Every finding on record at Western Hills Health Care Center

Based on record review and interviews, the facility failed to ensure one (#2) of three residents at risk for elopement out of three sample residents received adequate supervision and was kept free from elopement.Resident #2 was admitted on [DATE] with diagnoses of unspecified dementia, abnormalities of gait and mobility, history of falling and depression. On 7/3/26 the nurse noticed Resident #2 was not in the dining room for dinner. His room and the facility's lobby were checked because that was where the resident usually sat. Resident #2 could not be located. The facility was notified by the police department that Resident #2 was in the hospital following a fall outside with a head injury. Resident #2 suffered a traumatic right tentorial subdural hematoma (bleeding on the right side of the brain), which caused altered mental status, confusion, agitation and an inability to provide an accurate medical history. Specifically, the facility failed to ensure Resident #2 was provided with the supervision necessary to prevent an elopement, which resulted in a fall with a traumatic brain injury for the resident.Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 8/19/26, resulting in the deficiency being cited as past noncompliance with a correction date of 7/10/26. I. Elopement incident on 7/3/26On 7/3/26 the facility staff were unable to locate Resident #2 during the evening meal. Upon identifying Resident #2 was not in attendance, the elopement procedure was initiated. The director of nursing (DON) was notified and a search was conducted. The resident was unable to be located. The police were notified and conducted a search at the facility. The police determined Resident #2 was at a nearby hospital and the physician and family were notified.II. Facility plan of correctionThe correction plan implemented in response to Resident #2's elopement incident on 7/3/26 was provided by the nursing home administrator (NHA) on 8/19/26 at 12:57 p.m. The plan documented the following:A. Immediate action On 7/3/26 education was started with all staff regarding the policy and procedure for elopement. Education would be completed by 7/10/26 regarding the systemic changes as a result of the resident care assessment. A quality assurance performance improvement (QAPI) meeting was held on 7/7/26 with the medical director to review the resident care assessment and systemic changes.B. Identification of other residentsA review of residents at risk for elopement was completed. Care plans were reviewed to ensure they were updated for those residents that were identified to be at risk. Residents' photographs were validated and information was placed in a binder at the receptionist desk. Education was done with staff regarding interventions and elopement risk. C. Systemic changesResidents were assessed for risk of elopement upon admission, quarterly and as needed with a change of condition. Care plans were created and/or updated for those residents identified to be at risk for elopement. Residents' photographs would be obtained and uploaded into the residents' electronic medical records (EMR), with a copy placed at the receptionist's desk. Staff would be advised of residents at risk for elopement and interventions. Interventions would be put into place as needed. D. MonitoringThe DON/designee conducted an audit of elopement risk assessments and audited to ensure that residents' photographs were in place at the front desk. A weekly audit would be completed for four weeks of all high risk elopement residents to ensure resident's photographs were in place at the front desk. Pending no areas of concern, the audit would be completed monthly times two months to ensure compliance. Any deviations would be discussed at the QAPI meetings.III. Facility policy and procedureThe Unsafe Wandering and Elopement Prevention policy and procedure, revised 8/26/25, was provided by the NHA on 8/19/26 at 12:57 p.m. It read in pertinent part, The facility will ensure that residents are assessed to determine risk for elopement in accordance with current standards of practice and implement interventions as appropriate to mitigate the risk identified. The facility must ensure each resident receives adequate supervision and assistance devices to prevent accidents.Elopement occurs when a resident leaves the premises or a safe area without authorization and/or necessary supervision to do so. A resident who leaves a safe area may be at risk of heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. If the facility does not have a secure unit and the resident has indicators for elopement and wandering, the facility will need to initiate interventions to reduce the risk for wandering and elopement.IV. Resident #2A. Resident statusResident #2, age greater than 65, was admitted on [DATE] and discharged to the hospital on 7/3/26. According to the July 2026 computerized physician orders (CPO), diagnoses included unspecified dementia, abnormalities of gait and mobility, cognitive communication deficit, depression and history of falling.The 4/28/26 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) of one out of 15. He used a walker. He required moderate assistance with bathing. He required set up for oral hygiene and was independent with all other activities of daily living (ADL). B. Record reviewThe elopement care plan, initiated 1/6/26, documented Resident #2 was at risk for elopement. Interventions included adding the resident to the elopement book, completing an elopement risk and encouraging the resident to participate in activities to divert him from exit-seeking behavior. The elopement risk evaluation, dated 6/6/26, revealed Resident #2 was at risk for elopement. A behavior note, dated 5/31/26 at 6:32 a.m., revealed Resident #2 was presenting behavior for risk of elopement. He had been observed by staff on the porch outside of the facility on two occasions in the same day. A psychosocial note, dated 6/3/26 at 11:58 a.m. revealed Resident #2's representative was notified that referrals were being sent for a more secure community for the resident.An event note, dated 6/29/26 at 5:50 p.m., revealed Resident #2 was observed walking out of the facility and two staff members redirected him to go back to his room.-The facility failed to identify Resident #2's exit seeking behavior prior to his elopement and implement effective interventions to prevent a potential elopement.An event note, dated 7/3/26 at 7:42 p.m., revealed the nurse noticed Resident #2 was not in the dining room for the evening meal. The nurse checked the resident's room and the lobby where he usually sat. The staff checked the nearby fast food restaurant and around the outside of the facility. The staff was unable to locate Resident #2 and notified the DON and the NHA. The police were notified and arrived at the facility and searched for the resident on the premises. The police notified the facility that Resident #2 was at a local hospital following a fall.A facility physician's note, dated 7/14/26 at 11:05 a.m. (after the resident was discharged from the facility), revealed the note was entered to document the physician's professional assessment of Resident #2's baseline cognitive and functional status based on serial evaluations performed during his residency at the facility. The note indicated the resident's recent hospitalization following a presumed fall with a small traumatic right tentorial subdural hematoma represented an acute departure from his usual condition. The note indicated the hospital documentation described Resident #2 as having altered mental status characterized by confusion, agitation, and the inability to provide an accurate medical history. The note indicated that before the resident's hospitalization, he was consistently more interactive, communicative, cooperative, and cognitively engaged than reflected in the acute trauma evaluation. It was medically reasonable that the traumatic brain injury, unfamiliar hospital environment, and acute illness contributed to the transient worsening in Resident #2's cognition observed during his hospitalization.V. Staff InterviewsCertified nurse aide (CNA) #1 was interviewed on 8/19/26 at 11:23 a.m. CNA #1 said Resident #2 was forgetful and always trying to get out to the courtyard. He said Resident #2 gained a lot of strength with restorative therapy. He said Resident #2 loved ice cream so he would walk to a nearby fast food restaurant to get ice cream for him so he would not attempt to leave the facility. He said Resident #2 was a wanderer and was exit-seeking. He said the facility increased activities and hired more Spanish speaking staff. Registered nurse (RN) #1 was interviewed on 8/19/26 at 2:48 p.m. RN #1 said Resident #2 was very active and wandered around. She said he liked to sit in the front lobby. She said Resident #2 was Spanish speaking only and there was a language barrier for communication. She said Resident #2 wandered and was exit-seeking. She said she was not aware of any interventions to prevent an elopement for the resident.RN #2 was interviewed on 8/19/26 at 2:50 p.m. RN #2 said Resident #2 liked to sit at the nurses' station and was very confused. She said he wandered all the time, was very forgetful and would exit-seek. She said Resident #2 would try to exit the front door, the back door or any door available. She said it was very difficult to keep an eye on him due to the unit being very busy. The DON was interviewed on 8/19/26 at 2:58 p.m. The DON said Resident #2 did not have many behaviors. She said he did not exit-seek but liked to sit outside. She said she did not recall a referral being sent to a more secure community. She said Resident #2 was permitted to go in and out of the facility. She said he would sit outside, walk to the nearby fast food restaurant and then return to the facility. She said she was not aware of any interventions to prevent an elopement for the resident.-However, record review and additional staff interviews revealed Resident #2 had a tendency to exit-seek (see record review and staff interviews above). The NHA was interviewed on 8/19/26 at 3:22 p.m. The NHA said Resident #2's picture was at the receptionist's desk because he was a high elopement risk. She said she recommended the secure placement for the resident because there were more Spanish speaking staff there, not for the secure environment. She said she had seen him many times walking back from the nearby fast food restaurant with ice cream. She said the facility wanted to allow Resident #2 to be free from restraints but he should have been supervised when outside of the facility. -However, record review and additional staff interviews revealed Resident #2 had a tendency to exit-seek (see record review and staff interviews above).

