provide 1-2-word answers. Nurse #1 stated Resident #1 remained sleepy, and it was difficult to arouse her whole shift and late in the shift Resident #1 started complaining of her stomach hurting and not feeling well. The nurse stated she offered to send the resident to the hospital, but the resident refused. Nurse #1 discussed Resident #1 having symptoms of a headache, abdominal pain, and sleepiness often but could not remember for how long the resident had the symptoms. Unit Manager #1 was interviewed on 10/22/24 at 5:47pm. The Unit Manager discussed Resident #1 being off in her demeanor on 10/7/24 in the morning. She explained Resident #1's speech was quiet, and that the resident told her she did not feel well. The Unit Manager stated she offered to send Resident #1 to the hospital on 10/7/24 in the morning but the resident refused. She said the morning of 10/7/24 there were no prominent noticeable issues but by the afternoon when she stopped in to see Resident #1, she noticed the resident had right side facial drooping and thought Resident #1 may be having a stroke. The Unit Manager stated that was when she asked Nurse #2 to assess the resident. She discussed not being aware Resident #1 had sleep apnea but said she remembered at some point it was mentioned that Resident #1 needed a CPAP machine. The Unit Manager also discussed Resident #1 having periods of headaches, abdominal pain, and sleepiness for at least 6 months. The Unit Manager stated she was not aware Resident #1 had no oral intake on 10/6/24 or 10/7/24. Nurse #2 wrote a progress note on 10/7/24 documented at 4:08pm. Nurse #2 documented Resident #1 was observed with the right side of her mouth drooping, right eye drooping, unable to use right hand, and was unable to answer questions. The note showed 911 was contacted and the resident was transferred to the hospital. During an interview with Nurse #2 (the facility's skills development coordinator) on 10/22/24 at 5:32pm, the nurse clarified that an MD did not see Resident #1 on 10/7/24 but that it was the NP. Nurse #2 explained she saw Resident #1 on 10/7/24 after being asked to assess the resident by Unit Manager #1. When asked what time she saw Resident #1 she stated it was the time documented on her note which was 4:08pm. Nurse #2 described Resident #1 on 10/7/24 with drooping to the right side of her mouth, right eye drooping, unable to squeeze her hands, and unable to answer questions. Nurse #2 stated Resident #1 was normally alert and oriented x4 (person, place, time, and situation) and talkative. Nurse #2 explained as soon as she saw Resident #1 on 10/7/24 she immediately called EMS. She stated she did not know the resident well enough to say how long Resident #1 had been complaining of headaches, sleepiness, or abdominal pain. Nurse #2 stated she was not aware Resident #1 did not have any oral intake on 10/6/24 or 10/7/24. The Emergency Medical Service (EMS) report dated 10/7/24 revealed a call was placed to 911 at 3:56pm, dispatch was notified at 4:00pm, EMS arrived at the facility at 4:07pm and was at Resident #1's bedside at 4:09pm. EMS documented upon their arrival Resident #1 was sitting on her bed confused and repeating take me to the hospital. EMS noted Resident #1 was altered and could not tell the EMS staff who she was, where she was, or what was going on. Resident #1's skin was cold and sweaty, pupils constricted, oxygen sats were 60% (normal 90-100%) and her CO2 was 90. The EMS staff documented they placed Resident #1 on high flow oxygen with improvement and provided 2 milligrams (mg) of Narcan (medication used to reverse opioid effects) due to Resident #1's pupils being constricted (sign of possible overdose) with improvement. Resident #1 would show improvement but then the resident would become confused again and her sats would drop. A telephone interview occurred with Emergency Medical Technician (EMT) #1 on 10/29/24 at 5:17pm. The EMT discussed they arrived at the facility shortly after 4:00pm on 10/7/24. He stated he was escorted to Resident #1's room by the facility's receptionist. EMT #1 said when he arrived at Resident #1's room she was by herself in bed with the head of the bed in a full upright position and Resident #1 was slumped over. He explained the resident was not conscious and only responded to painful stimuli. EMT #1 stated when she did open her eyes and try to speak, Resident #1's speech was incoherent and that she would only stay awake for a 'few seconds. He stated approximately 5 minutes of being in Resident #1's room, an older nurse entered and told him EMS was called because of abnormal vital signs but the EMT stated the vital signs the nurse provided were with in normal range. EMT #1 stated upon his assessment Resident #1 had decreased respirations, altered mental status, and was hypoxic. He explained Narcan was given due to Resident #1 having constricted pupils which he stated could occur if there was an opioid overdose. EMT #1 also explained the overdose may not have been intentional but said if Resident #1 had not been fully conscious when given her medication or if she had an infection, this could impede the resident being able to fully process her medications through her system causing an overdose. He stated Resident #1's high CO2 levels would not have caused constricted pupils but would have caused the altered mental status. The EMT said upon leaving the facility Resident was unconscious and not talking. Review of Resident #1's medical record revealed no documentation of vital signs on 10/7/24. Review of Resident #1's hospital records revealed the resident was admitted on [DATE] and discharged on [DATE]. Upon admission, Resident #1's CO2 level was 90.5 and her oxygen level was 73%. The resident was assessed at the hospital with hypercapnia (CO2 retention with elevated CO2 levels), prolonged systemic hypoxemia/severe respiratory failure, acute kidney injury, and transaminitis (high level of liver enzymes in the blood) suspected due to the prolonged systemic hypoxemia/severe respiratory failure. The contributing factors included untreated obstructive sleep apnea. The resident had a Glasgow Coma Scale completed which showed Resident #1 was in a comatose state. She was transferred to intensive care where Resident #1 was treated with a BiPAP machine (a machine that helps to provide oxygen and remove CO2 from the lungs) for her hypercapnia. The hospital records documented Resident #1's migraines exacerbated due to untreated sleep apnea and the resident was given medication. An interview with Resident #1 occurred on 10/22/24 at 12:08pm. Resident #1 discussed her change in condition that started on 10/6/24. She explained she slept all day on 10/6/24 and 10/7/24 then woke up in intensive care at the hospital on 10/8/24. Resident #1 stated she did not remember having any conversations with staff, taking any medications or having anything to eat on 10/6/24 or 10/7/24. Resident #1 stated she never had a CPAP machine since she has been in the facility. She explained that the Physician (Physician #1) had discussed with her needing to see a Pulmonologist several months ago and explained to her the appointment was needed so she could obtain a CPAP machine but stated she never saw a Pulmonologist or received a CPAP machine. Resident #1 also explained another Physician (Physician #2) had also told her he wanted her to see a Pulmonologist a few months ago and have a CPAP machine but she was told by the facility (could not remember who) that the facility could not find transportation to get her to the pulmonologist so she could receive the CPAP machine. Resident #1 stated she was told there was no transportation available for someone her size. The resident discussed periods of excessive sleepiness, trouble remembering, headaches, and abdominal pain for at least the past 6 months. She stated one of the Physician's had ordered her to see a Neurologist for her headaches and to have an x-ray of her abdomen but said none of the appointments happened. Resident #1 discussed remembering a mobile x-ray coming to the facility but said she was told by the x-ray technician that she was too large for the mobile x-ray machine. Discussed with Resident #1 her refusal to go to the hospital. Resident #1 stated on 10/4/24 when the NP offered to send her to the hospital, she did not think she needed to go to the hospital and on 10/7/24 she said she had no recollection of talking to the NP or saying she did not want to go to the hospital. The resident stated no one explained to her that she would have been able to see a Pulmonologist and/or a Neurologist and have an x-ray at the hospital. She also stated no one explained to her that some of her symptoms could have been caused by increased CO2 levels. Resident #1 stated if she had known the information, she would have agreed to go to the hospital. The NP stated she saw Resident #1 again in the early morning of 10/7/24 and the resident was sleeping. She explained Resident #1 needed to be shaken to wake up but said she felt this was due to it being so early in the morning and the resident told her I am catching up on my sleep. The NP commented Resident #1 appeared sleepy. She stated she was unaware Resident #1 did not have any oral intake from 10/6/24 to 10/7/24. The NP stated she did not see Resident #1 again on 10/7/24. She stated she was not aware Resident #1 was ordered a CPAP machine back in April 2024 or that Resident #1 had an order to see a Pulmonologist in May 2024. She also stated she was not aware there had been a Neurology consultation order in August 2024 or that Resident #1 had not attended any of these appointments due to transportation issues. Discussed with the NP Resident #1's periodic symptoms of headaches, altered mental status, and abdominal pain. The NP confirmed all of Resident #1's symptoms could have been caused by her increased CO2 levels. She stated since Resident #1's CO2 levels were not considered out of range she did not inform Resident #1 that her symptoms could be caused by her increased CO2 levels. The NP commented that the only way to assess CO2 levels was to conduct an arterial blood gas test which she stated was normally completed in the hospital. She explained the arterial blood gas test would draw blood directly from the arteries which would show higher oxygen levels. She stated she had offered on 10/4/24 and 10/7/24 to send Resident #1 to the hospital but the resident refused. The NP stated she did not know if Resident #1 understood why going to the hospital was important. The Director of Nursing (DON) was interviewed by telephone on 10/29/24 at 10:09am. The DON explained she had not had much contact with Resident #1 and that the resident never voiced any concerns to her. She stated she was aware Resident #1 was not able to attend any of her scheduled appointments due to transportation issues and explained the need for non-emergency transportation company required a month in advance notice and the facility could not coordinate transportation with the time of the appointments. The DON discussed not being aware of Resident #1's increased CO2 levels or that Resident #1 did not have any intake on 10/6/24 or 10/7/24. She stated she did see Resident #1 on 10/7/24 right before the resident left the facility. The DON stated Resident #1 was awake but looked drowsy. The Administrator was interviewed on 10/23/24 at 3:20pm. The Administrator discussed being aware Resident #1 was unable to attend her scheduled appointments due to transportation issues. He had no comments related to Resident #1's hospitalization or how the lack of follow-through with Resident #1's appointments correlated to her hospitalization . The Administrator was notified of immediate jeopardy on 10/23/24 at 3:20pm. The facility provided the following credible allegation of immediate jeopardy removal: (1) Identify those recipients who have suffered, or are likely to suffer a serious adverse outcome because of the noncompliance: The facility failed to comprehensively assess a resident (Resident #1) who had untreated obstructive sleep apnea to determine the root cause of periodic abdominal pain, change in mental status, and migraines that occurred intermittently over the last 6 months in conjunction with elevated CO2 levels on labs completed in August and October 2024. The facility also failed to implement physician's orders for Resident #1 for a CPAP ordered on 4/13/24, pulmonology consultation (insurance requirement for obtaining CPAP) ordered on 5/10/24, neurology consultation ordered on 8-24-24 (ordered for constant migraines), x-rays and ultrasound ordered on 8/24/24 (ordered for abdominal pain). Resident #1 was identified as being affected by the noncompliance. The nurse practitioner performed a comprehensive assessment on 10/4/2024 and 10/7/2024 and it was recommended that she be transferred to hospital on both dates. Resident #1 refused to go to the hospital on 10/4/2024. On 10/7/2024 at 2:36 PM a note was documented at this time; Resident #1 was comprehensively assessed by the nurse practitioner who recommended she go to the hospital. However, Resident # 1 refused to go. On 10/7/2024 at 4:08 PM, Resident #1 had an acute change in status and was unable to answer questions and was sent to the hospital. Resident #1 was diagnosed in the hospital with altered mental status, acute respiratory failure, acute kidney injury, transaminitis, and migraines. Resident #1 was placed on a BIPAP and admitted to an intensive care unit. She received IV Lasix and supplemental oxygen. An Ultrasound was done due to transaminitis which demonstrated steatosis. In addition, Resident #1 received an order for Fioricet for migraines. Resident # 1's pulmonary and neurology consultations were discontinued on 10/7/2024 upon discharge to hospital. Upon return to the facility on [DATE], Resident #1 did not have any new orders for pulmonology consultation or follow up as she currently has BIPAP in place. Upon review, Resident [TRUNCATED]

Based on record reviews and staff interviews, the facility failed to complete a performance review every 12 months for 5 of 5 nurse aides (NAs) reviewed (NA # 4, #5, NA 7, NA #9 and NA #10). The findings included: a. Review of Nurse Aide #4's employee file revealed a date of hire of 4/10/23. The employee file for NA #4 did not include annual performance review documents based on the date of hire including April 2024. b. Review of NA #5's employee file revealed a date of hire of 3/28/23 . The employee file for NA #5 did not include annual performance review documents based on the date of hire including March 2024. c. Review of NA #7's employee file revealed a date of hire of 10/18/22. The employee file for NA #7 did not include annual performance review documents based on the date of hire including October 2023 and October 2024. d. Review of Nurse Aide #9's employee file revealed the date of hire of 11/9/22. The employee file for NA #9 did not include annual performance review documents based on the date of hire including November 2023. e. Review of NA #10's employee file revealed the date of hire of 1/31/23. The employee file for NA #10 did not include annual performance review documents based on the date of hire including January 2023 and January 2024. An interview was conducted 11/4/24 at 3:15 PM with the Director of Nursing who stated she was hired in May 2024 and was unaware of the facility's process for maintaining nurse aide competency skills training and performance reviews. She was unaware the mandatory requirements for nurse aide training/competency performance reviews had not been done for 2023 and 2024 for several employees. She stated she was unable to provide any evidence of any training done prior to her employment. She stated she began restructuring the documentation and records of staff training with the initiation of a new system developed with the Staff Development Coordinator that started with the new hires on 9/25/24 when the facility's skill fair was started to educate and provide nurse aide training to reinforce skills and best practices to practice skills used daily for the care of residents in a long term care setting in accordance with the healthcare regulations. An interview was conducted on 11/4/24 at 3:30 PM with the Staff Development Coordinator (SDC) who stated she was hired on 8/26/24 and was not aware of the facility's process for maintaining nurse aide competency skills training and performance reviews. She indicated after reviewing the employee files it was discovered the nurse aide competency skills and performance reviews had not been done for 2023 and 2024. She indicated she was currently doing new employee orientation in-services and competencies. She stated she had not been in the role of SDC for very long and she had not started to review employee training files or training nursing staff in order to complete annual performance evaluations or review. During an interview on 11/4/24 at 4:00 PM the Administrator stated Nurse Aides' skills assessment /competencies should be completed at hire and annually. The facility should also have a performance review completed annually to address the needs of staff. The Administrator stated at this time the facility was unable to provide documentation to indicate Nurse Aides' annual performance reviews were completed. The Administrator indicated the skill competencies evaluation and annual performance review should be completed and signed by Staff Development Coordinator (SDC) or her designee. The Administrator stated the facility had some turnover in the SDC position, resulting in no evidence that the training/education was completed and documented.