Based on record review and interviews, the facility failed to notify the resident's responsible party after a fall for one (#1) of three residents out of five sample residents. Specifically, the facility to notify the resident's responsible party when Resident #1 had a fall.Findings include:I. Facility policy and procedureThe Incident and Reportable Event Management policy and procedure, revised 2/24/26, was provided by the nursing home administrator (NHA) on 8/19/26 at 4:35 p.m. It read in pertinent part,A fall is an unintentional change in position coming to rest on the ground, floor or onto the next lower surface.The licensed nurse should create an event note and include the notification of the family or responsible party.II. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on [DATE]. According to the August 2026 computerized physician orders (CPO), diagnoses included unspecified dementia, abnormalities of gait and mobility, muscle weakness and a history of falling.The 5/28/26 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) of three out of 15. She had hallucinations. She used a walker and a wheelchair for mobility. She required maximal assistance with toileting hygiene, lower body dressing and transfers. B. Record reviewThe fall care plan, revised 5/29/26, revealed Resident #1 was at risk for falls related to weakness and osteoarthritis. The interventions included replacing non-skid strips to the floor in front of the bed with glow in the dark non-skid strips and a call light extender applied to the call light cord. An event note, dated 7/1/26 at 4:15 a.m., documented the registered nurse (RN) was called to the south station by the licensed practical nurse (LPN) assigned to the unit where Resident #1 had a fall. Resident #1 stated she had slipped off of the bed when she was attempting to bend over or get up. There was no visible injury.-The LPN failed to notify the resident's responsible party of the fall or document the incident as a fall.III. Staff interviewsLPN #1 was interviewed on 8/19/26 at 4:01 p.m. LPN #1 said she was the unit manager. She said the LPN on duty at the time of Resident #1's fall did not consider the incident a fall since the bed was in a low position when the resident fell from the bed. She said the resident's responsible party was notified of the fall on 7/3/26 by the hospice nurse, two days following the fall. She said education was provided to the LPN assigned to Resident #1 on 7/1/26. LPN #1 said the education included initiating an event note after a fall, notifying the physician, hospice and the responsible party and reporting the event.The director of nursing (DON) was interviewed on 8/19/26 at 4:04 p.m. The DON said following a fall, the resident should be assessed by a RN. She said the nurse assigned to the resident should notify the resident's family and the physician and complete a fall risk management report. The DON said she was notified via a text message of Resident #1's fall on 7/1/26 and assumed the LPN had done the required notifications. She said the LPN was provided with education on following the fall protocol after Resident #1's fall.The NHA was interviewed on 8/19/26 at 4:13 p.m. The NHA said the risk management team completed an investigation of Resident #1's fall on 7/3/26. She said the RN on duty completed the assessment and the nurse assigned to the resident was responsible for notifying individuals and completing an investigation, which was not done at the time of the resident's fall on 7/1/26.

Based on observations and interviews, the facility failed to ensure that essential food service equipment was maintained in a safe and functional condition in the main kitchen.Specifically, the facility failed to repair a broken, nonfunctional heated plate dispenser in the main kitchen.Findings include:I. ObservationDuring a continuous observation on 5/13/26, beginning at approximately 11:45 a.m. and ending at the kitchen's heated plate dispenser/lowerator was observed to be completely disconnected from electrical power, with its power cord left unplugged and coiled on the floor beside the unit.The staff were placing the plates on top of the broken dispenser without electrical power. The internal heating elements were inactive and the unit was cold to the touch. The lunch plates stacked inside the dispenser, which were being pulled by dietary staff to serve hot food to residents, were unheated and room temperature.II. Staff interviewsCook #1 was interviewed on 5/13/26 at 2:00 p.m. [NAME] #1 said the equipment had been broken and out of service for over six months. [NAME] #1 said the kitchen manager had been informed of the malfunction when the issue first arose. [NAME] #1 said the last time she attempted to plug the unit into an electrical outlet to use it, the equipment sparked fire, prompting staff to immediately disconnect it and leave it unplugged to prevent a safety hazard.The dietary manager (DM) was interviewed on 5/13/26 at 2:10 p.m. The DM said the equipment was broken and staff were placing the plates on top of the broken dispenser without electrical power just to hold the plates during the trayline services. The DS said he was aware the plates were not heated. The DM said it was important to ensure hot foods were served hot. The DM said he was informed by the NHA that a new dispenser had been purchased and that it would be delivered soon.The NHA was interviewed on 5/14/26 at 2:35 p.m.The NHA said she was aware the dispenser was broken. She said the unit was found to be damaged beyond repair. The NHA said she had already purchased a brand-new plate dispenser, which was currently scheduled for delivery to the facility on 5/24/26. The NHA said there was no interim protocol to address the current service gap.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for three of five certified nurse aides (CNA) reviewed.Specifically, the facility did not complete a performance review for CNA #3, CNA #7, and CNA #8.Findings include:I. Facility policy and procedureThe Performance Evaluation policy, reviewed 12/4/25, was received from the nursing home administrator (NHA) on 5/15/26 at 12:23 p.m. It read in pertinent part, Performance evaluations are defined as a formal and productive procedure to measure an associate's work and results based on their job responsibilities. It is an integrated platform for both the associate and employer to attain common ground on what both think is befitting a quality performance. This helps in improving communication, which usually leads to improved performance results. Annual performance reviews are given to all associates. II. Record reviewAnnual performance reviews were requested on 5/12/26 at 5:52 p.m. for CNA #3 (hired 8/12/20), CNA #7 (hired 2/12/25), and CNA #8 (hired 3/7/24).The provided review for CNA #3 was completed on 4/30/25.The facility was unable to provide a review for CNA #7.The provided review for CNA #8 did not have a date when the review was completed.A review of the provided evaluation for CNA #8 revealed that the employee failed to meet expectations in two competency areas: communication and punctuality.-There was no documentation revealing CNA #8 was provided education regarding communication and punctuality. III. Staff interviewThe NHA and the regional vice president were interviewed on 5/13/26 at 1:15 p.m. The NHA said the corporate guidelines for all branches of their corporation were to complete reviews once for all employees in May each year.The regional vice president said he would bring it up with corporate for discussion regarding the regulatory requirements to complete reviews at least every 12 months.The staff development coordinator was interviewed on 5/14/26 at 11:38 a.m. The staff development coordinator said the unit managers were responsible for completing employee reviews. The staff development coordinator said based on the outcome of the reviews, if an employee required additional training, he would provide that training.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of diseases and infection for two of three units.Specifically, the facility failed to:-Clean resident rooms in a hygienic manner;-Clean high touch areas; and, -Ensure dwell times were followed.Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures retrieved on 5/21/26 fromhttps://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html?CDC_AAref_Val=https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html Common high touch surfaces include bedrails, sink handles, call bells, bedside tables, doorknobs, and light switches.According to the Centers for Disease Control and Prevention (CDC) When and How to Clean and Disinfect a Facility on 5/5/26 fromhttps://www.cdc.gov/hygiene/about/when-and-how-to-clean-and-disinfect-a-facility.html#:~:text=During%20use,make%20sure%20germs%20are%20killed. After you apply the disinfectant to the surface, leave the disinfectant on the surface long enough to kill the germs. This is called the contact/wet time. The surface should stay wet during the entire contact time to make sure germs are killedAccording to the Diversey Virex 256 Manufacturer guidelines, retrieved on 5/21/26 at 6:00 p.m., retrieved from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.lalema.com/bt/bt_jh306278400_en.pdf The directions for use indicated that for disinfection, all surfaces must remain wet for 10 minutes. II. Facility policy and procedureThe Daily Room Cleaning policy and procedure, reviewed April 2026, was provided by the nursing home administrator (NHA) on 5/1/26 at 3:41 p.m. The policy read in pertinent part, The cleanliness of each resident's room is maintained on a daily basis by the housekeeping staff to provide a fresh, clean, and sanitary environment and reduce the potential for nosocomial infections. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Clean and disinfect using a hospital grade EPA registered cleaner/disinfectant solution. The facility should refer to the Diversey Approved Housekeeping Chemicals guide for a listing of appropriate cleaning and disinfectants -Clean high-touch surfaces at least daily including handwashing sinks. -Clean and disinfect high touch/frequently contaminated surfaces (sinks, faucets, handles, door handles, and clean toilet seat last) at least daily. III. Observations On 5/23/26 at 10:44 a.m. housekeeper (HK) #1 was cleaning room [ROOM NUMBER], a single occupancy room. At 10:44 a.m. HK #1 spray the sink with Virex disinfectant spray. At 10:46 a.m. HK #1 wiped the inside of the sink bowl and then wiped the outside of the sink and counter. At 10:46 a.m. HK #1 wiped the outside of the paper towel dispenser and the outside of the hand soap dispenser. HK #1 then cleaned the inside of the sink bowl again. -HK #1 failed to clean from the cleanest to dirtiest areas on the sink.On 5/13/26 at 10:53 a.m. HK #1 sprayed Virex onto a rag and then wiped the bedside table. At 10:56 a.m. the bedside table surface was dry. -However, according to the manufacturer guidelines the Virex 256 dwell time should have been ten minutes (see professional reference above).On 5/13/26 at 12:50 p.m HK #2 was cleaning room [ROOM NUMBER], a double occupancy room. At 12:51 p.m. HK #2 sprayed the sink with the Virex disinfectant cleaner. At 12:59 p.m. HK #2 wiped the inside of the sink and then the outside of the sink and counter with the same cloth. -However, according to the manufacturer guidelines the Virex 256 dwell time should have been ten minutes (see professional reference above).At 1:01 p.m. HK #2 scrubbed the inside of the toilet bowl and then the top of the toilet bowl rim with a toilet bowl scrub brush. At 1:02 p.m. HK #2 wiped the top of the toilet bowl rim and then brought the toilet seat down and wiped the top of the toilet seat with the same cloth. -HK #1 used the toilet bowl brush on the top of the toilet bowl. On 5/13/26 at 1:10 p.m. HK #2 sprayed the hallway door knob with the Virex directly and immediately wiped off the doorknob. -However, according to the manufacturer guidelines the Virex 256 dwell time should have been ten minutes (see professional reference above).IV. Staff interviewsHK #2 was interviewed on 5/13/26 at 1:20 p.m. HK #2 said she had been at the facility for two years and trained for about one week. HK #2 said it took five to ten minutes for the Virex to disinfect and kill bacteria. HK #2 said the surfaces did not need to remain wet for the entire five to ten minutes to be effective. HK #2 said the sink bowl was the dirtiest location of the sink. HK #2 said residents brush their teeth or blow their nose and everything falls into the sink. HK #2 said she only used one rag in the bathroom. HK #2 said she should have cleaned the toilet from top to bottom and/or from the cleanest to dirtiest areas. HK #2 said this was important to prevent contamination of one area to another.HK #2 said high touch areas included the bathroom sink and handles, bedside tables, drawer handles, and door knobs. HK #1 was interviewed on 5/13/26 at 11:15 a.m. HK #1 said she had been at the facility for a year and a half and was trained by her supervisor for a couple of days. HK #1 said she cleaned the inside of the sink to the outside of the sink. HK #1 said that because residents spit and brush their teeth inside of the sink, the inside of the sink would be dirtiest. HK #1 said, in the future, she would switch to a clean cloth after wiping the inside of the sink bowl.HK #1 said high touch areas included the bedside tables, phones, call lights, door knobs, counters, and rails. HK #1 said she sprayed a towel with the Virex enough to get it wet and used it to wipe surfaces. HK #1 said the facility did not have a bucket to dip rags into disinfectant, although she had seen that in her past work environments. HK #1 said she sprayed the Virex onto the rags so that she didn't accidentally spray the resident. HK #1 said she was taught to spray the Virex onto the rag during training. HK #1 said the Virex disinfectant should sit on surfaces for five minutes. -However, the bedside table did not remain wet with the disinfectant on it for ten minutes and therefore did not meet the dwell time (see observations above).The director of housekeeping was interviewed on 5/14/26 at 11:10 a.m. The director of housekeeping said the facility used Virex 256 disinfectant and the dwell time was five minutes. -However, the manufacturer guidelines indicated that the full Diversey Virex 256 dwell time was ten minutes The housekeeping supervisor said she understood the facility should base dwell times off of manufacturer guidelines and that the surface must stay wet for the dwell time. The housekeeping supervisor said that she would have a meeting with the housekeepers and ensure they understood surfaces had to stay wet for the entire dwell time. The housekeeper supervisor said the facility was planning on switching to a disinfectant with a shorter dwell in the near future. The housekeeping supervisor said high touch surfaces were bedside tables, call lights, controllers, door knobs, bathroom bars, and bathroom call lights. The housekeeping supervisor said that housekeepers should clean the sink from the outside of the sink to the inside of the sink. The housekeeping supervisor said it was not correct to clean the inside of the sink bowl and then clean the outside, because the inside of the sink was dirtier than the outside.The housekeeping supervisor said the proper way to clean the toilet was always from top to bottom. The housekeeping supervisor said that housekeepers should not have wiped the toilet bowl rim and then the toilet seat because that would spread germs. The housekeeping supervisor said housekeepers should be cleaning the toilets from top to bottom and then changing rags. The housekeeping supervisor said she would have a meeting with the housekeepers and review the adequate cleaning procedure.The infection preventionist (IP) was interviewed on 5/14/26 at 2:31 p.m. The IP said if a surface did not stay wet long enough, the surface was not being adequately disinfected and viruses and bacteria were not being killed. The IP said that could lead to MDRO (multidrug-resistant organism) or biofilms (a complex community of microorganisms that stick to the surface and encased themselves in a slimy protective matrix of extracellular polymeric substance).

Based on observations, record review and interview, the facility failed to develop an acute/baseline care plan for one (#51) of two residents reviewed for care planning out of 46 sample residents. Specifically, the facility failed to include Resident #51's seatbelt use on the baseline care plan.Findings include:I. Facility policy and procedureThe Person Centered Care Planning policy and procedure, reviewed 8/29/25, was retrieved from the executive director on 5/15/26 at 12:23 p.m. It read in pertinent part, Each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. The care plan will include measurable goals, timeframes to meet the patient's, cultural, nursing, mental, and psychosocial needs including services being provided to meet those needs. The care plan will reflect interventions that are person-centered, measurable, and include time frames to achieve the desired outcomes. The care plan will include services that may be needed but are not provided due to the patient's exercise of the right to refuse treatment, when applicable. The care plan will be developed and implemented to ensure consistency with implementation across all shifts. II. Resident #51A. Resident statusResident #51, age less than 65, was admitted on [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included nondisplaced spiral fracture of the shaft of the left tibia (a stable twisting break of the shinbone where the bone remains perfectly aligned), age related osteoporosis (a bone disease that causes bones to become weak and brittle), muscle weakness, spastic hemiplegic cerebral palsy (a neurological condition causing muscle stiffness and weakness on one side of the body), and unspecified lack of coordination. The 5/4/26 minimum data set (MDS) assessment revealed Resident #51 was cognitively intact and had a brief interview for mental status (BIMS) score of 15 out of 15. The MDS revealed Resident #51 used a wheelchair and required partial assistance from another person to complete self care. The MDS revealed Resident #51 had impaired movement on bilateral lower extremities. The MDS revealed Resident #51 required substantial/maximal assistance from staff to complete upper body dressing (the ability to dress and undress above the waist, including fasteners if applicable). B. Observations and resident interviewOn 5/12/26 at 3:49 p.m., Resident #51 was observed sitting in her room with a gait belt wrapped around her waist and her wheelchair. Resident #51 said she wanted to use the gait belt so she did not slide out of the wheelchair. Resident #51 said she could unclip the gait belt and demonstrated she could unclip the belt.C. Record reviewResident #51's Kardex (staff directive tool) was reviewed on 5/12/26 at 6:15 p.m. The Kardex did not reveal information or guidance regarding Resident #51's makeshift wheelchair safety belt.Review of Resident #51's baseline care plan on 5/12/16 at 4:02 p.m. did not reveal the use of a makeshift wheelchair safety belt. The care plan did not clarify whether or not Resident #51 had the ability to take off the makeshift wheelchair safety belt by herself. D. Staff interviewsCertified nurse aide (CNA) #4 was interviewed on 5/12/26 at 4:40 p.m. CNA #4 said it was their first time working with Resident #51. CNA #4 said they had not noticed the gait belt was around her waist and wheelchair. CNA #5 was interviewed on 5/12/26 at 4:48 p.m. CNA #5 said that she had just helped get Resident #51 back to bed. CNA #5 said Resident #51 was wearing a gait belt around the waist and wheelchair. She said Resident #51 was wearing it when they went into the resident's room. CNA #5 said Resident #51 wore the gait belt around her waist and wheelchair when she was up in her wheelchair for positioning. CNA #5 said that they took the gait belt off of Resident #51. CNA #5 said she had previously seen Resident #51 take the makeshift wheelchair safety belt off herself. CNA #5 said the Kardex contained information about the makeshift wheelchair safety belt. -However, review of the Kardex and baseline care plan did not reveal documentation regarding the makeshift wheelchair safety belt (see record review above). CNA #5 said they thought Resident #51 was using the belt for safety, to prevent Resident #51 from falling forward out of her wheelchair. CNA #5 said the gait belt had a clip which would release the gait belt. CNA #5 said she had previously seen Resident #51 take the belt off by herself. Licensed practical nurse (LPN) #4 was interviewed on 5/12/26 at 5:22 p.m. LPN #4 said she was not sure whether or not Resident #51's ability to remove the makeshift care plan should be included on the care plan. She said Resident #51 had the ability to take the belt off herself. LPN #4 navigated to the electronic medical record (EMR) on the computer. LPN #4 said she could not find any documentation in the physical therapy or occupational therapy notes regarding the gait belt. LPN #4 said she could not find information on the gait belt in Resident #51's care plan. LPN #4 said care plans were important because they directed nurses on how to provide care to residents. LPN #4 said it was important to have this information on the care plan, because the gait belt could potentially be a restriction to the resident. LPN #4 said Resident #51 asked for the belt to be around her waist and wheelchair. LPN #4 said the makeshift wheelchair safety belt could potentially be a restraint but the resident was requesting to wear it. LPN #4 said staff could not tell the resident that she could not wear the belt because it was her choice and her right to have whatever she wants.The director of rehabilitation was interviewed on 5/12/26 at 5:25 p.m. The director of rehabilitation said she was not aware that Resident #51 had been using the makeshift wheelchair safety belt. The director of rehabilitation said Resident #51 was in one of the facility's wheelchairs they provided her. The director of rehabilitation said Resident #51 transitioned to a different room less than a week ago. The director of rehabilitation said when Resident #51 moved, a friend or family member brought in her own personal wheelchair from home. The director of rehabilitation said they had not assessed Resident #51's usage of the gait belt yet. The director of rehabilitation said the facility would assess Resident #51 in her personal chair and see if the gait belt would be appropriate. The director of rehabilitation said Resident #51's ability to use the makeshift wheelchair safety belt was not currently care planned. The director of rehabilitation said Resident #51 and her usage of the makeshift wheelchair safety belt would be evaluated and then added to the care plan if appropriate to do so.Occupational therapist (OT) #1 was interviewed on 5/12/26 at 5:51 p.m. OT #1 said Resident #51 had just recently started using this new wheelchair and gaitbelt. OT #1 said Resident #51 had gotten this wheelchair from someone and that it was her own personal wheelchair. OT #1 said Resident #51 wanted to use the makeshift wheelchair safety belt and did not want to be transferred or sit in the wheelchair if she did not have the gait belt present. OT #1 said she used the makeshift wheelchair safety belt when going back to her room. OT #1 said Resident #51 had just recently started using this new personal wheelchair because Resident #51 felt more protected using it. OT #1 said that during Resident #51's initial evaluation, she had a facility provided wheelchair. OT #1 said there was not an assessment or evaluation done on the resident and her ability to take the gait belt off because Resident #51 recently started using it. OT #1 said Resident #51 was able to adjust the gait belt and take it off.