Based on record review, resident, staff, Physician, and Nurse Practitioner (NP) interviews the facility failed to ensure a resident (Resident #1) had a Pulmonary consultation appointment ordered once on 4/13/24 and again on 5/10/24. Resident #1 was diagnosed with obstructive sleep apnea and the appointment was required so Resident #1 could obtain a continuous positive airway pressure (CPAP) machine (used to treat sleep apnea by keeping the airways open while sleeping) that was ordered on 4/13/24. The facility also failed to ensure Resident #1 attended a Neurology consultation appointment ordered on 8/24/24 which was made due to Resident #1 complaining of constant migraines/headaches. This occurred for 1 of 3 residents reviewed for medically related social services. The findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included tachycardia (increased heart rate), asthma, morbid obesity, and obstructive sleep apnea. The resident did not have a diagnosis of migraines on admission. Physician #1 order dated 4/13/24 revealed an order for Resident #1 to receive a Pulmonary consultation and a CPAP machine for obstructive sleep apnea. Another Physician #1 order dated 5/10/24 revealed Resident #1 was to receive a pulmonology consult for her obstructive sleep apnea and CPAP machine. A phone interview occurred with Physician #1 on 10/22/24 at 3:52pm. Physician #1 verified he had written the order for Resident #1 to receive a CPAP machine and a pulmonology consultation. He stated he had ordered the pulmonology consultation and CPAP machine in April 2024 because he understood Resident #1 already had a CPAP machine, but it was not present at the facility. Physician #1 stated Resident #1 required a CPAP machine for her obstructive sleep apnea. The Physician stated about a month later he learned (could not remember from who) that Resident #1 did not have a CPAP machine and needed a Pulmonology appointment to obtain a CPAP machine, so he wrote an order for a Pulmonology consultation in May 2024. Physician #1 explained he did not remember writing the pulmonology consultation in April 2024 when he re-wrote the order in May 2024. He stated he did not know if Resident #1 ever attended the pulmonology consultation but said he knew Resident #1 never had a CPAP machine. A follow-up telephone interview with Physician #1 occurred on 11/4/24 at 11:03am. Physician #1 discussed due to Resident #1's weight, the lack of follow-through with her Pulmonology consultation, Neurology consultation, and lack of obtaining a CPAP machine could not have caused her hospitalization on [DATE]. He explained Resident #1 had been stable without her CPAP prior to her hospitalization s. During a telephone interview with Physician #2 on 10/22/24 at 3:36pm, Physician #2 explained he began seeing Resident #1 after Physician #1 had left the facility. The Physician stated Resident #1 was required by insurance to receive a pulmonary consultation prior to receiving a CPAP machine. He explained that the insurance company needed proof and severity of Resident #1's obstructive sleep apnea before they would approve Resident #1 for a CPAP machine. The Physician stated Resident #1 required a CPAP machine due to her obstructive sleep apnea. Physician #2 stated Resident #1 was never able to receive the consultation due to transportation difficulties. An interview with Transport Staff occurred on 10/22/24 at 4:54pm. Transport Staff confirmed she was responsible for making residents' appointments. She also discussed being responsible for securing alternate transportation if a resident did not fit in the facility's van. Transport Staff discussed Resident #1 being too large to transport in a wheelchair van and would need non-emergency stretcher transport. She stated the facility had a contract with a non-emergency transport company but said they are always booked up. Transport Staff discussed not receiving the consultation request for Pulmonology until 7/30/24. She stated since 7/30/24 she had been periodically trying to schedule the appointment with Pulmonology and Neurology that would also meet the non-emergency transportation schedule. The Transport staff explained periodically met she would try to call both the Pulmonology office and the Neurology office plus the transportation company every 2-3 weeks to try to arrange the schedules. She stated she had been unsuccessful in getting Resident #1 to the Pulmonologist. The Transport Staff also discussed her neurology consultation. She stated Resident #1 was not able to attend the consultations due to not being able to arrange transportation with the non-emergency transportation company. She stated she kept Unit Manager #1 and the DON up to date in her failed attempts to arrange the appointments. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact, no rejection of care, and no shortness of breath. The MDS also documented Resident #1 did not have a CPAP machine. Resident #1 was documented as having a weight of 430 pounds. Resident #1 was documented as having impairment on one side for her upper and lower extremities, dependent on toileting, bathing, upper and lower dressing, substantial/max assist with bed mobility, and dependent with transfers. On 8/24/24 there was a physician order from Physician #3 for Resident #1 to receive a neurology consultation for constant migraines. The resident's medical record revealed no evidence was documented that Resident #1 received her CPAP. The medical record also revealed Resident #1 never attended her pulmonology consultation, or the neurology consultation. Unit Manager #1 was interviewed on 10/22/24 at 5:47pm. She discussed not being aware Resident #1 had sleep apnea but said she remembered at some point it was mentioned that Resident #1 needed a CPAP machine. She also stated she was aware Resident #1 was unable to attend her Neurology consultation and Pulmonary consultation due to transportation issues. An interview with Resident #1 occurred on 10/22/24 at 12:08pm. Resident #1 stated she never had a CPAP machine since she had been in the facility. She explained that the Physician (Physician #1) had discussed with her needing to see a Pulmonologist several months ago and explained to her the appointment was needed so she could obtain a CPAP machine but stated she never saw a Pulmonologist or received a CPAP machine. Resident #1 also explained another Physician (Physician #2) had also told her he wanted her to see a Pulmonologist a few months ago and have a CPAP machine but she was told by the facility (could not remember who) that the facility could not find transportation to get her to the pulmonologist so she could receive the CPAP machine. Resident #1 stated she was told there was no transportation available for someone her size. The resident discussed periods of excessive sleepiness, trouble remembering, headaches, and abdominal pain for at least the past 6 months. She stated one of the Physician's had ordered her to see a Neurologist for her headaches but said none of the appointments happened. The resident stated no one explained to her that she would have been able to see a Pulmonologist and/or a Neurologist. The NP was interviewed on 10/23/24 at 8:18am. She stated she was not aware Resident #1 was ordered a CPAP machine or to see a Pulmonologist back in April 2024 or that Resident #1 had an order to see a Pulmonologist in May 2024. She also stated she was not aware there had been a Neurology consultation order in August 2024 or that Resident #1 had not attended any of these appointments due to transportation issues. The Director of Nursing (DON) was interviewed by telephone on 10/29/24 at 10:09am. The DON explained she had not had much contact with Resident #1 and that the resident never voiced any concerns to her. She stated she was aware Resident #1 was not able to attend any of her scheduled appointments due to transportation issues and explained the need for non-emergency transportation company required a month in advance notice and the facility could not coordinate transportation with the time of the appointments. The Administrator was interviewed on 10/23/24 at 3:20pm. The Administrator discussed being aware Resident #1 was unable to attend her scheduled appointments due to transportation issues. He had no comments related to the lack of follow-through with Resident #1's appointments.

Based on observations, record review, and staff and service technician interviews the facility failed to cover facial hair and wear gloves during food preparation; keep food service equipment clean and free from debris and maintain a clean kitchen environment; label and date open food items in 1 of 1 walk in coolers; maintain and monitor the kitchen's dish machine that was utilized to clean the dishware and eating utensils to ensure the machine's wash cycle and rinse cycle temperature reached a minimum temperature of 120 degrees Fahrenheit (F); and insulated dome lids and bases were dry before they were stacked for use. The findings included: 1. On [DATE] at 4:11 PM Dietary Aide #2 was observed placing lids on insulated mugs full of liquid for meal service with no gloves or facial covering in place. Dietary Aide #2 was observed to have facial hair (beard). Dietary Aide #2 observed surveyors in the kitchen and placed gloves at 4:13 PM on but no facial hair covering and continued placing lids on the insulated mugs full of liquid for meal service. A continuous observation on [DATE] from 10:16 AM to 10:18 AM revealed [NAME] #2 used a spatula to remove cooked fish filets from a large pan to a smaller holding container while not wearing gloves. During an interview with the Dietary Supervisor on [DATE] at 4:26 PM she indicated facial hair coverings should be in place while in the kitchen. She stated she had facial hair coverings available for staff in her office. The Dietary Supervisor also stated gloves should be worn during food preparation. An interview with [NAME] #2 on [DATE] at 10:18 AM indicated she should have been wearing gloves when handling the food but thought it was alright not to because she was using a spatula. An interview with the Administrator on [DATE] at 12:35 PM revealed staff should have facial hair coverings in place while in the kitchen and should wear gloves for food preparation. 2. Further observation of the kitchen revealed the following. -Continuous observation of the kitchen on [DATE] from 4:11 PM to 4:26 PM revealed the 3-compartment sink heavily soiled in all 3 compartments with food debris, a greasy jelly-like light brown substance and a deceased insect stuck to the inside wall of the right end sink. The sink was observed at 4:15 PM. An interview on [DATE] at 4:26 PM with the Dietary Supervisor revealed the kitchen was deep cleaned every Thursday. -Observation of the dish washing area on [DATE] at 8:00 AM revealed wooden material surrounding the garbage disposal electrical control box attached to the wall in the corner of the dish washing area. The wooden material was decaying, chipped, and covered with black matter/ growth. Observation and interview completed with Maintenance Director on [DATE] at 8:03 AM. The Maintenance Director discussed knowing the garbage disposal electrical control box wooded area needed repair. He stated the wooden area around the garbage disposal electrical control box was decaying, chipped and covered with black matter/growth prior to his employment. 3. An observation of the walk-in cooler on [DATE] at 4:23 PM revealed 9 unshelled hard-cooked eggs in a plastic storage bag that was undated. An opened 4 pound jar of grape jelly was also observed to be undated. The Dietary Supervisor was present for the observation. An interview with the Dietary Supervisor on [DATE] at 4:26 PM revealed she was responsible for completing a walk-through of the cooler each morning and checked that each item in the cooler that was open had a date when it was opened and an expiration date. The Dietary Supervisor did not recall seeing these items in the cooler this morning. An interview with the Administrator on [DATE] at 12:35 PM revealed food items in the walk-in cooler should be properly dated. 4. A continuous observation of the low temperature dish machine in use on [DATE] from 9:39 AM to 9:48 AM showed the dish machine temperature gauge reading at 102 degrees Fahrenheit (F) for both the wash and rinse cycle with a load of dishes in the compartment. The dish machine was then observed for three more wash and rinse cycles including one cycle each for 20 plastic drinking cups, 32 fruit bowls and 26 dinner plates with the temperature gauge remaining at 102 degrees F. Dietary Aide #1 was noted to be operating the machine during the observations. Review of the manufacturers' recommended temperatures affixed to the front of the dish machine for wash specified the dish machine should reach a minimum temperature of 120 degrees F with a recommended temperature of 140 degrees F. The manufacturers recommended temperatures for rinse revealed the dish machine should reach a minimum temperature of 120 degrees F with a recommended temperature of 140 degrees F. An interview on [DATE] at 9:42 AM with Dietary Aide #1 indicated he spot checked the dish machine temperature at the beginning of his shift prior to starting the dish washing process. He indicated once his initial temperature check was completed, he did not recheck the temperature gauge to make sure the dish machine was maintaining the minimum temperature of 120 degrees F. An observation and interview were conducted on [DATE] at 9:45 AM with the Dietary Supervisor regarding the dish machine which revealed the temperature gauge remaining at 102 degrees F. The Dietary Supervisor stated she would contact the vendor immediately for a service call. The Dietary Supervisor voiced that the Dietary Aides would initially complete several wash and rinse cycles to make sure the dish machine was reaching temperature prior to starting the dish cleaning process. The Dietary Supervisor explained that staff completed the initial check, but the temperature was not checked throughout the dish cleaning process. An observation and interview were conducted on [DATE] at 10:08 AM with the Maintenance Director regarding the dish machine. He stated the dish machine was leased and that he could not complete repairs. The temperature gauge remained at 102 degrees F and he stated the temperature gauge was probably not properly reading the water temperatures cycling through the dish machine. On [DATE] at 10:18 AM a telephone interview was conducted with the Service Manager for the dish machine service company. He stated the dish machine was a low temperature dish machine and water temperature readings for wash and rinse cycle should be a minimum of 120 degrees F but the recommended temperature should be at least 140 degrees F. The service manager explained the dish machine temperature gauges would become faulty over time and not read the correct water temperature or stay fixed on a certain temperature and need to be replaced. He stated the dish machine at the facility was installed in February of 2023. He further explained the dish machine was last serviced 8 weeks ago (no date given). The Service Manager voiced the service technician was in route to the facility to assess the dish machine. Review of the dish machine service company service report for the dish machine dated [DATE] revealed the dish machine had a water temperature reading of 128 degrees F during this service call. No other concerns or recommendations noted. Review of the dish machine service company service report for the dish machine dated [DATE] revealed the dish machine had a water temperature reading of 115 degrees F. Remarks from the service technician noted the temperature gauge was replaced with a new temperature gauge. No other concerns or recommendations noted. A continuous observation of the dish machine on [DATE] from11:45 AM to 11:51 AM and an interview with the dish machine service company Service Technician was conducted at 11:45 AM. The observation revealed that a new gauge was installed, and the old gauge had been disconnected. The Service Technician stated the old gauge was not working properly and did not show the actual dish machine water temperatures for washing and rinsing. The Service Technician completed several wash and rinse cycles and indicated the temperature gauge was working properly at this time with the temperature gauge reading showing above 120 degrees F. The temperature gauge was observed to read 128 degrees F. An interview with the Administrator on [DATE] at 12:35 PM revealed when staff notice the temperature gauge not working properly, they should notify the vendor so the issues could be corrected. 5. On [DATE] at 10:03 AM an observation of the light brown 4-compartment trolley holding insulated dome lids and bases revealed a stack of wet insulated dome lids and bases in 1 compartment. The compartment held a total of 31 insulated dome lids and bases. During an interview on [DATE] at 10:16 AM Dietary Aide #3 stated he forgot to let the insulated dome lids and bases dry prior to placing the items in the 4-compartment trolley. He stated he was rushing. An interview on [DATE] at 10:17 AM with the Dietary Supervisor revealed staff should make sure the insulated dome lids and bases are dry before storing them in the trolley. During an interview on [DATE] at 12:35 PM with the Administrator he indicated items should be properly dried and then stored.

Based on observations and staff interviews the facility failed to maintain a clean and sanitary environment as evidenced by the presence of a growth buildup in and on 1 of 2 ice machines observed and various colored growths on the floor for 1 of 2 observations that were conducted for clean and sanitary environment. The findings included: On 10/22/24 at 4:11 PM the following observations were made. 1. The ice machine located in a room with electronic equipment on Zone/hall 3 revealed blackish brown spots of matter on the external facing of the ice machine between the top portion of the ice machine and the ice machine door. The inside of the ice machine revealed pinkish/ black colored matter on the internal ceiling of the ice machine and small brownish-black spots on the internal ceiling front metal lip. 2. The floor and corner molding in the right corner behind the ice machine revealed blackish matter along the molding and underneath the exposed and decayed wood, light beige colored puffy growths among the blackish matter on the floor and corner molding. Yellow matted stringy material was also observed on the floor and among the blackish matter and light beige colored growths. An interview and observation on 10/22/24 at 5:26 PM with the Maintenance Director revealed he was not aware of the ice machine being in this condition. He explained that the ice machine was used by staff, and he had not received any concerns related to mold in the ice machine from staff. The Maintenance Director stated he cleaned the ice machines in the building quarterly. He verbalized he was not certain what the blackish or light beige or yellow colored matter was on the floor or the corner molding. He suspected that it was mold but not 100% certain. The Maintenance Director explained that he would shut down the ice machine, empty the ice machine out, complete a chemical clean, and repair the flooring around the ice machine. An interview with the Administrator on 10/23/24 at 12:35 PM revealed ice machines were checked weekly by staff and maintenance. The Administrator stated he was not certain of the deep clean schedule for the ice machines.

Based on observations and staff interviews, the facility failed to maintain the privacy of a resident's record by leaving a medication cart laptop unattended, with resident health information exposed in an area accessible and visible to the public, for 1 of 4 medication carts (Zone 1 medication cart). The findings included: An observation of the Zone 1 medication cart was completed on 10/23/24 at 9:57 AM, inclusive of the medication cart laptop which was unattended. The laptop displayed resident personal health information including name, medications and diagnoses. Staff and residents were observed to pass by the medication cart during this time. An interview with Nurse #4 was completed on 10/23/24 at 9:59 AM. Nurse #4 stated her medication cart was locked but she should have closed or locked her laptop screen so that resident personal health information was not displayed. An interview with the Director of Nursing (DON) was completed on 10/23/24 at 12:22 PM. The DON verbalized that Nurse #4 should have locked her laptop screen with the lock button prior to moving away from the medication cart. An interview with the Administrator was completed on 10/23/24 at 12:31 PM. He indicated staff should lock the laptop screen prior to leaving the medication cart unattended.

Based on observations and staff interviews, the facility failed to secure resident medications left in an unattended medication cart for 1 of 4 medication carts (Zone 1 medication cart). The findings included: An observation of the Zone 1 medication cart on 10/22/24 at 5:20 PM revealed the medication cart was unlocked and unattended. The locking mechanism on the right front of the medication cart was observed to be popped out in the unlocked position. Staff and residents were observed to pass by the unlocked medication cart during this time. On 10/22/24 at 5:23 PM Nurse #3 was observed approaching the medication cart from a resident's room. Nurse #3 was observed to lock the cart and proceed to gather items on the top of the cart. An interview was completed with Nurse #3, she stated she was giving evening medications to a resident in the resident's room. Nurse #3 stated the medication cart should have been locked when she was not in attendance of the cart. Observation of the medication cart contained resident medications, insulin pens, medicated ointments and medicated eye drops. An interview was completed with the Director of Nursing (DON) on 10/23/24 at 12:22 PM. The DON stated nurses should lock their medication cart when not in attendance.