Based on observations, record review and interviews, the facility failed to ensure two (#16 and #90) of three residents who required respiratory care received care consistent with professional standards of practice out of 46 total sample residents. Specifically, the facility failed to set the oxygen concentrator according to the physician's order. Findings include:I. Facility policy and procedureThe Oxygen Administration policy, revised on 3/3/26, was received from the nursing home administrator (NHA) on 5/15/26 at 12:23 p.m. It read in pertinent part, Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air (20.9%) with the intent of treating or preventing the symptoms and manifestations of hypoxia. To ensure that oxygen is administered and stored safely within the facility or in an outside storage area. Oxygen orders should include the specific liter flow required by the resident. Residents receiving oxygen at 4 liters per minute (LPM) or greater, via concentrator, should be connected to a humidifier.II. Resident #16A. Resident statusResident #16, age [AGE], was admitted on [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included COVID-19, chronic obstructive pulmonary disease (COPD), pneumonia due to COVID-19, interstitial pulmonary disease, acute and chronic respiratory failure with hypoxia, and dependence on supplemental oxygen.The 4/16/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required moderate assistance with showering and supervision with dressing. The MDS assessment indicated Resident #16 was receiving oxygen therapy.B. ObservationsOn 5/11/26 at 1:00 p.m. Resident #16 was lying in his bed on his back. The resident had an oxygen concentrator next to his bed. He was receiving oxygen through a nasal cannula (NC). The oxygen concentrator was set to 3.5 LPM.At 4:30 p.m. Resident #16 was in his bed, lying on his back. The resident had an oxygen concentrator next to his bed. He was receiving oxygen through a nasal cannula. The oxygen concentrator was set to 3.5 LPM.On 5/12/26 at 2:00 p.m. Resident #16 was in his bed, lying on his back. The resident had an oxygen concentrator next to his bed. He was receiving oxygen through a nasal cannula. The oxygen concentrator was set to 3.5 LPM.At 3:30 p.m. Resident #16 was in his bed, lying on his back. His oxygen concentrator was set to 3.5 LPM and he was receiving oxygen through a nasal cannula.On 5/13/26 at 8:15 a.m. Resident #16 was in his bed, lying on his back. The resident had an oxygen concentrator next to his bed. He was receiving oxygen through a nasal cannula. The oxygen concentrator was set to 3.5 LPM.-However, according to the May 2026 CPO Resident #16 oxygen flow rate was supposed to be 4 LPM (see record review).C. Record reviewA review of Resident #16's May 2026 CPO revealed the following physician's orders:-Oxygen at 4 LPM continuously per nasal cannula. Ordered on 3/20/26.-Check oxygen saturation every shift. Ordered on 3/20/26.-However, observations revealed Resident #16's oxygen was not administered per physician orders (see observations above). The oxygen care plan, revised 3/20/26, revealed the resident had oxygen therapy due to COPD. The intervention was to follow oxygen ordersReview of the May 2026 medication administration record (MAR) revealed nursing staff were documenting and signing off that Resident #4 was receiving oxygen at 4 LPM. -However, observations revealed Resident #16's oxygen concentration was set to 3.5 LPM (see observations above). D. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 5/13/26 at 10:15 a.m. CNA #1 said Resident #16 received 4 ti 5 LPM oxygen continuously through a nasal cannula. She said Resident #16 did not refuse to wear his cannula. CNA #1 said Resident#16 complied with his oxygen. She said Resident #16 did not adjust his own oxygen flow. She said the CNAs were responsible to check oxygen setting daily during vitals.Licensed practical nurse (LPN) #1 was interviewed on 5/13/26 at 10:18 a.m. He said Resident #16`s physician order for oxygen was 4 LPM. He said Resident #16`s oxygen concentrator was set to 3.5 LPM. He said the physician's order had not changed since the initial order on 3/20/26. He said Resident #16 should be on 4 LPM oxygen as the physician order dictated. He said there was no active titration for Resident #16. III. Resident #90A. Resident statusResident #90, age greater than 65, was admitted on [DATE]. According to the May 2026 CPO, diagnoses included COPD with exacerbation, chronic respiratory failure with hypoxia, and dependence on supplemental oxygen.The 4/27/26 MDS assessment revealed Resident #90 had moderate cognitive impairments with a BIMS score of twelve out of 15. He required setup assistance with eating and moderate assistance with toileting and dressing. The MDS assessment revealed that the resident required continuous oxygen.B. ObservationsOn 5/11/26 at 9:00 a.m Resident #90 was sitting in his room on a chair. There was an oxygen concentrator next to him. He was receiving 2.5 LPM via a nasal cannula.At 4:07 p.m Resident #90`s oxygen concentration was set to 2.5 LPM.On 5/12/26 at 9:35 a.m. Resident`s #90`s oxygen concentration was set to 2.5 LPM.On 5/13/26 at 8:04 a.m. Resident`s #90`s oxygen concentration was set to 2.5 LPM.On 5/12/26 at 10:00 a.m. Resident`s #90`s oxygen concentration remained 2.5 LPM.-However, Resident #90`s oxygen flow rate was supposed to be 3 LPM, per physician's orders (see record review below).D. Record Reviews A review of Resident #90's May 2026 CPO revealed the following physician's orders:-Oxygen at 3 LPM continuously per nasal cannula. Ordered on 4/24/26.-However, observations revealed Resident #90's oxygen was not administered per physician orders (see observations above). Resident #90's oxygen care plan, revised 3/28/26, revealed Resident #90 had oxygen therapy. The intervention was to administer 3 LPM via nasal cannula continuously.E. Resident interviewResident #90 was interviewed on 5/12/26 at 10:50 a.m. He said he did not adjust his own oxygen concentrator because he did not want to be short of breath. He said the nurse adjusted it if it was needed. He said the CNA took his vitals once a day and checked the oxygen level. He said he did not remember if anybody adjusted it on that day. D. Staff interviewsCNA #2 was interviewed on 5/13/26 at 8:20 a.m. She said CNAs took the resident's vital signs in the morning and the oxygen level was checked during that time. She said either CNAs or the nurse entered the readings into the electronic medical record (EMR). She said she would let the nurse know if the readings were out of baseline. CNA #2 said the nurse would inform staff of a new resident`s LPM on admission. She said she had access to the EMRto check the oxygen orders. She said the oxygen levels were mandatory during the vitals. She said the staff had to be eye level with the oxygen concentrator meter ball to read the setting correctly. CNA #2 said the line on the meter should cross the ball in the middle. Registered nurse (RN) #1 was interviewed on 5/12/26 at 10:00 a.m. She said CNAs took vitals in the morning. She said the nurse entered the results into the electronic medical record system. RN #1 said Resident #90`s oxygen concentration was set to 2.5 at the time of the interview. She said the CNA took Resident #90`s vital signs that morning and the CNA marked it as 3 LPM. RN #1 said Resident #90 should receive 3 LPM as the order said. She said it was important to follow the physician's order for the safety and well-being of the residents. IV. Additional staff interviewsThe director of nursing (DON) was interviewed on 5/13/26 approximately at 6:00 p.m. She said she expected the staff to follow oxygen orders. She said following oxygen orders was important for oxygenation. She said if a resident was not compliant with his oxygen orders, she would expect staff to mention it in the progress notes and in the care plan.