Based on record review and staff and physician interviews the facility failed to safely transfer a resident when utilizing a sit to stand lift for 1 of 3 residents reviewed for accidents (Resident #1). This unsafe transfer resulted in Resident #1 sustaining a mildly displaced left medial malleolus (boney presence on the inner side of the ankle) fracture and pain of 5 on a scale of 1 to 10 (10 being the worst pain). Finding included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included cerebral palsy, contractures to right hand, contractures to right knee and contractures to left knee. Review of Resident #1's care plan (revised date 10/9/23) revealed the focus area for a risk for Activities of Daily Living (ADL) self-care performance deficit related to cerebral palsy, contracture to right hand, right knee and left knee and bipolar disorder. One of the interventions was recommended transfers with stand lift. Resident was total assist with transfer. Review of the nursing note dated 11/30/23 at 5:54 PM indicated the assigned nurse (Nurse #1) was notified by the assigned Nurse Aide #1 # (NA) that Resident #1's ankle got caught up in his wheelchair while trying to transfer him to bed. The note also read in part Upon assessment no bruises or deformity noted at site, the resident complained of pain to the area. Nursing note indicated, as needed (PRN) Acetaminophen (Tylenol) pain medication was administered per physician orders. Physician orders received for X-rays. Review of the Medication administration note dated 11/30/23 at 10:09 PM read in part Acetaminophen Tablet 325 milligram (MG), Give 2 tablet by mouth every 6 hours as needed for pain. PRN (as needed) Administration was: Effective. Follow-up Pain Scale was: 0. Review of the X-ray report dated 12/1/23 indicated fracture to left distal tibial with no displacement. There was associated soft tissue swelling. Review of the Physician note dated 12/1/23 revealed Resident #1 was examined by the Physician in his room. The resident did not appear to be in acute distress. Per Physician note the resident's ankle got caught in his wheelchair while transferring him from his wheelchair to his bed. The resident had no gross deformity noted at the site and had some complaints of pain to the area. The resident's x-ray came back positive for acute left distal tibial fracture without any displacement. Resident was sent to emergency room (ER) for further evaluation. Note indicated Resident #1 had history of previous left knee fusion surgery. Documentation of Nursing note dated 12/1/23 at 1:33 PM by Nurse assigned to the resident (7 AM - 3PM shift) indicated Resident #1 had an x-ray of left ankle. The result displayed fracture of the distal tibia. Per Physician orders the resident was sent to the hospital for further evaluation. Resident# 1 was in no apparent distress at that time. Review of Pain scale documentation indicated on 11/30/23 at 4:43 PM, Resident #1's pain was documented as a 5 out of 10. On 11/30/23 at 10:09 PM was 0. On 12/1/23 at 9:15 AM was document as 7 and on 12/1/23 at 12:40 PM was 0. Physician Order dated 12/1/23 read in part Oxycodone HCl Oral Tablet 5 (Milligrams) MG (Oxycodone HCl) Give 5 mg by mouth every 6 hours as needed for pain for 5 Days. Physician Order dated 12/4/23 read in part Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) Give 5 mg by mouth every 6 hours as needed for pain/fracture for 14 days. Review of the Medication Administration Record revealed Acetaminophen Tablet 325 milligram (MG) Give 2 tablet by mouth every 6 hours as needed for pain was administered on 11/30/23 at 4:43 PM and pain level indicated as a 5 and on 12/123 at 9:15 AM and pain level indicated as a 7. As needed Oxycodone HCL was marked as administered as ordered by the physician starting 12/2/24 and pain levels were indicated at the time of administration. Hospital emergency room (ER) records dated 12/1/23 indicated Resident #1 was presented to the ER for a fall brought in by Emergency Medical services (EMS). The resident was being transferred from wheelchair (w/c) to bed when his legs got tangled under him. He endorses left ankle pain and right lower leg pain. He was unable to rotate his left ankle and states pain radiates from left ankle up to the middle of his calf. Facility performed X-rays and states he has a tibial fracture. Right foot X-ray does not show any fracture. The left tibia fibula x-ray shows mildly displaced left medial malleolus ( boney presence on the inner side of the ankle ) fracture. The resident was seen by ortho and recommended: non weight bearing, can be in CAM (Controlled Ankle Motion) boot while transferring, no need for boot when in bed; no further orthopedic surgery needed. Resident sent back to facility from ER the same day. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was assessed as cognitively intact and was dependent on staff for toileting, showers, personal hygiene, and chair/ bed to chair transfer. Assessment indicated the resident used a motorized wheelchair for mobility. During a telephone interview on 5/8/24 at 3:51 PM, Nurse Aide (NA)#1 stated he no longer worked for the facility, but recalls he was assigned to Resident #1 during the 3 PM - 11 PM shift (the date of the incident unknown). He further stated he was transferring the resident using a lift when the incident occurred. NA #1 did not recall what kind of mechanical lift he was using to transfer the resident. NA #1 indicated he was transferring the resident from his wheelchair to his bed and the resident's leg got caught on the plate on his wheelchair. NA #1 stated he did not realize that the resident's leg was caught on the plate until the resident was safely transferred to the bed. NA #1 further stated the resident had complained about pain and the assigned nurse was immediately notified about the incident. The NA indicated the nurse had assessed the resident and X-rays were ordered by the physician. NA #1 further indicated the assigned Nurse administered pain medication and the resident did not complain of pain later that night. NA #1 stated he was agency staff and worked sporadically at the facility. He indicated when he returned to the facility after few days, he was asked about the incident by management staff (name unknown) and received in-service and training on mechanical lift transfers. NA #1 further indicated was not assigned to the resident after the incident. During a telephone interview on 5/8/24 at 3:17 PM, Nurse #1 stated she was assigned to Resident #1 on 3 PM -11 PM shift. The nurse was unsure of the date of incident and vaguely remembered the incident. Nurse #1 stated the incident details were written in her note. The Nurse indicated she recollects the NA (name unknown) had informed her about the resident's leg got caught in the wheelchair while the resident has been transferred from his wheelchair. The resident had complained of pain. Nurse indicated she assessed the resident and notified the Physician. An X-ray was ordered. The resident was also administered as needed pain medication for pain management. Nurse further indicated the resident was transferred using a mechanical lift and unsure which type. During a telephone interview on 5/8/24 at 1:43 PM, the Physician stated he was made aware that Resident #1's leg got caught in his wheelchair while been assisted with transfer by the NA. The resident was complaining of leg pain. The Physician further stated X-rays were ordered and had come back positive for non-displaced fracture. The Physician indicated the resident was sent to the emergency room for further evaluation. The resident was evaluated by the Orthopedic in the ER and discharged to the facility in a CAM (Controlled Ankle Motion) boot and on as needed Oxycodone medication for 14 days for pain management. The Physician stated the resident had brittle bones, multiple contractures, and history of multiple fusion surgeries to legs and ankles and sometimes a complex movement like a transfer could cause a fracture. The Physician stated the resident recovered well. During an interview on 5/9/24 at 11:56 AM, the Director of Nursing (DON) stated the resident needed staff assistance for transfer. Resident #1 was assisted by the NA using a sit to stand lift for transfer. During the process of transfer the resident had complained about pain. The resident's nurse was notified. Nurse received Physician order for X-rays. X-ray result indicated the resident had a fracture. DON further stated the resident was sent to ER for further evaluation. The resident was on as needed medication for pain management and his pain was managed. The resident had existing co-morbidities making him more susceptible to fracture. DON indicated Resident #1 was discharged from the hospital the same day. No major treatment was done in the ER, and he came back to the facility with CAM boot that were needed to be worn during transfer. The DON stated per therapy recommendations, the resident was changed from sit to stand lift transfer to mechanical lift transfer after the incident. DON indicated as the facility had no other resident on sit to stand lift for transfer, the nurse aides were retrained on mechanical lift transfers. DON stated the following interventions were put in place: X- ray performed when resident complained of pain, based on X-ray results the resident was sent to ER, therapy was referred, and staff educated on mechanical lift transfers to ensure all residents were safely transferred when using a mechanical lift for transfers. Resident #1 was transfers were with mechanical lift and care plan was reviewed to reflect mechanical lift. During an interview on 5/9/24 at 12:30 PM the Administrator stated he was also made aware of the incident and the facility followed all the protocols to ensure the resident was safe. The Administrator stated he reviewed the interventions put in place. The interventions were currently working as there was no further incidence.

Based on record review, resident, staff, Physician, Psychiatric Nurse Practitioner, and Administrator interviews the facility failed to protect a resident's right to be free from employee to resident physical abuse, when an employee (receptionist) threw a plexiglass (acrylic) mask holder hitting Resident #2 on his forehead. The resident had a fall, and a laceration on his forehead. The resident was angry and upset when he was hit by the object thrown by the staff member. Resident #2 was sent to the emergency room and had undergone a procedure for 5 sutures on his forehead. This was for 1 of 2 residents reviewed for abuse (Resident #2). Findings included: Resident #2 was admitted to the facility on [DATE]. Resident #2's cumulative diagnoses included Anxiety Disorder, Bipolar disorder, Mood disorder, and Diabetes Mellitus type 2. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was assessed as cognitively intact and independent with Activities of Daily Living. Resident #2 was assessed as having no observed behaviors during the assessment period. Assessment indicated the resident was ambulatory. Resident #2 received antianxiety and antidepressant medications during the 7 day look back period. Review of Resident #2's care plan, which had a revision date of 1/15/24 revealed the resident was care planned for behaviors related to having verbally abusive behavior related to ineffective coping skills. The resident was also care planned for having inappropriate behavior with female staff. Intervention indicated when Resident #2 becomes agitated: staff to intervene before agitation escalated, guiding the resident away from source of distress, engaging calmly in conversation with the resident. If the resident becomes aggressive, staff had to walk calmly away and approach the resident at a later time. Observation of the lobby on 3/4/24 at 2:45PM revealed the receptionist window was facing the front lobby. The receptionist office door was towards the hallway and could not been seen from the front lobby. There was no mask holder near the receptionist window. An observation of the person working in the receptionist's office revealed she had a table in front of her and was facing the window which was greater than arm's length from the window. The room was large and spacious for the receptionist to stand up and move back safely away from the window. The receptionist's office had a phone and copier machine. There was a clip board with paper and pen on the windowsill for visitors to enter their name. Review of the 24-hour initial report dated 2/25/24 revealed the incident of physical abuse occurred on 2/25/24 at approximately 3:50 PM. Resident #2 had a laceration to his forehead. The employee (receptionist) (accused) was suspended pending investigation. Law enforcement was notified of the incident. Review of the 5-day investigation report dated 2/29/24 revealed the facility was made aware of the incident on 2/25/24 at approximately 3:50 PM. The incident of physical abuse occurred in the front lobby. The allegation details in the summary revealed Resident #2 was rude to the staff (Receptionist) and pushed a plastic mask container towards the staff (Receptionist). The staff (Receptionist) threw the mask container back at Resident #2 resulting in a laceration on the forehead. Law enforcement was notified, and charges related to the incident were filed. The report also indicated the incident was not reported to the County Department of Social Services. The employee was terminated, and the allegation was substantiated. During an interview on 3/4/24 at 10:00 AM, Resident #2 stated on 2/25/24 (Sunday), he wanted some of his medical records to be copied. As the copier at the nurse's station was not working, he had walked to the receptionist to have them copied. Resident #2 further stated the receptionist was not making any effort to make copies for him. Resident #2 indicated he was upset and informed the receptionist that he was going to come inside her office and copy the records himself. Resident #2 stated he had no intentions of making copies himself. However, he proceeded toward the office door which was locked. The resident indicated the receptionist tried to stop him from entering and threw a box used to put masks at him. The box hit his forehead resulting in laceration and bleeding. Resident #2 stated he was sent to the hospital via Emergency Medical Services (EMS) and returned later that night with sutures on his forehead. Review of the receptionist statement dated 2/26/24 revealed Resident #2 approached the receptionist desk rudely around 2:30 PM on 2/25/24. The statement indicated the receptionist purposely ignored the request and chose not to engage with the resident due to the resident's previous history of confrontation/harassment of the staff member. The statement also indicated Resident #2 was aggressive and yelling at the receptionist and tried to open the office door with unknown intentions. When the resident was unable to open the office door, he came back to the receptionist window and threw a plastic object (mask holder) towards the receptionist. The receptionist threw the plastic object back towards the resident without thinking and as an instinct. The box struck the resident resulting in an injury to his forehead. The statement was signed and dated by the receptionist. During a telephone interview on 3/4/24 at 1:19 PM, the receptionist stated she had multiple run-ins (when the resident used inappropriate language at her) with Resident #2 prior to this incident. Resident #2 would be rude and use inappropriate language towards her. She indicated she had reported these run-ins multiple times to the Administrator and her supervisor (Business office Manager). The receptionist stated she avoided all interactions with Resident #2 to prevent any issues. The receptionist stated on 2/25/24 (Sunday), Resident #2 walked up to the receptionist window and asked her to do something for him. The receptionist stated she ignored the resident as there was no one in the front lobby and if there was any interaction between the resident and the employee, there would be no witness to the incident. The receptionist stated the resident tried to enter her office, but she locked the door. The resident later tried to assault her from the window by throwing something (mask holder) at her. The receptionist further stated as an instinct, she threw it back at the resident. Unfortunately, it hit the resident on his head, The receptionist stated she did not intentionally try to harm the resident, but it was a reflex action to protect herself. The receptionist stated she was sent home after the incident and was later informed that she was terminated. The receptionist stated she received abuse/neglect education/training in January 2024. The receptionist stated she was charged by the police for assault on the resident. Review of the investigation details and Plan of Correction folder provided by the Administrator on 3/4/24 revealed a witness statement dated 2/26/24. The statement was written and signed by the Housekeeping Staff #1. The statement indicated Resident #2 was being disrespectful and using inappropriate language toward staff (receptionist). The resident then proceeded to grab the door handle and tried to break into the receptionist's office. The statement indicated the receptionist was ignoring the resident which made Resident #2 upset. Resident #2 was yelling inappropriate (racist) comments at the receptionist. The witness statement explained a container (mask holder) came flying out of the receptionist window and hitting the resident on his head. Both the resident and the receptionist called 911. During as interview on 3/4/24 at 1:58 PM, Housekeeping Staff #1 stated on 2/25/24 between 2:30 - 2:45 PM, he was getting ready to clock out of his shift and was on his way towards the front lobby. Housekeeping staff #1 stated he observed Resident #2 in the hallway. The resident was yelling and using inappropriate language towards the Receptionist. Housekeeping Staff #1 indicated Resident #2 was observed jiggling the door handle of the receptionist office. The receptionist office door was closed, and Resident #2 was unable to open the door. Resident #2 walked back to the receptionist window in the front lobby and had a confrontation with the receptionist. The receptionist was inside her office, behind her desk. The Housekeeping staff #1 stated even before he knew what was happening, he noticed a container (mask holder) flying out of the window and hitting the resident on his head. The resident fell on the floor. Resident #2 got up and started proceeding to the receptionist office. The resident had blood on his forehead. The receptionist was outside her office and out the front door on her cellphone. The resident was also on his cellphone. The Housekeeping staff stated someone had notified the resident's nurse and she had come up front immediately to assess the resident. Resident #2 refused to be assessed by the nurse or get treatment. The Housekeeping Staff stated EMS arrived within minutes of the incident. Resident #2 initially refused to have EMS assess him, but later agreed and was assessed. The resident was taken to the hospital by EMS for further evaluation. The police also arrived at the facility and took a statement from the resident and the receptionist. The Housekeeping staff stated the Administrator, Director of Nursing (DON), and his supervisor were all notified and came to the facility. The Housekeeping staff #1 indicated he was asked to write a statement about the incident. The receptionist was sent home after the incident. Housekeeping Staff #1 was unsure if the receptionist could see him as she was inside her office, and he had just walked from the hallway to the front lobby. Review of the nursing note written by Nurse #1, for Resident #2, dated 2/25/24 at 4:08 PM, revealed, Nurse #1 was called to the front lobby regarding the resident's emergency. The note indicated the nurse had observed blood on Resident #2's forehead. The resident was observed yelling at the receptionist. The note indicated that the resident was refusing to be assessed by the nurse. The Law enforcement and Emergency Medical Services (EMS) were notified. Resident #2 initially refused care from EMS and was yelling at EMS staff. The resident requested his phone, so that he could take pictures of the incident. The resident was given his phone, and he allowed the EMS to assess him. Resident #2 left to the hospital for further evaluation. Review of the Emergency Department Discharge Summary dated 2/25/24 revealed Resident #2 presented to the emergency room for evaluation of head injury with laceration. No significant blood loss. The resident had reported a fall at the facility when one of the nurses threw a plexiglass square box (mask holder) that was used to hold face masks at him. The report indicated the resident had sustained a laceration to the central and left forehead. The resident had also reported that he did fall back onto the ground but denied any injuries from the fall. The resident was ambulatory after the event. The resident was presented with laceration on his forehead. The length of the Laceration was 2 cm {centimeters}. The laceration needed a total of 5 sutures and the resident tolerated the procedure well. The report also read in part per EMS 2 X {times} ~ {about} 1 cm laceration on patient {resident} forehead. Bleeding was controlled by gauze at the time. Resident was alert and oriented and able to stand to stretcher. Resident was discharged back to the facility. Review of a nursing note written by Nurse #8 dated 2/26/24 at 6:04 AM revealed Resident #2 returned to the facility on [DATE] at around 4 :00 AM. The resident was noted to have two reddened areas on the forehead, one with a steri-strip and one with sutures. The note read in part No new orders were noted but resident does have a suture removal follow up and multiple appointments, copies of which were placed in the transportation box. Copy of the suture removal follow up was also made for the wound nurse, unit coordinator and DON {Director of Nursing} so that they are aware that resident needs a follow up in 3-5 days for suture removal. Resident is currently resting in bed; breathing is regular and unlabored. He tolerated his medication with no difficulty. {Medical Director name} was made aware of resident's return to the facility. During an interview on 3/4/24 at 10:30 AM, Nurse #1 stated she worked the first shift (7AM - 3PM) on 2/25/24 and 2/26/24 and was assigned to Resident #2 on both days for the first shift. Nurse #1 indicated on 2/25/24 she was paged on the overhead pager to come to the front lobby due to an emergency. She was not aware what the emergency was. She indicated when she arrived to the front lobby, she observed Resident #2 had blood on his face and was bleeding from the forehead. Nurse #1 stated she had requested the resident to sit down on a chair so that she could assess him, but he refused. Resident #2 was very upset and yelling at the staff (receptionist). She did not recollect what he was yelling, as she was more concerned about calming the resident and putting pressure on the wound. Nurse #1 stated EMS had arrived at the facility within couple of minutes and wanted to assess the resident, which he refused. Nurse #1 stated the resident was bleeding badly and there was blood on the floor, on his face, on his glass and on his shirt. Resident #2 wanted to take pictures of his face (injury), blood on the floor and on his glass. EMS could assess the resident after he had taken these pictures. The resident was sent to the hospital for further evaluation. Nurse #1 indicated the receptionist was outside in the parking lot, in front of the building talking on her cellphone. Nurse #1 stated she received a report from the night shift nurse (11AM - 7PM), that the resident had returned to the facility later that night (early next morning) and was not in any distress. Nurse #1 indicated at the hospital the resident received sutures on his forehead. Nurse #1 stated the resident was at his baseline the next day, did not complain of any pain or distress. She explained Resident #2 was on as needed pain medication and did not request any pain medication. During a telephone interview on 3/7/24 at 3:00 PM, the Physician stated Resident#2 was diagnosed with bipolar disorder and under psychiatric services to control his mood swings. The physician stated he was made aware of the incident and the resident was sent to the emergency room for further evaluation. In the hospital the resident received a few sutures on his forehead. Resident #2 tolerated the procedure well. The Physician stated the resident was assessed after he returned from the hospital. The laceration was not deep, there was no sign of any infection, and the sutures were healing well. During a telephone interview on 3/5/24 at 4:10 PM, the Psychiatric Nurse Practitioner (NP) stated the resident was seen by psychiatric services due to his mood and bipolar disorder. The Psychiatric NP indicated the resident was assessed a few days prior to the incident. The NP stated she had assessed the resident on 3/1/24 after the incident. The resident was able to provide her details of the incident. The resident was in good spirits during the assessment. The NP stated the resident had expressed understanding that it was one staff member's behavior and that it was not a reflection of the facility. The resident did express he felt safe at the facility. NP stated during the assessment the resident was at his baseline, managing well and did not have any residual symptoms from the incident. During an interview on 3/4/24 at 2:50 PM, the Administrator stated the mask holder was removed from the receptionist window after the incident. It was stored in a closed cabinet inside the receptionist's office. The mask holder was measured with the help of the Housekeeping/Maintenance Supervisor. It was approximately 8-inch (Width) X 4.5-inch (Height) X 5.5-inch (Diameter) and weighed approximately between 1 -2 pound (lbs.). The box also had 2 metal hinges approximately 1inch long at the back of the container. During an interview on 3/5/24 at 2:58 PM, Nurse #2 stated she was an agency nurse and was coming to the facility after a break. She indicated it was her first day after the break. She indicated worked the 7 AM to 3 PM (first shift) and was assigned to Resident #2. Nurse #2 indicated she did not receive any abuse/ neglect in-service prior to her shift, nor did she receive any information regarding de-escalation. She stated she was unaware of any incident that occurred in the facility with a resident. Nurse #2 stated she may receive a packet or something after her shift prior to her leaving the facility. The Administrator was interviewed again on 3/4/24 at 4:43 PM and on 3/5/24 at 2:30 PM. The Administrator stated the facility had a zero-tolerance policy of abuse. The Administrator indicated the receptionist was in a safe area, inside her office and the office door was locked. The Administrator stated the receptionist had acted violently, by stating it was in self-defense. The resident was injured by the action of the receptionist. The Administrator further stated the receptionist was terminated from the facility. The Administrator indicated the receptionist had on 1-2 occasions reported to him about Resident #2's hostile nature but nothing abusive towards her. The Administrator further indicated that it was just a statement made by receptionist and nothing indicating any appropriate behavior from Resident #2 towards the receptionist that needed to be addressed. The Administrator indicated all employees had to deal with some hostile residents and it was a part of the job. The Administrator stated he did not think this was a staff burnout issue and no interventions were implemented. The Administrator stated after the incident all facility staff were provided with educational information on Tips and strategies for de-escalating, aggressive, hostile or violent patient. All staff were also in serviced on abuse by the Unit Manager. The Administrator indicated he interviewed all residents with a BIMS (Brief Interview Mental Status) greater than 13 for any form of abuse by the receptionist (accused staff) or any other staff in the facility. Skin assessment for all residents with BIMS less than 13, and who were unable to be interviewed were performed by the Director of Nursing (DON) and Unit Manager. The Administrator stated the monitoring process consisted of 5 residents with BIMS greater than 13 interviewed weekly for 4 weeks and then 10 residents interviewed per month for 2 months. The DON and unit manager would perform 5 skin assessments per week on 5 residents with BIMS less than 13 for 4 weeks and then10 resident's skin assessment would be performed per month for 2 months. The administrator indicated follow up interviews regarding abuse and de-escalation would be conducted with the staff members. 5 staff members would be interviewed weekly for 4 weeks and later 10 staff members would be interviewed monthly for 2 months. The Administrator indicated the facility had provided an educational packet regarding abuse/ neglect and de-escalation to the contract staffing agency to ensure agency staff were also trained. The Administrator was, however, unable to state how the facility was ensuring that all agency staff were trained prior to their shifts in the facility. The Administrator stated any issues with the monitoring process would be addressed immediately. The finding of the monitoring process would be reported to the Quality Assurance and Performance Improvement Committee for any additional monitoring or any modification. The Administrator indicated he expected all residents to be free from abuse and neglect and free from any retaliation. The Administrator indicated that the abuse allegation was substantiated.

Based on staff interviews and record review, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions put into place by the Committee after each of the following surveys with citations that were recited on the current complaint survey of 3/6/24: 1) A complaint investigation survey of 1/14/22. This was evident for one recited deficiency in the area of Freedom from Abuse and Neglect (F600). 2) The annual recertification / complaint investigation survey of 8/18/22. This was for one recited deficiency in the area of Request / Refuse / Discontinue Treatment; Formulate Advance Directives (F578). 3) A complaint investigation survey of 3/16/23. This was evident for recited deficiency in the area of Reporting Alleged Violations (F609). 4) A follow-up, focused infection control, and complaint investigation survey of 4/13/23. This was also for one recited deficiency in the area of Reporting Alleged Violations (F609). 5) The annual recertification / complaint investigation survey of 9/14/23. This was for one recited deficiency in the area of Request / Refuse / Discontinue Treatment; Formulate Advance Directive (F578). The continued failure of the facility during six federal surveys of record show a pattern of the facility's inability to sustain an effective QAA Program. The findings included: This tag is cross referenced to: F578: Based on record review and staff interviews, the facility failed to ensure advanced directive information was up to date in the resident's electronic medical record for 1 of 1 resident (Resident #8) reviewed for advanced directives. During the recertification / complaint investigation survey of 8/18/22, the facility was cited for failing to determine code status on admission for 1 of 5 residents reviewed for advance directives. During the recertification / complaint investigation survey of 9/14/23, the facility was also cited for failing to have Advance Directives (code status) in the residents' records for 1 of 1 resident reviewed for Advance Directives. F600: Based on record review, resident, staff, Physician, Psychiatric Nurse Practitioner, and Administrator interviews the facility failed to protect a resident's right to be free from employee to resident physical abuse, when an employee (receptionist) threw a plexiglass (acrylic) mask holder hitting Resident #2 on his forehead. The resident had a fall, and a laceration on his forehead. The resident was angry and upset when he was hit by the object thrown by the staff member. Resident #2 was sent to the emergency room and had undergone a procedure for 5 sutures on his forehead. This was for 1 of 2 residents reviewed for abuse (Resident #2). During the complaint investigation survey of 1/14/22, the facility was cited for neglecting to monitor, assess and identify a resident's skin that was irritated and bleeding behind the ears from a surgical face mask strap that resulted in a partial thickness injury of one ear and a full thickness injury and partial amputation of the other ear for 1 of 2 sampled residents reviewed for injury. F609: Based on record review and staff interview the facility failed to report an abuse allegation to Adult Protective Services (APS), failed to immediately report an allegation of abuse to the facility administration and failed to report an abuse allegation to the state survey agency for 2 of 2 residents reviewed for abuse (Resident #2 and Resident #5). During the complaint investigation survey of 3/16/23, the facility was cited for failure to report an allegation of abuse to the State Agency within two hours of becoming aware of the allegation for 1 of 2 allegations of abuse reviewed. During the follow-up / focused infection control, and complaint investigation survey of 4/13/23, the facility was also cited for failure to report an allegation that a resident's financial information from a debit card was used fraudulently due to suspicious charges to the account by failing to submit a 24 hour and 5 day report within the required time frame to the State Agency of North Carolina for 1 of 1 resident reviewed for abuse. An interview was conducted on 3/6/24 at 3:18 PM with the facility's Administrator to discuss the facility's Quality Assurance and Performance Improvement (QAPI)/QAA Improvement Activities. The Administrator reported the QAA Committee included himself, the Medical Director, Director of Nursing (DON), Unit Manager, Therapy Director, Maintenance Director, Dietary Manager, and Social Worker. The committee was scheduled to meet at least quarterly. However, the Administrator noted the committee typically meets about once a month (with the last ad hoc committee meeting held on 2/26/24). When asked how the committee decided on which opportunities they would become involved in, the Administrator stated that they would review open citations and any type of quality measure where the facility did not obtain their desired goal. When asked how repeat citations were handled, the Administrator reported the QAA Committee would typically do a root cause analysis for these opportunities, pull out the facility's old plan of correction (POC) to see what had been done in the past, develop a new POC, and then adjust the new POC as needed.

Based on record review and resident, family, staff and Detective interviews, the facility failed to prevent misappropriation of Resident #2's property by Housekeeper #1. Housekeeper #1 used Resident #2's personal debit card account without the resident's consent for multiple personal purchases and cash apps (mobile financial transfers) was reported to be totaling over $1,000.00. This financial loss caused the resident to feel angry and resulted in a loss of independence for the resident as her family removed the debit card from her possession to avoid any further incidents. This deficient practice was for 1 of 1 (Resident #2) reviewed for misappropriation of property. The findings included: Resident #2 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #2 had moderate cognitive impairment. A statement written by the Director of Nursing (DON) on 3/10/23 included the following information: On 3/10/23, the Director of Nursing (DON) and Administrator had a conversation with Resident #2's daughter, regarding money transactions on Resident #2's debit card account that did not make sense. The daughter was upset regarding the missing money. The Administrator advised the daughter the police would be notified. Later in the evening the daughter called the DON and informed him an investigation had been opened and a Detective was in charge of the investigation. A review of the police report written by the Detective on 3/10/23 revealed an itemized list of charges, purchases, and money transfers reported by Resident #2's daughter. The police report listed in the property description as: one debit card, twenty-three pending inventory property and one money in the amount of $642. Review was conducted of emails and bank statements for February 2023 and March 2023 submitted by Resident #2's daughter to the police department on 3/15/23. The transactions occurred between 3/3/23-3/10/23. The documents revealed charges and purchases that included a local furniture store, cellular store, fast food restaurants, delivery food services, a hotel, an internet travel site, ride shares, cash app transactions, and a cable/cellular provider were being investigated by the police department. The identity of Housekeeper #1 was determined by the purchases. An interview was conducted on 4/11/23 at 10:36 AM. Resident #2 stated she used her debit card to make specific food purchases to her favorite food spots. Housekeeper #1 offered to help her make the food purchase at one of her favorite places 3/3/23. Housekeeper #1 took her debit card information from the debit card and brought the food. She explained her daughter called her very upset, she could not recall the day, about charges on the bank statement that were not her usual purchases. She further explained, her daughter told her about the charges that were made to furniture stores, cash apps and places of which she had not heard. Resident #2 further stated I was very angry and mad as h .ll. The resident stated her daughter removed the debit card from her in fear the staff would do this again and it was not fair that she could not make her preferred food purchases because a staff stole her information. A telephone interview was conducted on 4/11/23 at 9:48 AM with Resident #2's daughter who stated she was extremely upset, angry and frustrated that the facility did not protect Resident #2's personal money from an employee. The daughter stated she reviewed her mother's bank statement for February 2023 and March 2023, and she noticed large sums of money being taken from the account between the end of February 2023 and the first week of March. The daughter further stated the withdrawals and purchases did not make sense since Resident #2 was unable to make those types of purchases from the facility. She explained the purchases included local furniture store, cellular store, fast food restaurants, delivery food services, a hotel, an internet travel site, ride shares, cash app transactions, and a cable/cellular provider. The daughter indicated she had spoken with the police department who helped identify the staff as Housekeeper #1. Resident #2's daughter stated the total amount of money missing from the resident's account was reported to be in the amount of $1,000 or more. The daughter reported Housekeeper #1 confessed to the police department she had taken the account information from Resident #2's debit card. An attempt to interview the Housekeeper #1 on 4/11/23 at 10:00 AM via the telephone was made and the number provided by the facility was disconnected. An interview was conducted on 4/12/23 at 1:41 PM with the Detective who stated he received a call on 3/10/23 from Resident #2's daughter who was very upset/frustrated the facility may have allowed an employee to make charges on her mother's debit account. The daughter stated she had contacted the facility because she was concerned about the unexplained charges that occurred on her mother's account. The Officer stated he had spoken with the daughter numerous times to obtain copies of bank statements/account information and it was discovered the individual was a former employee, Housekeeper #1. He stated once he saw the name of the alleged staff, he was familiar with the individual and contacted the former employee for questioning. Housekeeper #1 was interviewed on 3/16/23 and she admitted and confessed to making the unauthorized charges on Resident #2's debit account while she was an employee at the facility and after. Housekeeper #1 stated the resident had given her the card to purchase a pizza for her. Housekeeper #1 stated she had forgotten that she had linked the card information to her phone. Housekeeper #1 did not have the physical debit card, but had a screen shot the information on her telephone. After further questioning about the continuation of charges to locations associated to her personal life/events (i.e., paying personal bills, cash app family). Housekeeper #1 was charged with fraudulently obtaining property and identity theft. An interview was conducted on 4/11/23 at 11:00 AM, the Director of Nursing (DON), stated an in-service was done with staff on the abuse policy which included misappropriation of property on 3/16/23 and 10 residents were interviewed by the administrator who asked if anyone had taken any personal belongings or items without consent. There was no other action taken after the in-service and resident interviews. The DON further stated systemic changes would occur to include the protection of resident's personal property of debit card and financial information. An interview was conducted on 4/11/23 at 11:20 AM, the Administrator stated an in-service was done with staff on the abuse policy which included misappropriation of property on 3/16/23 and 10 residents' interviews were done on 3/20/23. He further stated revisions to the current abuse policy and financial record maintenance system would be developed and monitored to prevent a reoccurrence.