Based on observation, record review and interviews, the facility failed to ensure the resident was treated with respect and dignity and care was provided in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life to one (#90) out of three residents of 46 total sample residents.Specifically, the facility failed to ensure Resident #90 was provided with clean clothing. Findings include:I. Facility policy and procedureThe Resident Rights policy, revised on 3/3/26, was received from the nursing home administrator (NHA) on 5/15/2026 at 12:23 p.m. It read in pertinent part, A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. II. Resident #90A. Resident statusResident #90, age greater than 65, was admitted on [DATE]. According to the May 2026 computerized physician's order (CPO), diagnoses included chronic obstructive pulmonary disease with exacerbation( a respiratory disease with suddening symptoms), chronic respiratory failure with hypoxia (a long-term condition of failure to exchange oxygen), and dependence on supplemental oxygen.The 4/27/26 minimum data set (MDS) assessment revealed Resident #90 had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 12 out of 15. He required setup assistance with eating and moderate assistance with toileting and dressing. B. ObservationOn 5/11/26 at 11:00 a.m Resident #90 was sitting in his room. He was wearing blue jeans and a black t-shirt. The t-shirt was soiled with food stains. His closet contained a clean blue pair of underwear and a clean dark blue set of shorts. There were four long sleeve button-up shirts hanging in the closet.There was a pile of soiled clothing in a blue bag at the bottom of the closet.On 5/12/26 approximately at 9:00 a.m Resident #90 was wearing the same clothes as he was the day before. On 5/13/26 approximately at 10: a.m Resident #90 was wearing the same clothes as he was on 5/11/26.On 5/14/26 at approximately 1:00 p.m. Resident #90 was wearing the same clothes.C. Resident interviewResident #90 was interviewed on 5/11/26 at 11:00 a.m. He said he did not have any clean clothes besides one set of underwear and shorts. He said he was saving his last clean outfit for his discharge date . Resident #90 said he had been wearing the same clothes since Saturday (5/9/26).Resident #90 said he had asked the staff several times to take his soiled clothes to the laundry. He said he had around five to six pairs of underwear and he did not think his soiled clothes were ever taken to the laundry since he had been at the facility. Resident #90 said the staff kept forgetting about his laundry or they said that they were too busy and the next shift would do it. Resident #90 said he was upset that he did not have clean underwear to wear. He said he wanted to change his underwear at least every other day if not more often.D. Record reviewA review of the dressing task sheet for Resident #90 (4/24/26 to 5/14/26) documented the following:On 5/11/26 at 10:00 a.m. and 10:54 a.m. It documented Resident #90 was independent with changing his own clothing:On 5/12/26 at 5:00 p.m. It documented Resident #90 was independent with changing his clothes;On 5/13/26 at 12:07 a.m. and 10:53 a.m. It documented Resident #90 was independent with changing his clothes; [NAME] 5/14/26 at 4:35 a.m. and 7:49 a.m. It documented Resident #90 was independent with changing his clothes.-However, the facility failed to clean the resident's clothes (see resident interview above).III. Staff interviewsCertified nurse aid (CNA) #2 was interviewed on 5/13/26 at 8:20 a.m. She said the residents would let the staff know if they needed the staff to take soiled clothes to the laundry. She said the CNAs, nurses, or housekeeping were responsible for picking up and delivering the laundry. She said the facility did not track the frequency of each resident`s request and there was no system in place to make sure residents always had clean clothes to wear. She said the staff checked the residents` closet for soiled clothes. CNA #2 said if a resident had no clean clothing to wear the facility would look at donated clothes on hand to see if there was any clothing they could give to residents. CNA #2 said if residents were independent with changing their clothing, the staff would ask if they had changed or if they needed clean clothing. She said the staff collected soiled clothing during both shifts. CNA #2 said residents had complained to her about running out of clean clothes before because housekeeping could not keep up with the demand sometimes. She said she let housekeeping know if a resident ran out of clothes. CNA #1 was interviewed on 5/13/26 at 9:15 a.m. She said the staff collected soiled laundry daily. She said Resident #90 did not refuse to change clothes or get his soiled laundry collected. She said if a resident was independent with dressing, she would still ask if they had soiled laundry to wash. She said she collected and asked all residents if they needed laundry to be laundered.The housekeeping supervisor was interviewed on 5/13/26 at 9:35 a.m. She said the laundry was completed daily. She said she did not have a way of knowing if a resident's laundry was not being done for any period of time. The housekeeping supervisor said the CNAs would know more about this. Registered nurse (RN) #1 was interviewed on 5/13/26 at 10:00 a.m. She said Resident #90 was independent with most of his activities of daily living and he was able to change clothes independently. She said she did not know when Resident #90 changed his clothes last time, but she was going to ask Resident #90. She said it was the CNAs responsibility to notice if a resident had not or needed to change their clothing. The director of nursing (DON) was interviewed on 5/14/26 approximately at 6:00 p.m. She said that CNAs should be asking residents daily if they needed their clothing laundered. She said from the nursing point of view staff should be noticing if a resident had not been changed for days.

Based on record review and interviews, the facility failed to thoroughly investigate an allegation of misappropriation of residents property for two (#44 and #66) of two residents out of 46 sample residents.Specifically, the facility failed to investigate allegations of misappropriation of property for Resident #44 and Resident #66. Findings include:I. Facility policy and procedureThe Resident Rights policy, reviewed September 2025, was provided by the nursing home administrator (NHA) on 5/15/26 at 12:23 p.m. It read in pertinent part, The resident has the right to be free from abuse, neglect, misappropriation of the resident's property, and exploitation. The Abuse Protection of Residents policy, reviewed April 2026, was provided by the NHA on 5/15/26 at 12:23 p.m. It read in pertinent part, The facility must develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property.Establish policies and procedures to investigate any such allegations.II. Resident #44A. Resident statusResident #44, age [AGE], was admitted on [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus (a chronic condition where the body resists insulin or fails to produce enough insulin, causing high blood sugar), cognitive communication deficit, chronic fatigue, muscle weakness, restless legs syndrome (a neurological condition causing an irresistible urge to move the legs) and major depressive disorder.The 4/9/26 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired, with a brief interview for mental status (BIMS) score of three out of 15.B. Resident #44's representative interviewResident #44's representative was interviewed on 5/12/26, at 1:43 p.m. The representative said the social services director (SSD) originally notified her of the disappearance of Resident #44's hearing aids on 5/5/26. The representative said the SSD told her the hearing aids, their storage case and the charging port could not be located. The representative said the SSD told her Resident #44 had thrown the items into her room's trash can. She said it was highly unlikely that the resident would dispose of multiple components without staff noticing.The resident's representative said she was concerned about the facility's failure to protect the devices, which were left unsecured at the bedside. The resident's representative said the SSD did not mention during their conversation whether the incident was being investigated. She said the SSD asked if she would be willing to contribute $600.00 toward replacing the hearing aids. The representative said the SSD also proposed substituting the hearing aids with a pocket talker device. The representative said she disagreed with permanently replacing the hearing aids with a pocket talker. She said she did not believe Resident #44 would benefit from that type of equipment. The resident's representative said she believed the facility failed to protect the resident's property. She said the facility failed to investigate the missing hearing aids. She said she wanted the hearing aids replaced because the facility failed to properly investigate the circumstances surrounding the disappearance. She said as of the date of the interview, the facility had failed to resolve the issue to her satisfaction.C. Resident interview Resident #44 was interviewed on 5/13/26 at 2:05 p.m. Resident #44 said she was informed by a staff member that her hearing aids were being repaired and would be returned to her upon completion. Resident #44 said she did not remember the staff member's name.D. Record reviewThe communication care plan, initiated 6/18/19 and revised 5/5/26, revealed Resident #44 had a communication problem related to hearing deficits and a history of throwing away hearing aids and equipment. Pertinent interventions included anticipating and meeting the resident's needs, ensuring the resident's hearing aids were charged at night, and observing for the residents' ability to express and comprehend language, memory and reasoning ability.-The care plan did not include interventions to ensure the resident did not throw away her hearing aides. A review of the facility's grievance forms for Resident #44 over the previous six months revealed a grievance form, completed by the social services director on 5/5/26 at 4:47 p.m. The grievance form indicated that Resident #44's hearing aids were reported lost to social services. The SSD documented that it would cost $300.00 out of pocket to replace each one.-However, there was no documentation indicating the facility completed an investigation to determine how the resident's hearing aids, charger and storage case went missingA psychosocial note, dated 5/5/26 at 4:57 p.m., revealed that social services was alerted that Resident #44's hearing aids had been misplaced. -However, there was no documentation indicating the facility investigated to determine if the hearing aids were stolen or misplaced.III. Resident #66A. Resident statusResident #66, age less than 65, was admitted on [DATE]. According to the May 2026 CPO, diagnoses included chronic respiratory failure with hypoxia (a condition in which body tissues and cells do not receive enough oxygen to function properly), chronic diastolic congestive heart failure, type 2 diabetes mellitus, major depressive disorder and anxiety disorder.The 5/7/26 MDS assessment revealed Resident #66 was cognitively intact with a BIMS score of 15 out of 15. B. Resident interviewResident #66 was interviewed on 5/13/26 at 2:44 p.m. Resident #66 said two boxes of personal Christmas ornaments, which had sentimental value, went missing from her room right after the Christmas holidays. Resident #66 said she notified the NHA immediately upon becoming aware that they were missing from her bathroom. Resident #66 said the NHA did not provide her with a grievance form to complete. She said she did not hear back from the NHA and the items were not located. Resident #66 said there was no resolution to the issue and felt the facility did not care to resolve the issue.C. Record reviewA request for an investigation regarding Resident #66's allegation of her missing sentimental Christmas ornament on 5/13/26 at 8:10 a.m. The NHA said the facility had not investigated the resident's allegation of missing Christmas ornaments. IV. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 5/13/26 at 11:32 a.m. LPN #2 said Resident #44 had a history of throwing hearing aids in the trash and accidentally leaving the device on a meal tray. LPN #2 said she did not remember what interventions were introduced for staff to implement to help prevent the devices from being lost. LPN #2 said the device and its accessories were kept on top of the resident's bedside drawer. LPN #2 said there was a trash can positioned by Resident #44's bedside drawer. LPN #2 said that Resident #66 had informed her about her missing Christmas ornament boxes a while back. LPN #2 said she did not inform the director of nursing (DON) or the NHA about Resident #66's missing ornaments. LPN #3 was interviewed on 5/13/26 at 11:40 a.m. LPN #3 said that Resident #44 had hearing impairments. LPN #3 said the staff had to talk loudly when speaking to her. LPN #3 said that the resident's hearing aids were stored on top of the resident's bedside drawer at all times when not in active use. LPN #3 said he had not seen the hearing aids or their accessories for quite some time. He said he had been out on vacation, and upon his return to the facility, the devices were no longer available. LPN #3 said he did not know why the hearing aids had been left on top of the resident's bedroom drawer rather than being safely secured when not in use.The SSD was interviewed on 5/13/26 at 11:50 a.m. The SSD said Resident #44 had hearing impairments. She said the hearing aids were stored on top of the resident's bedside drawer at all times when not in active use. The SSD said the staff reported to her on 5/5/26 that the hearing aids, along with all associated accessories, were missing from the resident's room. The SSD said it was unlikely for a resident with severe cognitive impairments to have intentionally thrown away the hearing aids along with all of their accessories. The SSD said that she did not know why the hearing aids had been left on top of the resident's bedroom drawer rather than being safely secured when not in use.The NHA was interviewed on 5/14/26 at 10:12 a.m. The NHA said she was aware that Resident #44's hearing aids, storage equipment and charger were missing and had not been found. The NHA said it was the facility's policy to ensure all personal property, especially assistive devices necessary for a resident's quality of life, were logged, tracked, and securely stored. The NHA said facility staff were trained and were expected to assist residents who could not manage these devices independently. The NHA said staff relied on the care plan for interventions. The NHA said if specific interventions were not written, consistency across shifts became a significant challenge. The NHA said Resident #44 had a documented history of throwing away her hearing aids in the trash. The NHA said she did not conduct a formal investigation of the missing hearing aids.The NHA said Resident #66 informed her that her Christmas ornaments were missing from her bathroom. She said she asked an activities staff member to help the resident find the missing ornaments. The NHA said she did not receive feedback from the activities staff member and she failed to follow up with the staff member and Resident #66. The NHA said she felt the Christmas ornaments were not a big deal to Resident #66. -However, Resident #66 said the Christmas ornaments were sentimental to her (see resident interview above).