Based on record review, staff, Nurse Practitioner (NP) and facility and hospital Physician's interviews, the facility neglected to monitor, assess and identify a resident's skin that was irritated and bleeding behind the ears from a surgical face mask strap that resulted in a partial thickness injury of one ear and a full thickness injury and partial amputation of the other ear for 1 of 2 sampled residents reviewed for injury (Resident #1). Immediate Jeopardy began on 12/10/21 when the NP and staff observed surgical face mask elastic over the resident's ears with debris present, hair stuck, scabbing and redness. This observation was followed by inaccurate assessments, continued use of the same mask, poor hygiene and poor communication about the area. It resulted in skin injury and partial amputation of the ear. Immediate Jeopardy was removed on 1/9/22 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (not actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service training. The findings included: Resident #1 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Area Assessment for behavioral symptoms for the Annual Minimum Data Set (MDS) assessment dated [DATE] noted the resident was resistant to care and combative with staff. This was related to poor judgement, impaired thinking and memory problems. The resident's confusion often leads to his refusals of care. His behaviors are deliberate in that he is refusing to comply. He hits and kicks at staff when they are providing care. The care plan considerations were to avoid complications and to minimize risks. The most recent Minimum Data Set (MDS) Assessment (Quarterly) dated 10/9/21 revealed the resident had severe cognitive impairment and had no behaviors. The MDS noted the resident required limited assistance with activities of daily living (ADLs) with the exception that he required total assistance with bathing. The MDS noted the resident was not steady during transitions and only able to stabilize with staff assistance, had no impairment in range of motion of the upper extremities and used a wheelchair for mobility. The care plan for Resident #1 last reviewed on 11/23/21 revealed the resident had the potential to demonstrate verbally abusive and physical behaviors due to poor impulse control. The intervention was to monitor the resident for behaviors. The care plan noted the resident was resistive to care related to dementia and refused baths, showers and vital signs. The intervention was if the resident resisted ADL care, reassure the resident and leave and return 5-10 minutes later and try again. Review of the progress notes for Resident #1 from 10/1/2021 to 12/29/21 revealed no documentation the resident had refused to remove the face mask or any concerns with skin issues behind the ears related to the face mask. There was no documentation the resident refused weekly skin assessments. NA #2 stated in an interview on 1/6/22 at 11:59 AM that approximately one month ago she reported several times to the nurse that the back of the resident's ears was bleeding, and the mask strap was stuck, and Nurse #1 came to the room to look at the resident's ears and his hair was stuck to the strap and the NP came to the shower room to look at his ears and his hair was stuck to the strap and the NP cut off the mask. The NA further stated there were scabs and dried blood. The NA stated she washed behind the resident's ears but was unable to remove all the dried blood because it was painful to the resident and he was combative. The NA stated the NP did not give her any instructions regarding the face mask. The NA stated since that time the area was scabbed over, but she did not see any active bleeding. The NA stated the resident continued to wear the same type of face mask. On 1/6/22 at 11:05 AM, NA #1 stated in an interview the resident was often combative with care and if she spoke calmly to the resident and explained what she needed to do and why, sometimes he would allow her to shower or bathe him and other times he would refuse. The NA stated approximately 2 weeks ago she had to cut off the face mask and the top of his ears were painful with irritation and bleeding from the ear and his hair was tangled up and she had to cut it off. The NA stated she told Nurse #1 about the problem and she went in the room to look at his ears. The NA stated the resident would wear the mask all the time even when he went to sleep, and she and the Nurse told him to take off the mask when he went to bed or was in his room. Weekly Skin Assessment forms dated 12/03/21 and 12/10/21 and signed by Nurse #1 read: Skin intact. No wounds. The Nurse Practitioner saw Resident #1 on 12/10/21 at the request of Nurse #1 and NA #2. He was in the shower and the staff had concerns about his ears. The NP did not document a note after the 12/10/21 observation. The NP documented a note about the 12/10/21 observation on 12/17/21. The note indicated the patient was initially noncompliant and resistant to examination. Patient denies any ear complaints or needs. With the assistance of the NA noted above each ear the patient with long hair sticking above the ear with the mask ties hold over the ears with debris present. Initially with concern of scab, but upon cutting the resident's hair sticking to the area and removing the debris, noted mild skin redness, skin intact, no open wound. Recommended skin care and the use of a different mask that had ties that loop around the head instead of above the ears. Discussed with the CNA and patient's nurse. There was not a nurse's note documented on 12/10/21 regarding the observations made in the shower. Review of a physician's note dated 12/14/21 revealed the resident was seen by the physician but there were no notes regarding an issue with the resident's ears or the face mask. The 12/17/21 NP note continued with On reassessment, patient with recurrent debris over the ears, no open wound, minimal redness, no drainage. The resident refused to allow touch to the ears, refused examination. With ongoing noncompliance with personal care or hygiene. Discussed with staff, recommended as before to provide skin care, wash the area, avoid a mask that had ties that loop over the ears. On 1/6/21 at 11:00 AM, an interview was conducted with the Nurse Practitioner (NP) that worked with the resident. The NP stated that weeks before the resident went to the hospital, he saw the resident while in the shower and upon assessment the resident had dirt in his hair above the ears and the hair was cut and the dirt came off with the hair. The NP further stated there was some mild redness and the skin was intact. The NP stated he told NA #2 and Nurse #1 to change the mask to one where the straps went around the head instead and to provide good skin care behind the ears. The NP stated he did not write orders for this. On 1/14/22 at 8:40 AM the Nurse Practitioner stated in an interview that he was asked to go in and look at a resident in the shower (12/10/21) and saw a hygiene issue and not a medical issue, so he did not document his observations. A Weekly Skin Assessment form dated 12/17/21 and signed by Nurse #1 read: Skin intact. No wounds. On 1/7/21 at 10:30 AM an interview was conducted with Nurse #1 regarding the skin assessments she signed for 12/03/21, 12/10/21 and 12/17/21 where she documented the skin was intact and there were no wounds. The Nurse initially stated the resident would not allow her to do the skin assessments. The nurse was asked if she ever documented the resident refused the assessments and the Nurse stated: No. The Nurse further stated the NAs would let her know if the resident had any skin issues. The Nurse later retracted her statement (1/7/22 at 10:45 AM) and stated she did not remember whether she was able to do the skin assessments for 12/03/21, 12/10/21 or 12/17/21 or not. A Weekly Skin assessment dated [DATE] and signed by Nurse #1 read: Skin intact. No wounds. An interview was conducted with Nurse #1 on 1/6/22 at 10:37 AM. The Nurse stated Resident #1 was frail, uncooperative and would curse at the staff. The Nurse further stated the resident did not like to bathe or shower, wash behind his ears or wash his hair and would kick at the staff. The Nurse stated if the face mask was not on his face it was pulled down below his chin. The Nurse stated the resident was able to remove the face mask himself. On 1/6/22 at 12:15 PM Nurse #1 stated in an interview that she did not recall the NP giving her any instructions regarding putting a different kind of face mask on the resident or any specific instructions regarding skin care. The Nurse further stated the mask the resident was wearing was the only kind of mask they had in the facility. The Nurse stated even if the NP had given any orders for skin care the resident would not have allowed it to be done. The Nurse was asked about the skin assessment she signed on 12/24/21 that stated Skin intact. No wounds and the Nurse stated the resident would not remove his clothing and would not let her look at his ears. On 1/6/22 at 11:19 AM Nurse #1 stated in an interview that the resident did not want to take off the mask because if was painful and he would fight the staff. The Nurse further stated his ears were red with brown material behind his ears. The Nurse stated the NP was aware and the NP cleaned his ears when in the shower about one month ago. The Nurse stated she had not heard anything about his ears since that time. The Director of Nursing (DON) stated in an interview on 1/6/22 at 12:45 PM that the resident was noncompliant with taking off the mask. The DON further stated on one occasion she noticed the mask was visibly soiled, but he refused to take it off and put on a clean one. On 1/6/21 at 12:52 PM the Administrator stated she was not aware the resident had any skin breakdown from the mask. The Administrator further stated on one occasion (unable to recall the date) she could see the mask was visibly soiled and he would refuse to take it off and the resident was observed to jerk and pull on the mask. The Administrator stated she told the Unit Coordinator to take a look at it. On 1/6/21 at 12:58 PM an interview was conducted with the Unit Coordinator who stated she was not aware of any skin breakdown or bleeding behind the resident's ears. The Unit Coordinator stated one day (maybe the day before he went out to the hospital but not sure) she was discussing the face mask with the NP and asked him about getting a scarf for the resident to wear instead of the surgical mask and the NP told her that would be fine. The Unit Coordinator stated she purchased the scarf the same day and when she gave it to the resident, he threw it on the floor and would not wear it. The Unit Coordinator further stated the resident liked to wear a hat and they asked him about sewing 2 buttons on the hat to loop the ear straps to and the resident refused to let them do this. The Unit Coordinator stated on one occasion (could not recall the date) the wound doctor was in the building and she asked him to look at the resident's ears and the resident refused and would not allow him to examine his ears. The Unit Coordinator stated the resident was only required to wear the face mask when he was out of his room but at some point, he had become attached to the mask and did not want to take it off. On 1/6/21 at 4:50 PM an interview was conducted with the DON and the Administrator who stated the resident was his own Responsible Party and a family member was his emergency contact, and they would call her in an emergency. On 1/6/21 at 5:25 PM an interview was conducted with the Nurse Practitioner (NP) who stated he had multiple discussions with the family member listed as the resident's emergency contact regarding his refusal of personal care and the health issues it could cause. The NP further stated he talked with her about the resident's aggressive behaviors toward staff and the NP stated the family member told him she had tried to talk to him before regarding his behaviors but was not successful. The NP was unable to provide documentation of these conversations. An interview was conducted with the Nurse Practitioner, the Unit Coordinator and NA #2 on 1/12/22 at 11:30 AM. The Unit Coordinator stated on the same day the Nurse Practitioner recommended a different type of mask she offered the resident a mask that tied in the back of the head, but he refused. NA #2 stated on the day the Nurse Practitioner recommended a different mask, she also offered him the mask that tied in the back of the head and he refused the mask. The NA further stated the next day she offered the resident a mask that tied behind the head and he refused. On 1/10/22 at 3:58 PM the Director of Nursing (DON) stated in an interview that if a resident refused a skin assessment, the nurse should wait 5-10 minutes and try again. The DON further stated if the resident still refused, the nurse should document the refusal, notify the DON, the physician and the resident's contact about the refusal. On 1/10/22 at 4:55 PM an interview was conducted with the physician who cared for Resident #1 in the facility. The Physician stated the resident was very difficult, frequently refused care and his hygiene was not the greatest. The Physician further stated even when he tried to auscultate his chest the resident would swing at him. The Physician stated he did not have the resident's notes to review with him but unless the resident complained of something or the staff told him about an issue, he would probably not know about it. The Physician stated that skin issues can develop from wearing a face mask in 2-3 days. On 12/29/21 at 6:06 AM a progress note written by Nurse #2 revealed Resident #1 had an altered mental status, a fever and was sent to the hospital for further evaluation. On 1/6/21 at 3:00 PM an interview was conducted with NA #3 who was working on the 11 PM to 7 AM night shift on 12/28-29/21. The NA stated he heard a commotion and went in the resident's room between 12-1:00 AM and the resident was jerking and struggling to breathe, and EMS (Emergency Medical Services) was called. The NA stated EMS told him the resident's mask was caught on his ear. The NA further stated he had not seen any problems with the resident's ear and no blood on his pillow. On 1/6/22 at 2:55 PM an interview was conducted with Nurse #2 who was working when Resident #1 sent out to the hospital on 12/29/21. The Nurse stated the NA told her the resident was not acting like himself and was breathing different and she assessed him and his vital signs were off (could not remember how they were off) and EMS was called. The nurse was not able to provide any information regarding a problem with the resident's ears. An attempt was made to interview the EMS staff that responded to the facility on [DATE]. EMS provided a written statement on 1/10/22 at 8:49 AM that revealed on their arrival to the room of Resident #1, the mask ear loop had lacerated his left ear almost middle way. The right loop of the mask had begun to grow into the ear and had a scab on top of it. On 12/29/21 the Emergency Department Physician documented that the physical exam was remarkable for a mask strap eroding into the left ear with approximately half of the ear displaced from his head. This does not appear to be an acute change given minor bleeding as well as some granulation tissue that has already begun to form. The face mask was removed, and a full thickness wound noted to the left ear with cartilage visible. A skin assessment, signed by a hospital Registered Nurse, dated 12/29/21 noted the following: Right outer ear, partial thickness wound. Left outer ear, full thickness pressure injury with visible cartilage. Left outer ear partially amputated. On 1/11/22 at 10:00 AM an interview was conducted with a physician that attended to Resident #1 in the hospital. The Physician stated the resident had a pressure injury between both ears and the skull from the ear loop mask that was 1/2 inch to 1 inch deep. The Physician stated it would take days to weeks for the ear loop mask to cause this type of injury. The Physician further stated at this point the only treatment would be to leave off the mask and provide wound care. At this time of this interview, Resident #1 remained in the hospital. The administrator was identified of the immediate jeopardy on 1/7/22 at 12:20 PM. The facility provided a credible allegation of Immediate Jeopardy Removal that indicated: Credible Allegation of Immediate Jeopardy Removal: The facility alleges Immediate Jeopardy removal on 1/9/22. The facility failed to monitor, assess and identify skin that was irritated behind the ears from a surgical face mask that resulted in a partial thickness injury of one ear and full thickness injury of the other ear for Resident #1. Resident #1 exhibits behaviors of refusing care and assessment by facility staff. Resident #1 refused to remove surgical mask and refused personal care. Resident #1 developed opened areas to bilateral ears related to extended wear of surgical mask and refusal of care. Nurse #1 documented in the residents' medical record that a weekly skin check was completed on 12/3/21, 12/10/21, 12/17/21, skin was noted to be intact on all assessments. The Nurse Practitioner stated in his note on 12/17/21 that this was a follow-up visit from initial visit on 12/10/21 when patient was seen with patients nurse and CNA at staff request while patient was in shower room . Resident #1 was showered on 12/10/21 by NA #2. She reported to Nurse #1 and NP (during shower) that she thought Resident #1 had scabs and dried blood behind his ears. The Nurse Practitioner assessed Resident #1 ears in the shower with Nurse #1 and Nursing Assistant #2 present. Resident #1 was initially non-compliant and resistant to examination, with assistance from Nursing Assistant #2 Nurse Practitioner was able to assess the resident's ears he noted that Resident #1 had long hair sticking above the ear with the mask ties hold over the ears with debris present. The NP states initial concern was for a scab, but upon cutting Resident #1 hair sticking to the area and removing the debris Resident #1 had mild skin redness, skin intact, no open wound. The NP recommended to provide skin care, wash area, avoid mask that has ties that loop over the ears. The Unit Coordinator stated that she provided alternative scarf mask for resident #1 that would not cause pressure behind the ears she was (unable to recall the date). Resident #1 refused the alternative scarf mask and threw it on the floor when facility staff attempted to implement its use. Resident preference was to wear a standard surgical mask with ear straps. His preference was to wear a standard surgical mask with ear straps. Resident was seen by the Physician on 12/14/21 he did not note any skin concerns. Nurse #1 failed to accurately document Resident #1's refusals of weekly skin assessment on 12/24/21. Nurse #1 failed to notify the physician, NP, and emergency contact of resident refusal of weekly skin assessments on 12/24/21. The Nurse Practitioner stated on 1/6/22 that he had spoken with Resident #1 emergency contact on multiple occasions regarding his refusal of care, aggressive behaviors and health issues that could arise from refusal of care and behaviors (the facility is unable to determine the exact date). The Nurse Practitioner further stated that Resident #1's emergency contact stated that she had attempted to speak with Resident #1 related to his behaviors and refusal of care however it did not have an impact on Resident #1 and there was no change in his behaviors (the discussion was not documented into the medical record). On 12/29/21 at 6:06 AM Resident #1 was not responding to verbal commands, he had an elevated temperature and respirations. Resident #1 was sent to the hospital for further evaluation. Upon assessment in the emergency department it was noted that Resident #1 had wounds to bilateral ears. Residents who refuse weekly skin assessment have the potential to be affected. The Nursing Supervisor and Unit Coordinator interviewed direct care staff on 1/7/22 and 1/8/22 to determine if any other residents have refused to change their face mask or refused to have skin assessed, no other residents were identified. The license nurses have been instructed to notify Physician, Nurse Practitioner, and Responsible Party of refusal of weekly skin check, documentation of refusal will be reflected in the resident's medical record. The Staff Development Coordinator and/or Director of Nursing began in servicing on 1/7/2022 of all licensed nurses regarding the process for completing and documenting weekly skin assessments. Education to include notification of the Physician and/or Nurse Practitioner and responsible party for resident refusals of weekly skin assessments. The Staff Development Coordinator and/or Director of Nursing will validate competency of licensed nurses by return demonstration of licensed nurse performance of head to toe skin assessment and documentation of assessment. In-service education and competency validation will be completed prior to next scheduled shift. On 1/7/22 in-service education by the Staff Development Coordinator and/or Director of Nursing began for certified nursing assistants and agency staff. Education to include the use of surgical masks and replacement of masks when soiled, notification to nurse of resident refusals of care including removal of surgical masks and notification to nurse for alterations in the resident's skin integrity. In-service education will be completed prior to next scheduled shift. On 1/7/22 in-service education by Staff Development Coordinator and/or Director of Nursing began for all staff including agency staff, to include the use of surgical masks and replacement of masks when soiled. The direct care staff was instructed to report to the nurse any concerns related to mask use to include alterations in skin integrity and refusals by resident to wear mask appropriately. In-service education will be completed prior to next scheduled shift. On 1/7/22 the Director of Nursing and Facility Administrator reviewed with Nurse Practitioner the expectation of initiation of orders for all required changes in resident's plan of care. The IDT team including the Medical Director met on 1/7/22 and formulated the credible allegation and removal plan for immediate jeopardy. The Director of Nurses and Administrator is responsible for overall compliance. The facility's credible allegation of Immediate Jeopardy was validated on 1/12/22 from 1:00 PM to 2:00 PM where multiple interviews were conducted with the nursing assistants working in the facility were aware if they observed any new skin problems to report them to the nurse and/or the Unit Coordinator, the Director of Nursing or the Administrator. Interviews with the nurses revealed all changes in skin condition were to be documented on a skin assessment form, the provider, Unit Coordinator and the family contact was to be notified. The Nurses were also aware if a resident refused a skin assessment to document this in the medical record and report to the medical provider, the Director of Nursing and the family contact. In-service information and staff sign in sheets were reviewed and found to be complete. Return demonstration of skin assessments were reviewed with no concerns. The facility's Credible Allegation of Immediate Jeopardy removal was validated, and Immediate Jeopardy was removed on 1/9/22.