Based on observations, record review, and interviews, the facility failed to provide ongoing programs to support choices of activities and engaging programming based on the comprehensive assessment and care plan, that were designed to meet the interests of and support the physical, mental, and psychosocial well-being of one (#89) of two residents reviewed for activities out of 46 sample residents.Specifically, the facility failed to offer and provide personalized, meaningful activity programs for Resident #89 as documented in her care plans.Findings include:I. Facility policy and procedure The Therapeutic Activities Program policy, revised 3/24/26, was received from the nursing home administrator (NHA) on 5/14/26. It documented in pertinent part, Based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. Activities refers to any endeavor, other than routine activities of daily living (ADLs), in which a resident participates that is intended to enhance her/his sense of well-being and to promote or enhance physical, cognitive, and emotional health. These include, but are not limited to, activities that promote self-esteem, pleasure, comfort, education, creativity, success, and independence.II. Resident #89A. Resident statusResident #89, age greater than 65, was admitted on [DATE]. According to the May 2026 computerized physician orders (CPO) diagnoses included vascular dementia with agitation and depression (mood imbalance).The 5/5/26 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment, with short term and long term memory issues per staff assessment. The resident was dependent on staff assistance for all ADLs.The MDS assessment revealed it was very important to the resident to listen to music, watch movies, be read to, and participate in animal-related activities. It was somewhat important to her to watch television.B. ObservationsDuring a continuous observation on 5/12/26, beginning at 1:43 p.m. and ending at 5:36 p.m., the following was observed:At 1:43 p.m. Resident #89 was asleep in bed. There was no music playing in the resident's room or any other type of meaningful activity. At 3:39 p.m. the resident was transferred to a wheelchair and positioned outside her room holding a stuffed animal. At 5:17 a.m. an unidentified staff member walked past Resident #89 and did not engage with the resident or provide meaningful activity.At 5:36 p.m. Resident #89 remained in her wheelchair in the hallway.During a continuous observation on 5/13/26, beginning at 8:30 a.m. and ending at 9:27 a.m., the following was observed:At 8:45 a.m. Resident #89 was lying in bed in her room with the television (TV) on. -No staff offered to assist Resident #89 to the scheduled 9:15 a.m. radio activity. C. Resident #89's representatives interviewResident #89's representative was interviewed on 5/11/26 at 2:30 p.m. Resident #89's representative said any time she came to visit her mother she often found her alone without any of the stuffed animals or busy boxes she had provided forResident #89to use. She said she had a strong desire to see Resident #89 involved in social activities. She said She knew Resident #89 was unable to participate in some activities due to her cognition, but sitting alone was not okay.D. Record reviewResident #89's activity care plan, revised 3/19/26, revealed Resident #89 was not alert, nor able to make her activity needs known. The care plan documented Resident #89 enjoyed music, reading, TV, animal visits and coloring. Pertinent interventions included encouraging as much social participation as possible during care activities, having one-on-one interactions, respecting the residents right to refuse conversation, encouraging the resident to play with a toy, busy blanket, or baby doll to comfort her as needed. Review of Resident #89's activity participation record (2/29/26 to 5/14/26) revealed the resident actively participated in TV daily. -The record failed to reveal documentation indicating the resident had participated in her preferred activities. The participation record revealed Resident #89 participated in six out of 35 music-related activities. The record did not document the resident had refused to attend. The participation records revealed out of 17 pet visits, Resident #89 did not participate in any of them. There were no documented refusals for pet visits.The participation records revealed out of 10 opportunities to participate in watching movies Resident #89 participated in one. There were no documented refusals. The participation records revealed out of 16 nail care activities Resident #89 participated in none. There with no documented refusals.III. Staff interviewsThe activities director (AD) was interviewed on 5/14/26 at 11:50 a.m. The AD said he was newly hired to the facility. The AD said the Resident #89 attended music activities including a one-on-one music therapy session in her room, but Resident #89 needed assistance to get to the activities. The AD said the activity department had staff coverage seven days a week and that activities staff invite all residents to each activity. He said everyone was invited to all activities. He said they even invited the residents who did not want to participate in the activity. He said it was his personal goal to have something for everyone to do, even if it was in their own room. The AD said that if an event was canceled, the activities staff try to let the residents know in a timely manner, and try to replace the event with something else, and post the change to the events calendar near the dining room. The AD said he and his staff conduct activities assessment for each resident quarterly or make changes based on changes in each resident's care plan.

Based on observations, record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain hearing abilities for one (#44) of two residents reviewed for hearing and vision problems out of 46 sample residents.Specifically, the facility failed to ensure Resident #44 was assisted with alternate devices while she waited for her missing hearing aids to be replaced. Findings include:I. Facility policy and procedureThe Vision and Hearing Assistive Devices policy, revised September 2025, was provided by the nursing home administrator (NHA) on 5/15/26 at 12:23 p.m. It read in pertinent part, To ensure residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident with assistive devices, which include but not limited to hearing aids and amplifiers.II. Resident #44A. Resident statusResident #44, age [AGE], was admitted on [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus (a chronic condition where the body resists insulin or fails to produce enough causing high blood sugar), cognitive communication deficit, chronic fatigue, muscle weakness, restless legs syndrome (a neurological condition causing an irresistible urge to move the legs), and major depressive disorder.The 4/9/26 minimum data set (MDS) assessment revealed the resident was cognitively impaired, with a brief interview for mental status (BIMS) of three out of 15.The assessment indicated the resident required hearing aids.B. Resident #44's representative interviewThe resident representative was interviewed on 5/12/26 at 1:43 p.m. The representative said the social services director (SSD) notified her that Resident #44's hearing aids went missing on 5/5/26. The resident representative said the absence of hearing aids created a severe communication barrier with Resident #44. She said that without the device and any alternative devices or methods, it became difficult and frustrating to communicate with the resident over the phone and significantly more difficult to engage in meaningful interactions. The resident's representative said it affected the overall quality of their time spent together.C. Resident observationsOn 5/12/26 at 2:10 a.m. Resident #44 was sitting in her recliner in her room with two family members. Throughout the interaction, Resident #44 frequently leaned forward to decrease the distance between herself and her daughter in an attempt to understand what was being said. Additionally, the resident repeatedly leaned back into her recliner, pointed to her ears, said she could not hear her daughter, and asked her daughter what she said.On 5/13/26 at 4:14 p.m. Resident #44 was in her room sitting in her recliner without her hearing aids and no alternative communication device was available to her.On 5/14/26 at 9:55 a.m. Resident #44 was in her room without her hearing aids and no alternative communication device was available to the resident.D. Record reviewThe communication care plan initiated on 6/18/19 and revised on 5/5/26, revealed the resident had a communication problem related to a hearing deficit. The care plan documented it was reported hearing aids were missing on 5/5/26 and had not been replaced. The care plan documented Resident #44 had a history of throwing the hearing aids in the trash. Interventions included using alternative communication tools as needed and discussing with the resident and resident's family concerns or feelings regarding communication difficulties.III. Staff interviewsCertified nurse aide (CNA) #2 was interviewed on 5/13/26 at 12:55 p.m., CNA #2 said Resident #44 had a hearing impairment and it was difficult to communicate with her without her hearing aids. CNA #2 said the resident's hearing aids had been missing for about three weeks. She said there had been no alternative communication device available.Licensed practical nurse (LPN) #3 was interviewed on 5/13/26 at 1:14 p.m., LPN #3 said Resident #44's hearing aids had been missing for some time now. LPN #3 said it has been difficult communicating with the resident without her hearing aids. He said the staff had to speak very loudly into Resident #44's ears in order for her to hear. LPN #3 said Resident #44 became frustrated when she could not hear and communicate appropriately with the staff. LPN #3 said there was no alternative communication device available to the resident.The SSD was interviewed on 5/14/26 at 10:20 a.m. The SSD said Resident #44 had a hearing deficit and required hearing aids. The SSD said she was informed Resident #44's hearing aid was missing and could not be located. The SSD said the staff was supposed to maintain and safeguard the hearing aids. The SSD said the resident requires assistance to wear the hearing aids and agreed that it should not be left on the resident's bedside drawer. The SSD said she was in contact with the resident's representative to obtain a replacement hearing aid or an alternative communication device. The SSD said Resident #44 did not currently have an alternative communication device.