Based on observation, record review, staff interview, and Nurse Practitioner interview, the facility failed to supervise a cognitively impaired resident with known exit seeking behaviors to prevent the resident from exiting the facility while unsupervised for 1 of 3 residents reviewed for accidents. (Resident #1). Resident #1 exited the facility while unsupervised and fell from a loading dock attached to the facility. The resident was found outside on the ground by staff and was transported to the hospital for evaluation. Resident #1 was diagnosed with [REDACTED]. Immediate Jeopardy (IJ) began on 10/9/20, when Resident #1 while unsupervised by staff, exited the facility through an emergency exit to the loading dock outside the building and fell off the loading dock from a height of 4 to 5 feet, landing on her face. She sustained facial laceration, facial bones fracture, head, left hip trauma, and hospitalization . The Immediate Jeopardy was removed on 10/22/20 when the facility provided and implemented an acceptable credible allegation of IJ removal. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete staff training and ensure that monitoring systems put into place are effective to prevent accidents. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses, including metastatic [MEDICAL CONDITIONS], diabetes mellitus, and a history of stroke. The fall risk assessment, dated 7/6/20, revealed that Resident #1 was at high risk for falls due to history of falls, poor balance, psychoactive drug use and unsteady gait. The resident ' s Quarterly Minimum Data Set assessment, dated 7/7/20, revealed she was severely cognitively impaired, required extensive assistance by one-person physical assistance for activities of daily living (ADL), including walking in the room and corridor. She was frequently incontinent for bowel and bladder, known for verbal behavior toward others, exhibited wandering behavior one to three times per week, received antipsychotics, antianxiety and antidepressant medications. Resident 1 ' s plan of care, dated 8/4/20, indicated she was at risk for falls, related to declining in the ability to ambulate, history of falls, unsteady gait, impaired cognition, decreased safety awareness, and impaired visual function. Resident #1 was at risk of elopement and exit seeking behavior. The interventions included fall risk assessment, mats to bedside, ambulation with assistance only, distract resident from wandering with structured activities, and wanderguard placement. The Kardex, dated 9/21/20, for Resident #1 revealed that she required assistance with ambulation, to check placement/function of the wanderguard on her right ankle every shift, and distraction from wandering. The care tracker for October 2020 revealed that on 10/8/20, Resident #1 was independent (no help or staff oversight at any time) for walking in the corridor on second and third shifts. A nurses ' notes dated 10/9/20 at 7:04 AM, and written by Nurse #1, revealed that Resident #1 got out of building side door around midnight, fell off the dock porch to the ground and sustained 2 inch laceration above the left eye. She was sent to the hospital. The DON, ADON, Health Service provider, and family were notified at 12:30 AM. The exit door alarm was not heard by the staff through the building among the simultaneously sounding loudly bed alarms on the same hallway. A nurses ' notes, dated 10/9/20 at 6:28 AM, revealed that Nurse #2 came to help Nurse #1 with Resident #1, who fell outside of the facility. Nurse #1 was not aware of how Resident #1 went outside. She conducted an assessment and checked vital signs, which were within normal limits. Resident #1 had a 2 inch gash over her left eye and facial swelling. The treatment was provided in a timely manner and Resident #1 was transported to ER via EMS. An incident report revealed that on 10/9/20 at 12:00 AM, Resident #1 was found outside of the facility on the ground. She fell off the loading dock and injured her left eye with 2 inch laceration. The immediate actions were to call Emergency Medical Service (EMS), conduct assessment, including vital signs, notify the Director of Nursing DON), Assistant Director of Nursing, Health Service provider, and family. Resident #1 was confused but oriented in person. She was ambulating without assistance. There were no witnesses to the incident. A written statement, provided by Nurse #1, revealed that on 10/9/20 at 12:00 AM, he walked toward the zone 3 nurses ' station, and noticed the door alarm sound. The exit door was closed. Nurse #1 opened the door, did not see anybody on the loading dock, came back to the hallway, and checked Resident #1 in her room, because of her known exit seeking behavior. The resident was not in her room. At 12:05 AM, Nurse #1 went back to the loading dock and discovered Resident #1 laying on the ground on her back. She was breathing, alert, talking, moving her legs, and bleeding from the left side face laceration. Nurse #1 notified Nurse #2, received help with further assessment, called EMS, the Health Service provider, and the supervisor. At 12:30 AM, the EMS took Resident #1 to the hospital. On 10/21/20 at 11:10 AM, during a phone interview, Nurse #1 indicated that on 10/8/20 at 11:45 PM, he was working with the schedule at the back nurses ' station. At midnight, Nurse #1 observed Resident #1 in bed in her room. On the way back to zone 3 nurses ' station (Nurse #1 was unsure of the exact time), he heard the door alarm sound. Nurse #1 went to the side door, opened it, and looked outside the door to the loading dock, attached to the facility. On the dark loading dock, he did not see anybody and came back inside. Nurse #1 checked Resident #1 ' s room, because she was known for exit seeking behavior and her room was near the zone 3 nurses ' station. Resident #1 was not present in her room. Nurse #1 called Nurse #2 for help. Both nurses went back to the loading dock and found Resident #1 on the ground near the loading dock. Resident #1 was alert, could talk, move her extremities but could not explain how she fell . She had a small bleeding laceration above her left eye. Nurse #1 with Nurse #2 assessed the resident and checked the resident ' s vital signs, which were within normal limits. The staff called EMS, notified the DON, the physician on call, and the family. The EMS arrived in 5-10 minutes, assessed the resident, and took her to the ER. Nurse #1 mentioned that he did not observe Nurse Aide #1, assigned for Resident #1, near the zone 3 nurses ' station at the time of the incident. On 10/21/20 at 3:40 PM, during an interview, Nurse #2 indicated that on 10/9/20 at 12:10 AM, she worked on another nurses ' station. Among multiple intravenous and tube feeding pump alarms on the hallway she heard the door alarm sound from another hallway. Nurse #2 could not recall the exact time of the alarm activation on zone 3 exit door. She walked to the zone 3 nurses ' station area and observe Nurse #1 opened the side door to the loading dock. Nurse #2 was holding the side door when Nurse #1 told her he found Resident #1 outside on the ground near the loading dock. Nurse #2 came outside to loading dock and assessed Resident #1 together with Nurse #1. Upon assessment, Resident #1 was alert, had a small laceration on her left eye area, with normal vital signs and no other visible injury. Nurse #2 remained with the resident while the staff called EMS, the physician on call, supervisor, and family. The EMS arrived within a few minutes, assessed the resident, and took her to the hospital. On 10/21/20 at 12:20 PM, during the phone interview, Nurse Aide #1 indicted she was assigned for Resident #1 on the third shift of 10/8/20. Resident #1 showed wandering behavior, walked independently on the hallway and the staff often redirected her to her room. She had wanderguard on her ankle, which should initiate the door alarm, every time Resident #1 comes close to any exit door. At the beginning of the third shift, Nurse Aide #1 observed Resident #1 in her room in the bed. The resident did not attempt to leave her room. After midnight, Nurse Aide #1 was in another resident ' s room on the hallway, providing care. She could not hear the side door alarm from the hallway, because of the sounding bed alarm in the resident ' s room. Nurse Aide #1 did not observe how Resident #1 opened the side door and left the facility. By the time Nurse Aide #1 came to the zone 3 nurses ' station, the staff already found Resident #1. Nurse Aide #1 continued that she did not receive report from the second shift about Resident 1 ' s exit seeking activity. The EMS report revealed that the 911 call from the facility was received on 10/9/20 at 12:52 AM. The EMS team arrived at the facility at 1:08 AM. Upon assessment, Resident #1 was alert, laid on her left side on the ground near the loading dock, attached to the facility. The resident complained of neck and back pain and did not follow simple commands. She had 2 inch of bleeding laceration to the forehead along with a hematoma and crepitus (a grating sound, associated with fractured bones) in the right jaw. The resident was loaded into the ambulance via stretcher and was transported to the ER. The EMS team departed the facility at 1:14 AM and transferred Resident #1 to the emergency room (ER) at 1:20 AM. The hospital records revealed that Resident #1 arrived at the ER in the hospital on [DATE] at 1:21 AM. After assessment and a series of imaging diagnostic tests, her [DIAGNOSES REDACTED]. Due to the severity of multiple injuries and underlying metastatic [MEDICAL CONDITION], the patient was transitioned to comfort care/inpatient hospice. On 10/21/20 at 9:30 AM, during a phone interview, the Director of Nursing (DON) indicated that the staff reported on 10/9/20 at midnight, Resident #1 was wandering near the zone 3 nurses ' station, opened the side door, left the facility, and fell off the loading dock. The staff heard the door alarm, came to the side door to assess the situation but could not observe the resident outside the door. The staff could not locate Resident #1 in her room, went back to the loading dock outside the side door, and found Resident #1 on the ground with face laceration. Per staff, she was alert, could talk but could not explain what happened. Resident 1 ' s vital signs were normal. The staff called EMS, notified the nurse supervisor, physician on call, and family. The EMS arrived quickly and took the resident to the hospital for evaluation. The staff confirmed Resident #1 had her wanderguard in place at the time of the incident. The resident ' s room was near the nurses ' station and the staff redirected her back to her room every time she came to the hallway. All the staff was aware of her exit seeking behavior. Last time, the staff observed Resident #1 in her room before midnight on 10/8/20. On 10/21/20 at 11:00 AM, the Maintenance Director stated that the side door to the loading dock was equipped with an alarm system that will sound when opened without entering the special code. Together with the sound alarm, there was a light notification system on every nurses ' station, to show the alarm location. The wanderguard related alarm system was mounted on the main entrance door only. The maintenance staff tested the door alarms for all doors in the facility weekly, and the side door to the loading dock passed the test on 10/5/20. The Maintenance Director was aware of Resident 1 ' s exit seeking behavior, but for fire safety, the side door cannot be permanently locked. On 10/21/20 at 11:05 AM, during observation with the Maintenance Director and the Administrator of the zone 3 nurses ' station area, room [ROOM NUMBER], where Resident #1 resided, located approximately 15-20 feet from the side exit door. The zone 3 nurses ' station was between the resident ' s room and the side exit door. The side door to the loading dock was closed and locked. The Maintenance Director pushed the door handle for three-five seconds, opened the door and the alarm began. At the same time, the light with the zone number was activated on the nurses ' station near the side door. The Maintenance Director entered the digital code to stop the alarm sound. During observation outside of the side exit door, there was the loading dock, with four-five feet drop from the edge of the loading dock to where Resident #1 was found on the ground on 10/09/20. On the side of the loading dock, there was a dark red wooden handrail installed. The maintenance logbook for October 2020 revealed that the weekly test operation of the doors and locks was conducted on 10/5/20 and the zone 3 door (the door, Resident #1 opened to leave the facility) passed the test. This emergency exit door was not associated with the wanderguard system. The description indicated: push the door release hard for more than three seconds, the door alarm will sound, and the door will automatically open within 15-30 seconds. Close the door and reset the alarm. On 10/29/20 at 1:30 PM, a phone interview, was conducted with the Administrator. The Administrator was asked about time discrepancies between the EMS report and the statements from the staff regarding how things transpired when Resident # 1 was found by staff outside of the facility on 10/09/20. The Administrator stated that during this stressful situation, when the resident was found outside of the facility, the staff were not accurate with their reporting of time, because they concentrated on assessment and communication with EMS and healthcare provider. After the incident, Nurse #1 and Nurse #2 could provide approximate times only. The administrator specified after Nurse #1 discovered Resident #1 on the ground, he called EMS within about 10 minutes. On 10/21/20 at 2:30 PM, during an interview, Nurse Practitioner #1 indicated that Resident #1 received [MEDICAL CONDITION] treatment for [REDACTED]. Recently, he observed a psychiatric Nurse Practitioner reviewed Resident 1 ' s medication regimen to adjust the therapy for better results. He was aware of the recent resident ' s unsupervised exit from the facility which resulted in a fall with injury. Resident #1 received psychiatric service but often refused to take [MEDICAL CONDITION] medications. Nurse Practitioner #1 believed, Resident #1 did not require one-by-one monitoring but needed supervision for safety. On 10/23/20 at 3:30 PM, during the phone interview, Nurse Practitioner #2 indicated she provided psychiatric service for Resident #1. The resident often refused to take [MEDICAL CONDITION] medications, was not aggressive or dangerous to self and others. During the last visit, on 10/8/20, Resident #1 refused to communicate with Nurse Practitioner #2. Nurse Practitioner #2 reviewed the resident ' s medication regimen. The Administrator and DON were notified of Immediate Jeopardy on 10/22/20 at 12:20 PM. On 10/22/20 at 6:10 PM, the facility provided the following credible allegation of Immediate Jeopardy removal: 1 Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The interdisciplinary team (IDT) including the Administrator, Director of Nursing, and Corporate Regional Director of Operations met on 10/9/2020. The root cause was determined that the facility failed to provide supervision to prevent the resident from exiting the building. The facility staff failed to respond to the door alarm to prevent the resident from exiting to the loading dock and sustaining a fall. At the time the resident exited the building facility staff were adjusting the staffing assignment as a staff member left duty for the shift. Per nurse, there were other alarms for air mattress malfunctions sounding at the same time which decreased the staff's ability to hear door alarm. The resident had previously been identified as at risk for elopement. The resident had a wanderguard in place at the time of the incident. The wanderguard system is in place for the front door of the facility only. All other exterior doors are keypad entry and exit. All exit doors have 15-second egress to be compliant with the life safety code. If exterior doors are opened without utilizing a keypad and/or are left open for an extended period they will alarm to alert staff. The resident is noted to have a history of psychiatric conditions with behaviors and was evaluated by psychiatry services. Residents that have been assessed as at risk for elopement and exhibit exit seeking behaviors have the potential to be affected. 2. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 10/9/20, the Maintenance Director placed wooden hand railing to side of the walkway on loading dock by the exterior exit door to zone 3, checked all exit doors to ensure proper functioning with no irregularities noted, an elopement drill was completed on 10/9/20 at 2:30 PM by the facility Administrator with all staff on duty at the time of the drill. The staff successfully responded to the missing resident. On 10/9/2020, the in-service education began by Assistant Director of Nursing for all staff related to elopement risk, the procedure for missing residents, and checking for placement and function of wanderguard devices. On 10/9/2020 – 10/11/2020, all residents were reassessed for elopement risk by the Unit Coordinator. Upon assessment residents that indicated a risk for elopement had care plan interventions revised and updated as needed upon completion of the assessment. On 10/14/20 all exit doors were checked by the door alarm manufacturer for proper functioning including alarm function and egress function with no irregularities noted. On 10/22/20, re-education began by Director of Nursing, Assistant Director of Nursing, and/or Corporate MDS Consultant related to elopement risk, the procedure for missing residents, checking for placement and function of wanderguard devices, and response to door alarms. All staff will be in-serviced prior to their next scheduled shift. On 10/22/20, Maintenance Director placed signs stating to stop with a large red stop sign on all doors exiting to the exterior of the facility to alert residents to stop and not exit. Beginning 10/9/20. the facility Administrator, Director of Nursing, Assistant Director of Nursing, and/or Unit Coordinator conducted elopement drills and drills were performed on 10/9/2020 2:30 PM, 10/13/2020 3:00 AM, 10/16/2020 3:30 PM, 10/19/2020 11:00 AM and 10/22/2020 5:15 PM. The Administrator, DON, ADON, and other administrative nurses were responsible for the implementation of the credible allegation of Immediate Jeopardy removal. The date of the removal of the immediate jeopardy is 10/22/20. The credible allegation of IJ removal was verified on 10/23/20 as evidenced by licensed and non-licensed nursing staff interviews on each of the halls on all three shifts. The staff had been re-educated on the procedure for missing residents, checking for placement and function of wanderguard devices, and response to door alarms. Interviews with the licensed and unlicensed staff confirmed they were in-serviced prior to working on the floor. The facility's credible allegation of Immediate Jeopardy removal was verified as having been implemented as of 10/23/20. The facility ' s IJ removal date of 10/22/20 was validated.

Based on observations, staff interviews, record reviews, review of the facility's Infection Control policies and procedures, review of the facility's Emergency Preparedness Plan and an interview with the local public health department nurse and a nurse practitioner, the facility failed to prevent an infection control system failure when employees and a surveyor entered the facility by using 3 of 3 facility entrances, which did not have Covid-19 screening stations, and accessed resident hallways and common areas without being screened for the COVID-19 virus. Staff also failed to apply personal protective equipment (PPE) before they entered the designated Covid-19 unit and did not remove PPE when they exited the unit. These system failures occurred during the Covid-19 pandemic and had the likelihood to affect all residents in the facility. A total of 71 of 95 residents tested positive for the COVID-19 virus as of April 22, 2020. Immediate Jeopardy began on 4/19/20 when observations and staff interviews revealed employees and a surveyor used three different entrances to enter the facility that did not have an identified Covid-19 screening station and they were not screened prior to accessing resident hallways and common areas. Staff also were observed to enter the facility's designated COVID unit without applying PPE and did not remove PPE when they exited the unit. The Immediate Jeopardy was removed on 5/3/20 when the facility implemented an acceptable crediable allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of F that is not Immediate Jeopardy to ensure monitoring systems put in place are effective. Findings included: The facility's Infection Control Policies and Procedures, dated revised July 2014, were reviewed and revealed they were not updated to include the Centers of Disease and Prevention (CDC) and the Centers for Medicare and Medicaid Services (CMS) guidance to prevent the spread of the COVID-19 virus. The Infection Control policies did not contain specific guidelines on screening employees and visitors for the Covid-19 virus or maintaining transmission-based precautions in the COVID-19 designated unit. The facility's Emergency Preparedness Plan (EPP) for Pandemic Influenza-Covid-19, dated as revised March 2020, revealed employees and visitors should be evaluated daily for symptoms, and staff were to self-assess and report symptoms of COVID-19 before reporting to work. The EPP specified standard and droplet precautions were to be used when staff were in close contact with residents. The local health department conducted an onsite visit at the facility on 04/14/20. Review of the health department's report revealed staff members were going between the facility's COVID unit and the Non-COVID unit, staff on the COVID unit utilized the same time clock as the other staff and the time clock was not disinfected between uses, and staff on the COVID unit removed their PPE at the unit's front lobby entrance and then exited the facility through the front lobby, which was accessible to residents and other staff, instead of using the exit door on the unit. The report specified the health department recommended facility staff be cohorted to work either on the facility's COVID unit or the Non-COVID unit and the staff on the COVID unit have a time clock designated for their use or for them to use paper time sheets. The report noted how the health department staff were working daily with the Director of Nursing to identify strategies regarding PPE, infection control, staffing, and the cohorting of staff. The health department report revealed a daily surveillance report on the facility's COVID positive staff was conducted which identified staff were working while exhibiting symptoms of the [MEDICAL CONDITION]. The health department discussed with the Director of Nursing (DON) the importance of a proper screening process. The health department report noted guidance was given and it was disregarded. On 4/20/20 at 1:23 pm a phone interview was conducted with the local public health department nurse who visited the facility on 04/14/20. The health department nurse stated the health department was working with the facility and made an onsite visit to the facility on [DATE]. After the visit, the health department nurse stated she discussed the following recommendations with the DON; to limit access into the facility to the use of only one entrance, perform the COVID screening process upon entry into the building and develop a system for the staff, who worked on the COVID unit, to be able to clock in so they did not have to use the time clock located in the front lobby area. The health department nurse stated on 4/20/20 the facility reported that 62 residents and 26 employees tested positive for COVID. On 4/19/20 at 7:10 am attempts to open the facility's front entrance by a surveyor revealed the entrance was locked. Nurse #1, who was wearing an isolation gown and mask, was observed to enter the front lobby area, unlock the front door and allowed the surveyor to enter the facility without screening her for the [MEDICAL CONDITION]. Nurse #1 stated she needed to run out to the parking lot to get her face shield and left the surveyor alone in the lobby area. Nurse #1 was observed to exit the facility and went to the parking lot. Observations of the front lobby area revealed there was no COVID screening station, PPE or personnel. Signage was observed on a small table in the lobby which requested visitors to wear a mask and use hand sanitizer. On 4/19/20 at 7:15 am, Nurse #1 was observed to reenter the facility and stated to the surveyor, need to get you screened. Nurse #1 then escorted the surveyor, who was not wearing any PPE and who had not been screened, through a plastic partition to the left of the lobby. The plastic partition was approximately 40-50 feet from the facility's front entrance and no precautionary signage was present. Nurse #1 was asked why the plastic partition was in place and she stated it was the entrance to the facility's COVID unit. Without another spoken word, Nurse #1 requested the surveyor to go back through the plastic partition, utilize the front entrance to exit the facility and to use the second door on the right to reenter the facility. In the process of leaving the COVID unit no PPE was observed on either side of the unit's plastic partition. On 4/19/20 at 7:20 am, observations of the side entrance that Nurse #1 directed the surveyor to use to reenter the facility (the employee entrance for the Non-COVID unit) revealed it was unlocked. Observations inside this unlocked entrance revealed there was no screening station, PPE or personnel. Nursing station-1 was observed on the right side of the hallway with four resident rooms between the entrance and the nursing station and closed double doors were observed straight ahead. A staff member who was walking by the surveyor was informed a nurse instructed her to enter through the side entrance to be screened, and the staff member directed the surveyor to the double doors straight ahead. Signage on the double doors read Authorized staff only. PPE on, no exceptions. Enhanced droplet and contact precautions. Nurse #1 was observed, through a window pane in one of the doors, at a nurse's station. The surveyor returned to the Non-COVID unit side entrance to wait for Nurse #1. Nurse #1, wearing a gown and mask, approached the surveyor from the left hallway (went to the front entrance lobby) and escorted the surveyor to the Café room, that was located near the front lobby. Nurse #1 and the surveyor walked past five resident room to get to the Café' room. During an interview with Nurse #1 on 4/19/20 at 7:30 am, Nurse #1 stated she was trained the COVID screening included a questionnaire and temperature check, and employees were screened at the nursing station of the COVID unit or the Non-COVID unit. Nurse #1 stated on 4/19/20, the PPE she was wearing was applied after she reported to work on the facility's COVID unit. Nurse #1 stated on 4/19/20, she did not remove her PPE when she exited the COVID unit, walked through the unit's plastic partition to enter the front lobby to let the surveyor into the facility and then exit the facility. Nurse#1 stated she was taking the surveyor through the COVID unit to conduct a screening at the nursing station. When Nurse #2 entered the Café room, Nurse #1 stated Nurse #2 was there to perform the surveyor's screening. During a follow-up phone interview with Nurse #1 on 5/5/20 at 6:35 pm, she stated on 4/19/20 no one was at the front lobby entrance to screen employees or visitors, and she did not know where to locate the front lobby's thermometer or screening forms when she let the surveyor enter the facility, so she did not screen the surveyor. On 4/19/20 at 7:30 am, while the surveyor was sitting in the Café room, a resident, who was not wearing a mask, was observed in a wheelchair propelling himself from the front entrance lobby area toward the Non-COVID hallway. On 4/19/20 at 7:40 am, Nurse #2, who had a gown and mask on, was observed to enter the café room and screened the surveyor. Nurse #2 monitored the surveyor's temperature and completed a COVID screening questionnaire on the surveyor. Nurse #2 stated she had worked the COVID unit during the night shift. During a phone interview with Nurse #2 on 5/5/20 at 2:59 pm, Nurse #2 stated she walked through the front entrance lobby partition from the Covid-19 unit to conduct a COVID screening on the surveyor on 4/19/20 at 7:40am. Nurse #2 stated she removed her mask and gown prior to exiting the Covid-19 unit and applied a new gown and mask upon entering the front entrance lobby. On 4/19/2020 at 8:18 am, the Director of Nursing (DON) provided a map of the facility and explained the closed double fire doors on the back and mid hallway and a plastic partition, the infection control barrier, at the front lobby entrance separated the COVID unit from the Non-COVID unit. The DON noted the Non-COVID unit (Nurse's Station #1) consisted of resident rooms 35-68 and the COVID unit (Nurse's Station #2) consisted of resident rooms 1-34 and resident rooms 61-66. On 4/19/20 at 8:47 am, Nurse Aide (NA) #1 was observed standing at a medication cart outside of room [ROOM NUMBER] on the Non-COVID unit. NA #1 was not wearing any PPE and entered resident room [ROOM NUMBER]. NA #1 was heard talking with a resident in room [ROOM NUMBER]. NA #1 was observed to exit the room and then asked Nurse #3 to take her temperature. Nurse #3 was observed to take NA #1's temperature at the medication cart. NA #1 then walked down the hallway past resident rooms to nursing station-1. NA #1 obtained a gown and mask at the nurse's station, put the PPE on and completed a COVID screening form. NA #1 left the screening form in a 3-ring binder at nursing station-1. No staff member was observed to review her COVID screening form. NA #1 was interviewed on 4/19/20 at 8:50 am. NA #1 stated she had just arrived at work and entered the facility through the Non-COVID employee side entrance. NA #1 stated staff who worked on the facility's Non-COVID unit were to report to nursing station-1 to complete a screening form that was located in a notebook and have their temperature checked. During another interview with NA #1 on 5/5/20 at 5:37 pm, she stated on 4/19/20 she was at the medication cart waiting for the nurse to take her temperature when the resident in room [ROOM NUMBER] called out. NA #1 stated she entered the room, prior to being screened, and asked the resident what he needed. NA #1 stated when she reported to work on 4/19/20 there was no screening station or PPE at the Non-COVID unit side entrance. NA #1 stated she was educated on completing the form when she reported to work, but no one was reviewing her screening forms at the time she completed the form. NA #1 explained if she had an elevated temperature or answered, yes, to any of the questions on the screening form, she was to inform the closest nurse. NA #1 further stated 4/19/20 was her last day working with the Non-COVID residents. She stated the residents on the Non-COVID unit who re-tested positive were moved to the COVID unit, and she was reassigned to help on the COIVD unit. An interview with Nurse #3 was conducted on 4/19/20 at 9:05 am. Nurse #3 stated the employee and visitor COVID screening process started in March 2020. Nurse #3 stated staff working on the Non-COVID unit used the employee side entrance to enter the unit, and when staff reported to work, they were to come to the nursing station-1 for a temperature check and to complete the COVID screening questionnaire. A follow up phone interview on 5/5/20 at 5:55 pm was conducted with Nurse #3. Nurse #3 stated the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) usually reviewed the screening forms, but any nurse could review the screening forms when staff had a temperature greater than 100 and having any respiratory signs or symptoms when reporting to work. Nurse #3 stated the Non-COVID unit side entrance did not have PPE or a screening station. Nurse #3 explained the decreased number of residents on the non-COVID unit since 4/19/20 was due to some of the residents on this unit started to exhibit elevated temperatures, tiredness, and required oxygen therapy. The residents on this unit were retested and some tested positive and were moved to the facility's COVID unit. On 4/19/20 at 10:19 am, an observation of the COVID unit revealed there was no PPE available at any of the unit's entry points. The unit's side employee entrance did not have a designated screening station. Upon entering this employee side entrance, the unit's nursing station was observed approximately 15 feet from the entrance. Resident room [ROOM NUMBER] was observed to be to the left of this side entrance/exit door (if exiting the unit). Containers of PPE were observed in front of the unit's nursing station and inside a small office located to the left of the nursing station. An interview conducted on 4/19/20 at 10:30 am with Nurse #4. Nurse #4 stated he utilized the employee side entrance to enter the COVID unit when he came to work. He explained on 4/19/ 20 he entered the unit not wearing any PPE and his temperature was checked and he competed the screening form at the unit's nursing station. Nurse #4 stated after he completed the screening process, he exited the unit through the plastic partition and went to the lobby to clock in at the time clock. He then re-entered the COVID unit and applied a gown and mask at the unit's nursing station. Nurse #4 stated at the end of his shift, he removed his PPE in the bathroom that was approximately 15 feet from the unit's plastic partition, washed his hands and exited the unit through the plastic partition. Nurse #4 stated he then clocked out using the time clock in the front lobby area and exited the facility through the front door. During an interview with Nurse Aide #2 on 4/19/20 at 12:00 pm, Nurse Aide #2 stated when she came to work on 4/19/20 she used the employee side entrance to enter the COVID unit. NA #2 stated after she performed hand hygiene, she applied a gown, mask, and face shield. NA #2 explained she then exited the COVID unit, wearing her PPE and without being screened and she walked to the time clock located in the front lobby area to clock in. NA #2 noted no resident care was provided before walking to the time clock. After she clocked in, she returned to the unit's nursing station to complete the COVID screening process which included having her temperature checked and completing the screening form. NA #2 stated she often checked her own temperature. NA #2 stated education in-services were conducted on how to remove PPE before exiting the COVID unit and how to reapply PPE before re-entering the unit. On 4/19/20 at 12:35 pm, the plastic partition between the front lobby and the COVID unit was observed with a second piece of clear plastic hanging over the large slit in the plastic partition and a sign was at the top left corner of the partition that read No entry beyond this point. The COVID unit was located beyond the partition. An employee time clock was observed outside the administrative assistant's office door in the front lobby. The plastic partition for the COVID unit was approximately 27 feet from the time clock. The time clock was accessible to staff who did not work on the COVID unit and to residents who were in the front lobby. An interview with the administrative assistant was conducted on 4/20/20 at 3:05 pm. The administrative assistant stated there was a staff member assigned to work as the administrative assistant from 8:30 am to 9:30 pm daily, who was responsible for conducting the COVID screening on employees and visitors who entered the facility through the front entrance. She stated between the hours of 9:30 pm and 8:30 am the front entrance was to be locked and a nurse was to respond to the entrance's door bell and screen all staff and visitors who were attempting to enter the facility. She stated all employees and visitors who entered through the facility's front entrance were to be screened by having their temperature taken and completing the screening questionnaire. The administrative assistant explained If a question was answered yes on the screening form or the person's temperature was greater than 100 degrees Fahrenheit, the employee or visitor was referred to the DON, Assistant DON (ADON), or the first or second shift supervisor. The administrative assistant stated there were no personnel screening employees at the two side employee entrances and employees who entered through the side entrances were screened at the nursing stations on each unit. In a follow up phone interview on 5/5/20 at 6:05 pm, the administrative assistant stated she was expected to monitor the front entrance and perform the COVID screenings along with her normal duties as the administrative assistant. She stated the two new responsibilities did not require a lot of extra work due to the limitations of visitors in the facility and noted only a few venders entered through the front entrance. The administrative assistant stated when she took breaks the Administrator and the Human Resource Coordinator monitored the front entrance. An interview was conducted with the DON at 9:18 am on 4/19/20. The DON stated the employee and visitor screening process started in March 2020 and required staff upon reporting to work to complete a COVID screening questionnaire and to have their temperature checked. The DON stated a COVID screening books was located at the front lobby entrance, as well as, at nursing stations 1 and 2. The DON stated the licensed nurse was responsible for reviewing an employee's screening form to determine if the employee could enter the building for work. The DON explained an employee who worked during the 11:00 pm to 7:00 am shift on 4/3/20, who was screened, went to the emergency roiagnom on [DATE] and tested positive for COVID. She specified on 4/9/20, a resident tested COVID-19 positive while in the hospital after experiencing a fall at the facility. The DON stated she contacted the local Public Health Department, who recommended all residents and employees be tested for the [MEDICAL CONDITION] on 4/10/20. The DON stated residents were tested on [DATE] and 4/11/20 and the last results of these tests were reported on 4/13/20 and 4/14/20. The facility's original COVID unit consisted of rooms 1-8 and was closed off to other areas by a plastic partition, which separated the front entrance lobby and the COVID unit, and a set of fire doors between rooms [ROOM NUMBERS]. The facility received the residents test results over a 4-day span and the COVID unit expanded to include 60 of the 90 residents who tested positive. On 4/19/20, the facility census specified 54 of the 82 residents tested positive for COVID, and the DON noted some residents were transferred to the hospital over the weekend. No deaths were reported by the DON on 4/19/20. The DON stated employee/visitor COVID screening forms were in a notebook located at nursing station on the COVID unit and the employees used the unit's key pad side entrance when reporting to work on the unit. The DON stated COVID screening notebooks were located at nursing station on the Non-COVID unit. Staff who worked on the Non-COVID unit were to use the unit's key pad side entrance to enter the unit when they reported to work. The DON explained that staff were required to perform a COVID screening which included; completing the screening form and having their temperature taken at the nursing station. The DON stated the licensed nurse was responsible for reviewing an employee's screening form to determine if the employee could report to work. Personal protective equipment was located at the nursing station for the staff working on the Non-COVID unit. During an interview with the DON on 4/19/20 at 12:40 pm, the DON stated the employees completed the COVID screening form prior to starting to work, and if any questions were answered yes, the employees took their form to the nurse. The DON stated staff had received educational in-services on the screening process. During an interview with the DON on 4/19/20 at 1:21 pm, the DON stated the COVID unit staff exited the unit's plastic partition that separated the COVID-19 unit