Based on record review and interviews, the facility failed to ensure residents were provided prompt efforts by the facility to resolve grievances for two (#44 and #66) of three residents reviewed for grievances out of 46 sample residents. Specifically, the facility failed to:-Effectively report, document, resolve, and follow-up on Resident #44's grievance regarding missing hearing aides and charger; and, -Effectively report, document, resolve and follow-up on Resident #66's grievances about two boxes of Christmas ornaments that went missing. Findings include:I. Facility policy and procedureThe Grievance Program Concern and Comment policy, revised 1/7/25, was received from the nursing home administrator (NHA) on 5/15/26 at 12:23 p.m. It read in pertinent part, The resident has the right to, and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph. Prompt efforts to resolve refers to the facility acknowledgment of a compliant/grievance and actively working toward the resolution of that complaint/grievance. Any associate can assist in the completion of a concern and comment form. The facility will maintain a recordkeeping system of all complaints reported via the Concern and Comment Program and it shall include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns, and a statement as to whether the grievance was confirmed or not confirmed. Following up with the resident and family to communicate a resolution or explanation and ensure that the issue was handled to the resident and family's satisfaction. The executive director and/or designee is responsible for overseeing the facility's overall grievance program. II. Resident #44A. Resident statusResident #44, age [AGE], was admitted on [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus (a chronic condition where the body resists insulin or fails to produce enough causing high blood sugar), cognitive communication deficit, chronic fatigue, muscle weakness, restless legs syndrome (a neurological condition causing an irresistible urge to move the legs), and major depressive disorder.The 4/9/26 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) of three out of 15.B. Resident #44's representative interviewThe resident's representative was interviewed on 5/12/26, at 1:43 p.m. The representative said the social services director (SSD) originally notified her of the disappearance of Resident #44's item on 5/5/26. The representative said the SSD told her that the resident's hearing aids, their storage case, and the charging port could not be located. The representative said the SSD told her Resident #44 had thrown the items into her room's trash can. She said it was highly unlikely that the resident would dispose of multiple components without staff noticing.The resident's representative said she was concerned about the facility's failure to protect the devices, which were left unsecured at the bedside. The resident's representative said the SSD did not mention during their conversation whether the incident was being investigated. She said the SSD asked if she would be willing to contribute $600 toward replacing the hearing aids. The representative said e the SSD also proposed substituting the hearing aids with a pocket talker device. The representative said she disagreed with permanently replacing the hearing aids with a pocket talker. She said she did not believe Resident #44 would benefit from that type of equipment. The resident's representative said she believed the facility failed to protect the resident's property. She said the facility failed to investigate the missing hearing aids. She said she wanted the hearing aid replaced because the facility failed to properly investigate the circumstances surrounding its disappearance. She said as of the date of this interview, the facility had failed to resolve the issue to her satisfaction.C. Resident interview Resident #44 was interviewed on 5/13/26 at 2:05 p.m. The resident said she was informed by a staff member that her hearing aids were being repaired and would be returned to her when the repairs were completed. Resident #44 said she did not remember the staff member's name.D. Record reviewA review of the facility's grievance forms for Resident #44 over the previous six months revealed a grievance form was completed by the SSD on 5/5/26 at 4:47 p.m. The grievance form revealed that the SSD had been notified that Resident #44's hearing aids were lost. The SSD documented that it would cost $300 out of pocket to replace each one.-However, there was no documentation regarding the facility resolved the concern.A psychosocial note, dated 5/5/26 at 4:57 p.m., revealed that the social services were alerted that Resident #44's hearing aids had been misplaced. A second grievance report summary was filed and provided by the NHA on 5/13/26. The report was completed and signed by the NHA. It revealed that the SSD left a voicemail with the resident's representative to inform her that the facility had resolved the incident of the missing hearing aids. It revealed the facility to order a pocket talker and the incident was considered resolved.-However, the grievance form was completed and considered resolved without Resident #44's representative's approval. The representative said she did not approve of the pocket talker as a replacement (see interview above). III. Resident #66A. Resident statusResident #66, age less than 65, was admitted on [DATE]. According to the May 2026 CPO, diagnoses included chronic respiratory failure with hypoxia (a condition in which body tissues and cells don't receive enough oxygen to function properly), chronic diastolic congestive heart failure, type 2 diabetes mellitus, major depressive disorder, and anxiety disorder.The 5/7/26 MDS assessment revealed Resident #66 was cognitively intact with a BIMS of 15 out of 15. B. Resident interviewResident #66 was interviewed on 5/13/26 at 2:44 p.m. Resident #66 said two boxes of personal Christmas ornaments, which had sentimental value, went missing from her room right after the Christmas holidays. Resident #66 said she notified the NHA immediately upon becoming aware that they were missing from her bathroom. Resident #66 said the NHA did not provide her with a grievance form to complete. She said she did not hear back from the NHA and the items were not located. Resident #66 said there was no resolution to the issue and felt the facility did not care to resolve the issue.C. Record reviewA review of the facility's grievance log from 12/1/25 through 5/13/26 revealed that no entries were documented regarding Resident #66's reported missing Christmas ornaments. IV. Staff interviewsThe SSD was interviewed on 5/13/26 at 10:15 a.m. The SSD said it was the responsibility of every staff member to ensure that residents' grievances were documented and reported to the NHA, the grievance official. The SSD said the initial grievance form would be submitted to her and she would immediately initiate an investigation and if the incident was not resolved, she would turn it in to the NHA for further review and consideration. The SSD said she was not aware of any missing boxes of Christmas ornaments belonging to Resident #66. The SSD said she became aware that Resident #44's hearing aids were missing on 5/5/26, and immediately contacted the audiologist to inquire about obtaining replacements. She said that the audiologist indicated it would cost $600 to obtain the replacement devices. -However, the grievance form documented the cost was $300 (see record review above). The SSD said she contacted the resident's representative to inquire whether the resident would be willing to cover the out-of-pocket cost, and she also discussed the alternative of replacing the hearing aids with a pocket talker. The SSD said she said Resident #44 probably should have not had access to her hearing aides when they were not in use, since she had a history of leaving them on meal trays due to her impaired cognition. She said that it was highly unusual for all of the hearing aid accessories, including the charger, to have gone missing along with the devices.Licensed practical nurse (LPN) #2 was interviewed on 5/13/26 at 11:25 a.m. LPN #2 said that if a resident reported a missing item or if staff identified that a resident's personal property went missing, it was the responsibility of each staff member to assist the resident in locating the item. LPN #2 said that if the item could not be found, staff were expected to assist residents in completing a grievance form if the resident was unable to do so independently, and to submit it to the SSD. LPN #2 said Resident #66 had informed her about her missing Christmas ornament boxes a while back.LPN #2 said she did not complete a grievance form for the resident's concern, even though she should have. LPN #2 said she forgot to document the missing items in the resident's electronic medical record (EMR). The NHA and the regional vice president were interviewed on 5/13/26 at 1:25 p.m. The NHA said she was the grievance official and was involved in most grievance resolutions. The NHA said staff members filled out a grievance form whenever a resident reported a personal item was missing. The NHA said she believed Resident #44 had thrown away her hearing aids because of a history of doing so. She said she did not know why the hearing aids were left by the resident's bedside to charge. The NHA said she did not investigate the missing hearing aids because she did not investigate every reported missing blue sock.Cross reference F602: free from misappropriation of property. The NHA said Resident #66 informed her that her Christmas ornaments were missing from her room and asked an activity staff member to assist in locating them. The NHA said the activity staff member no longer worked for the facility. She said she did not complete a grievance form when she became aware of the missing ornaments. The NHA said she did not follow up on it to ensure Resident #66's concern was resolved. The regional vice president said the facility would review its grievance process and educate staff to ensure grievances are documented, investigated, and resolved in a timely manner.