and the front lobby entrance to use the time clock in the lobby at the beginning and the end of their shift. During another interview with the DON on 4/19/20 at 2:12 pm, the DON stated linen barrels and trash barrels were at nursing station-2 and in the hallways of the COVID unit for isolation gowns and trash. She specified staff removed PPE prior to exiting the COVID unit through the plastic partition at the front lobby entrance or at unit's side entrance. The DON stated that she and the ADON were monitoring the PPE practices of the staff. During a follow up interview with the DON on 5/5/20 at 12:55 pm, the DON stated on 4/19/20 there was no screening stations located at the side entrance for the Non-COVID unit and a screening book was used at the unit's nursing station. The DON stated staff working on the Non-COVID unit entered the facility through either the unit's employee side entrance or the front lobby entrance and screened themselves. She explained that ADON and herself were responsible for checking the screening forms. The DON explained on 4/19/20 staff who worked on the Covid unit were required to wear a face shield, N-95 mask, gowns and gloves when they provided resident care. The DON stated the employees who worked on this unit were to use the unit's side entrance near nursing station-2 to enter the facility, applied PPE located at the nursing station or in the nursing coordinator's office and conducted the COVID screening. Upon completion of the COVID screening, the staff on the COVID unit walked through the plastic partition barrier to the lobby to use the time clock and returned to the unit for work. The DON noted the employees removed the PPE at the end of the shift and used the time clock in the front lobby to clock out. The DON stated on 4/20/20 the COVID employees began recording the time they worked on paper time sheets instead of using the time clock in the front lobby. The DON noted the public health department mentioned on 4/14/20 about getting another time clock for the COVID unit and wanted to keep the staff on this unit on one side of the facility and suggested the COVID staff only used the unit's side entrance to enter and exit the facility. The DON reported there had been 15 COVID related resident deaths as of 5/5/20. The DON answered; Don't Know when asked why the Health Department recommendations on 4/14/20 regarding the time clock and the reduction in employee and visitor entrances were not implemented. The DON stated on 5/2/20 the facility started the 24-hour employee coverage at the front entrance and required all employees to use to the facility's front entrance for COVID screening when they reported to work. The resident surveillance information forms provided on 4/19/20 was reviewed on 4/20/20. This review revealed 60 of the 95 residents, who were tested , from 4/07/20 through 4/11/20 tested positive. The first resident that tested positive for COVID was on 4/7/20 while hospitalized . The resident surveillance information form provided on 5/5/20 revealed twenty-four residents on the Non-COVID unit were retested on [DATE], and 11 of the 24 residents tested positive. The employee surveillance information forms provided on 4/19/20 were reviewed on 4/20/20. This review revealed 21 of 95 employees, tested positive for COVID and the first employee that tested positive for COVIID-was on 4/7/20. The remaining staff were tested from 4/11/20 through 4/14/20 and some results were pending. The employee surveillance information forms provided on 5/5/20 revealed 28 of the 88 employees listed were positive for the [MEDICAL CONDITION]. On 4/19/20 at 2:50 pm, an interview was conducted with the Administrator. The Administrator stated the COVID screening process started on 3/13/20 for all employees and visitors and was conducted at the front lobby entrance and at the two nursing stations. The Administrator explained all staff and visitors were to be screened with a questionnaire and have their temperature checked when they entered the facility. On 4/28/20 at 9:52 am, a phone interview was conducted with the DON. The DON stated on 4/28/20 she was working at the facility and was asymptomatic after testing positive for Covid-19. The DON stated she used the facility's Non-COVID employee side entrance to report to work since it was the closest entrance to her office which was located on the Non-COVID unit. She explained she wore a gown and a N-95 mask when she left her office. She stated she refrained from interacting with residents who were not COVID positive. The DON stated on 4/19/20 she completed the screening process at nursing station-2 and could not explain why her screening form was located in the notebook on the Non-COVID unit on 4/19/20. The DON reported since 4/19/20 the 24 residents on the Non-COVID unit were retested on the physician's recommendation, and 11 of the 24 residents tested positive for having the [MEDICAL CONDITION] and were moved to the facility's COVID unit. An interview was conducted with the Nurse Practitioner (NP) on 5/5/20 at 11:21am. The NP stated that some residents who initially tested negative for COVID-19 developed symptoms and were retested . Some of the residents, who were retested , tested positive and were moved to the facility's COVID unit. During a follow up interview with the Administrator on 5/5/20 at 1:41 pm, the Administrator stated she was not present on 4/14/20 when the local Health Department visited the facility. The administrator explained on 4/19/20 the front lobby entrance doors remained locked and employee, visitors and vendors were to be screened at the front lobby entrance by a designated employee from 8:00 am to 9:00 pm. The Administrator stated after 9:00 pm, nursing staff from either unit could answer the front lobby entrance. She explained if a nurse, who worked on the COVID unit answered the front lobby doorbell, the nurse was to remove PPE before exiting through the unit's plastic partition to answer the door. The Administrator stated on 4/19/20 the employees, who worked on the COVID unit, were screened at nursing station-2, and employees were to enter the facility by using the unit's side entrance. The Administrator explained, when an employee entered the COVID unit, the screening process was completed. The Administrator was unsure if PPE was applied by staff in the COVID unit before or after they walked to the time clock in the front lobby to clock in. The Administrator stated employees were to remove PPE before exiting through the unit's plastic partition to use the time clock in the front lobby. The Administrator stated the DON was providing continuous education to the employees on COVID changes. The Administrator explained on 05/03/20 the facility was able to make contact the company to lock the two key pad side entrances, and the facility started allowing staff and visitors access only into the facility through the facility's front entrance. The Administrator was notified by phone of the immediate jeopardy on 5/2/20 at 11:45am. On 5/2/20 at 9:57 pm the facility provided the following credible allegation of Immediate Jeopardy removal: 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; All residents have the potential to be affected. 2. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: Screening stations were consolidated to screening station in main lobby for screening of all employees and visitors. All exterior doors including front entrance are secure keypad entry only. Signage was placed on all doors to alert all staff and visitors to use front entrance only for mandatory screening at beginning of shift and / or visit to facility. Screening station will have a designated staff member assigned 24 hours per day. The Designated screening staff member will reconcile screens as they are completed with the daily staffing schedule to ensure all staff listed are screened upon arrival for work. A group of 4 designated staff members assigned to complete screens have been educated the Director of Nursing to notify the Director of Nursing, Administrative Nurse on call and/or facility administrator for any screen with temp noted greater than 100.0 and / or yes to any listed symptoms. Upon notification of positive screen (temperature greater than 100.0 and / or yes to any listed symptoms) the Director of Nursing, Administrative Nurse on Call and / or facility Administrator will advise the employee of their ability to work. Employees noted with positive screen (temperature greater than 100.0 and / or yes to any listed symptoms) will be sent home and will not be allowed to return to work until at least 3 days (72 hours) have passed since recovery defined as resolution of fever without the use of fever reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath); and at least 7 days have passed since symptoms first appeared as per the CDC return to work guidance for essential workers. If employee screen is negative (temperature not greater than 100.0 and no to any listed symptoms) and they are assigned to the non Covid unit they are to clock in for the day and report to their assigned area after applying full PPE. PPE for staff assigned to non Covid unit will maintained in front lobby at screening location. If employee screen is negative (temperature not greater than 100.0 and no to any listed symptoms) and they are assigned to the Covid unit they are not to utilize the time clock, they are to utilize a paper clock correction form for their shift. Staff assigned to work on the Covid unit are to apply PPE (gown, mask and face shield) prior to entering the Covid unit. Gloves are applied prior to providing direct resident care. Upon completion of direct resident care gloves are removed and hand hygiene is completed. PPE for staff members assigned to Covid unit is located directly outside of temporary barrier located closet to front lobby. Upon arrival for work staff members assigned to the Covid unit will use the temporary barrier / entrance located closest to the front lobby to enter the Covid unit for work. If an employee or visitor enters the facility without a mask, they will be supplied a mask by the designated screening employee. Asymptomatic Covid positive employees will only be allowed to work on the Covid Unit per CDC guidance for Mitigating Healthcare Personnel Staffing Shortages memo received from the(NAME)County Health Department. All employees are screened at the screening station in main lobby. In-services began 5/2/20 by the Director of Nursing for all staff related to screening process, location of screening, utilization of time clock and application of PPE. All staff will be in-serviced prior to reporting for

Based on resident and staff interviews and record reviews, the facility failed to protect a resident's right to be free from verbal abuse including yelling, pointing the finger and threat not to provide care for 1 of 1 resident reviewed for abuse (Resident #1) resulting in the resident upset, feeling hurt, berated, and crying for a period of time. The findings included: Resident #1 was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE], indicated Resident #1 cognition was intact and she was totally dependent upon staff for all activities of daily living. The care plan dated 1/16/19 identified the problem as resident had an activities of daily living self-care performance deficit related to amputation, limited mobility, limited range of motion and musculoskeletal impairment. The goal included resident would maintain current level of function. The interventions included assist resident to have a neat and clean appearance as needed, encourage resident to discuss feelings about self-care deficit, encourage resident to participate to the fullest extent possible with each interactions, resident requires oral inspection with oral care and report changes to the nurse, resident requires daily skin inspection with activities of daily care and weekly skin checks and provide the resident with short, simple instructions. During an interview on 2/26/19 at 6:30 AM, Resident #1 reported that she was verbally abused by NA #4. The resident explained that on Saturday 2/9/19, nursing assistant (NA) #4 did not complete the resident's normal routine care, like brush her teeth, comb her hair, put on her earrings and get her ready for the day. The NA was called out of the room before she could complete the normal routine care and she did not come back later. The resident's remote control was also missing, and she had to watch the same channel on Saturday. Resident #1 revealed that, on 2/10/19, when NA#4 came back to work, the resident asked the NA why she did not complete the routine personal care for the resident on 2/9/19 and asked her if she had seen the remote to the resident's television. The resident stated I was just asking when (NA#4) became very upset yelling and telling me that she knew she took good care of me. The resident reported the NA saying to the resident why would you say I didn't do my job and I didn't take your remote. The resident stated I was so stunned and upset that she would be yelling at me and pointing her finger in my face, like I didn't matter. My feelings were hurt, and I felt berated by her. There was no reason for her behavior toward me or anyone else. She was a very good worker and has done good care for me, just don't know why she would react the way she did. I cried and cried for two hours so much I didn't know what to do. I went to the administrator and director of nursing about what happened. I was still so upset, and the administrator really helped me calm down and told me that the staff would be suspended until the investigation was completed. I was later told the staff was terminated. I am very satisfied with the action the administrator and director of nursing took to address NA#4's verbal abuse. I feel like the administrator and director of nursing handled things appropriately During a follow-up interview on 2/26/19 at 11:20 AM, Resident #1 stated I know I was verbally abused by the staff and it should never happen to anyone in the facility, I still get upset talking about it because I know I did not deserve that kind of behavior. I hated she got fired, I just pray she doesn't do that to anyone else when she gets upset. (NA#4) did give me good care overall. During a telephone interview on 2/26/19 at 1:42 PM, NA#4 stated she had worked with Resident #1 for the past 4 years and she was very familiar with her care needs and her preference regarding ADLs. She reported she had worked with the resident on Saturday and was pulled away to assist with another resident. NA #4 reported she had told the resident this information and another staff would be in to do her weights. NA#4 reported she had provided all the resident's care and did not think to go back to do the resident's hair. The NA reported that when I arrived to work on Sunday 2/10/19, I was orienting an agency aide when the resident started accusing me of not doing my job on Saturday. I did tell her that she knew I took very good care of her. The conversation did get a little loud because I know I have taken very good care of the resident and she got upset because I didn't comb her hair and I didn't know where her remote was. I normally put the remote in a specific place to make sure it didn't get wet when I would provide care for the resident. When the resident started to accuse me of not doing my job and taking a remote, things got loud, I never put my hand or finger in her face. I was told she was very upset and crying for a long period by other staff and the administrator who called me on the phone and told me I was being put on suspension. I have not received a follow-up call from the facility on my status. I was told by my co-workers that I was terminated. I did not hear it from the administrator or the director of nursing as of this date. During a telephone interview on 2/26/19 at 1:34 PM, NA#5 stated that she had worked with the resident on Sunday 2/10/19 in which she observed Resident #1 and NA#4 in a heated verbal discussion about care that NA#4 did not provide on Saturday. NA#5 further stated Resident #1 asked NA#4 about not getting her care and the loss of the remote control. NA#4 started to raise her voice with the resident, stating how well she had provided care for the resident and she was offended by what Resident #1 had stated. NA#5 stated NA#4 had pointed her finger in the resident face as she was talking very loudly. NA#4 eventually left the room and went to the nurses' station and started talking about the situation, therefore, NA#5 thought she did not need to report it to director of nursing (DON) or administrator because the nursing staff already knew what was going on. The DON later came and asked NA#5 what she saw and heard, and she told the DON then. NA reported that she did not receive any in-service training at the time of the incident. An interview was conducted on 2/26/19 at 5:00 PM, with Nurse #2 who was responsible for Resident #1's care on the 7-3 shift on 2/11/19. Nurse #2 stated she heard other staff talking about the situation between Resident #1 and NA#4 at the nursing station. Nurse #2 stated, I went to speak with the resident and she stated she wanted to speak with the DON. The resident did not give me any details. When the DON arrived on Monday morning, I asked her to speak with the resident based on what she heard over the weekend. Nurse #2 stated at times Resident #1 would be upset or overly emotional about different things, however, when I heard that the staff was in the resident's face, was very loud and there was some finger pointing and the resident had been upset for several hours, I felt like the DON should be involved. Nurse #2 stated she did not receive an in-service on abuse at the time of the incident but did receive an in-service on 2/26/19. An interview was conducted with Nurse #3 on 3/11/19 at 3:11 pm. Nurse #3 worked from 7 am till 3 pm shift on 2/10/19. Nurse #3 said she was responsible for providing care to Resident #1 and the resident did not tell her about the incident that happened between her Resident #1 and NA #4 on 2/10/19. Nurse #3 said the staff did not tell her about any incident that happened between the resident and the NA on 2/10/19. Nurse #3 said she heard from the staff in passing that there was a disagreement between Resident #1 and NA #4. Nurse #3 said she thought it was minor. Nurse #3 never went back to the resident nor to the staff that were talking in passing nor NA# 4 to ask them what happened. Nurse #3 said she did not see NA#4 that day and did not look for her to talk to her. Nurse #3 said if there was abuse, then she would separate the staff from the resident and then tell her supervisor or the DON. Nurse #3 said if she could not contact the supervisor or the DON or the administrator, then she would send the accused staff home and tell the supervisor as soon as possible. During an interview on 2/26/19 at 7:00 AM, the Director of Nursing stated the charge nurse reported to her on 2/11/19, Resident #1 had a complaint regarding verbal abuse with a nurse aide over the weekend on 2/10/19. The nurse reported that NA#4 had been very mean to Resident #1 and hurt her feelings and made her cry for several hours. The discussion held with Resident #1 revealed NA#1 was assigned to her on 2/9/19 and NA#4 left without completing her care. Resident #1 stated she could not find her television remote, but the 3rd shift aide found the remote in laundry and gave it back to her. Resident #1 had asked the aide if she was ok when she came to work on 2/10/19. Resident #1 reported the aide became very defensive and very upset loud and yelling at her. The aide was berating her and had her hand in her face stating she would not take care of her again. There was another aide in the room. Resident #1 was very emotional during her report and upset the aide had acted this way. After completing the investigation, management substantiated the allegation and a decision was made to terminate the staff. The Director of Nursing was unable to present any information and/or in-service record that was done with staff on abuse policy at the time of incident. During a telephone interview on 2/26/19 at 4:26PM, the Administrator stated that when staff informed her that Resident #1 wanted to speak with her, the resident was very upset because NA#4 had verbally abused her. The Administrator stated the resident reported the staff was yelling and screaming and pointing in her face and she was very upset for several hours and felt like she should not be treated like that. Administrator stated she had called NA #4 and informed her that she was on suspension pending the investigation. I tried to call the staff (NA #4) for several weeks and the staff did not respond to the calls. Since the staff did not respond, I just left it alone. The Administrator stated that she had done a huddle and verbal in-service training on the different types of abuse and the reporting process with all the staff on that day. The Administrator added that she was uncertain why the in-service documentation could not be found. Facility faxed the 24-hour report to the State Agency on 2/11/19 and 5-day report on 2/14/19 regarding the incident of 2/10/19. Review of the report indicated the staff had been terminated on 2/14/19.