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection for two out of three units. Specifically, the facility failed to: -Ensure disinfectant dwell times were followed by the housekeeping staff when cleaning resident's rooms; and, -Ensure staff performed hand hygiene appropriately when passing medications. Findings include: I. Failure to ensure disinfectant dwell times were followed appropriately A. Facility policy The Daily Room Cleaning policy and procedure, revised 2/24/22, was received by the nursing home administrator (NHA) on 2/27/24 at 12:37 p.m. The policy read in pertinent part, The cleanliness of each resident's room is maintained on a daily basis by the housekeeping staff to provide a fresh, clean, and sanitary environment and reduce the potential for nosocomial infections. All housekeeping personnel must adhere to infection prevention and control guidelines. Using a damp rag (Hospital Grade EPA Registered Disinfectant List N and water) damp dust the room starting with the resident's area (over bed table, bedside table, and phone) and move to the rest of the items in the room. This includes window sills, door frames, shelves, walls, and doors. Clean and disinfect restrooms. Using a Hospital Grade EPA Registered Disinfectant List N solution and clean rag, wipe counters, shelves, shower, horizontal, and vertical surfaces. B. Observations During an observation on 2/22/23 at 11:48 a.m. in room [ROOM NUMBER], housekeeper (HSK) #1 was cleaning the resident's room. HSK #1 sprayed Virex II 256 disinfectant around the sink and inside of the sink and then went into the bathroom and flushed the toilet and sprayed around the toilet with Virex II 256 disinfectant. -At 11:49 a.m. (one minute after spraying the sink with the disinfectant), HSK #1 turned on the water in the sink and wet the clean rag and used the wet rag to clean inside the sink. HSK #1 took another clean rag and wiped around the sink. She grabbed a couple of paper towels and finished cleaning around the sink. HSK #1 disposed of the two rags she had used to clean the sink area. -HSK #1 failed to leave the sprayed disinfectant on the sink surface for the 10 minute dwell time before wiping the sink. At 11:52 a.m. HSK #1 took the Virex II 256 disinfectant spray and two clean rags back into room [ROOM NUMBER]. She sprayed one of the clean rags with the disinfectant spray, turned on the water in the sink and got the rag wet and began wiping down the top of the resident's bedside table. -HSK #1 wiped the top of the resident's bedside table for 10 seconds. -HSK #1 failed to spray the top of the bedside table directly with the disinfectant and wait the dwell time of 10 minutes before wiping down the bedside table. During an observation on 2/26/24 at 9:40 a.m. in room [ROOM NUMBER], HSK #2 was cleaning the resident's room. HSK #2 had the Virex II 256 disinfectant spray and two clean rags sitting on top of the sink. At 9:47 a.m. HSK #2 sprayed the Virex II 256 disinfectant spray around the sink and in the sink. She turned on the sink and placed the clean rag under the water to wet it and began cleaning around the sink and inside the sink. -HSK #2 failed to leave the sprayed disinfectant on the sink surface for the 10 minute dwell time before wiping the sink. At 9:48 a.m., HSK #2 got a clean rag, sprayed, Virex II 256 disinfectant spray directly on the rag and began wiping down the top of the resident's bedside table. -HSK #2 failed to spray the top of the bedside table directly with the disinfectant and wait the dwell time of 10 minutes before wiping down the bedside table. C. Record review The material safety data sheet (MSDS) was provided by the housekeeping director (HSKD) on 2/26/24 at 2:00 p.m. The disinfectant in the facility was identified as VIREX II 256. It was a one-step disinfectant cleaner. The directions for the VIREX II 256 disinfectant spray read in pertinent part, Apply solution to hard, non-porous environmental surfaces. Contact time: allow surface to remain wet for 1 (one) minute to kill human immunodeficiency virus (HIV)-1, 5 (five) minutes to kill hepatitis b virus (HBV) and hepatitis c virus (HCV), and for 10 minutes to kill all other organisms cited on the label. D. Staff interviews HSK #1 was interviewed on 2/22/24 at 11:55 a.m. She said when she used the Virex II 256 disinfectant spray she used a little bit of water because the smell was strong for the residents. HSK #2 was interviewed on 2/26/24 at 9:50 a.m. She said when the residents were not in the room she could do a better job deep cleaning but when the residents were in the room she could only clean what she was able to get to. She said she would deep clean three to four rooms a week. She said she did not know if the disinfectant spray she used was safe to clean the bedside table tops so she said she used soap and water and a little bit of the Virex II 256 disinfectant spray to clean them. HSK #2 was interviewed again on 2/26/24 at 1:10 p.m. HSK #2 said she had been trained to leave the disinfectant spray on for three to four minutes and then wipe it off the surfaces. She said she thought that was the right way to do it. HSK #1 was interviewed again on 2/26/24 at 1:20 p.m. HSK #1 said she left the disinfectant spray on surfaces for five minutes before wiping it off. She said she was trained to leave the disinfectant spray on for five minutes. The HSKD was interviewed on 2/26/24 at 1:47 p.m. She said the dwell time for the disinfectant spray was 10 minutes. She said she trained housekeeping staff on the appropriate dwell times. She said she reminded her staff at least once a month about dwell times. She said housekeeping staff used water and the disinfectant spray because the residents did not like the smell of the disinfectant spray. The HSKD said it was not okay to dilute the disinfectant spray. She said diluting the disinfectant spray with water was concerning because it would not kill all the viruses or bacteria if it was diluted. 47960 II. Failure to ensure hand hygiene was performed effectively during medication administration A. Professional reference According to the Centers for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings (1/18/21), retrieved on 2/29/24 from https://www.cdc.gov/handhygiene/providers/index.html, Cleaning your hands reduces the spread of potentially deadly germs to patients. Alcohol-based hand sanitizers are the most effective products for reducing the number of germs on the hands of healthcare providers. Alcohol-based hand sanitizers are the preferred method for cleaning your hands in most clinical situations. Wash your hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom. When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use towel to turn off the faucet. Avoid using hot water, to prevent drying of skin. B. Observations On 2/26/24 at 9:02 a.m., licensed practical nurse (LPN) #1 prepared medications for a resident. She walked to the resident's room with her blood pressure cuff and stethoscope and administered medications to the resident after obtaining the resident's blood pressure and pulse. LPN #1 returned to the medication cart, put on gloves and cleaned her equipment. She discarded her gloves and went to the sink behind the nurses station and began washing her hands at 9:11 a.m. -She washed her hands with soap and water for six seconds. At 9:16 a.m., LPN #1 went to a resident's room and obtained vital signs from the resident. She returned to the medication cart and cleaned her equipment. At 9:20 a.m., she returned to the sink behind the nurses station to wash her hands. -She washed her hands with soap and water for six seconds. At 9:26 a.m., LPN #1 administered medications to a resident. At 9:28 a.m., she went to the sink in the resident's room and washed her hands. -She washed her hands with soap and water for eight seconds. At 9:30 a.m., LPN #1 went to a resident's room and obtained his vital signs. At 9:33 a.m., she returned to the medication cart and cleaned her equipment. At 9:35 a.m., she returned to the sink behind the nurses station to wash her hands. -She washed her hands with soap and water for six seconds. At 9:36 a.m., LPN #1 went back to the resident's room and administered his medications. At 9:38 a.m., she returned to the sink behind the nurses station to wash her hands. -She washed her hands with soap and water for two seconds. At 9:45 a.m., LPN #1 went to a resident's room and obtained his vital signs. At 9:47 a.m., she returned to the medication cart and cleaned her equipment. At 9:49 a.m., she returned to the sink behind the nurses station to wash her hands. -She washed her hands with soap and water for six seconds. At 9:57 a.m., LPN #1 administered medications and applied a medication patch to a resident. At 10:00 a.m., she went to the sink behind the nurses station and washed her hands. -She washed her hands with soap and water for seven seconds. At 10:14 a.m., LPN #1 was notified of a small yellow pill on the floor in the medication room. She picked it up and destroyed it. At 10:19 a.m., she went to the sink behind the nurses station and washed her hands. -She washed her hands with soap and water for six seconds. At 10:22 a.m., LPN #1 applied a medication patch to a resident. At 10:23 a.m., she went to the sink in the resident's room and washed her hands. -She washed her hands with soap and water for three seconds. C. Interviews The director of nursing (DON) was not available for an interview during the survey. The regional nursing consultant (RNC) was interviewed on 2/27/24 at 9:50 a.m. She said that staff should wash their hands or use hand sanitizer before and in between each resident during the medication pass. She said when staff washed their hands they should wash them for a total of 20 seconds or the amount of time it took to sing the happy birthday song twice. She said failure to perform hand hygiene properly could lead to the spread of viruses or infections in the facility.

Based on record review and interviews, the facility failed to report an allegation violation of potential abuse to the State Survey and Certification Agency in accordance with state law for one (#41) of two residents reviewed for abuse out of 36 sample residents. Specifically, the facility failed to report an allegation of verbal abuse of Resident #41 by a staff member to the facility administrator, local law enforcement or the State Agency. Findings include: I. Facility policy The Abuse Prevention policy, reviewed on 7/18/23, was provided by the nursing home administrator (NHA) on 2/27/24 at 5:47 p.m. It documented in pertinent part, It is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation. Identify, correct and intervene in situations in which abuse, neglect, exploitation. and or misappropriation of resident property is more likely to occur to include trained and qualified. registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual resident's care needs and behavioral symptoms, if any. Assure that residents are free from neglect by having the structures and processes to provide needed care and services to all residents, which includes, but is not limited to, the provision of a facility assessment to determine what resources are necessary to care for its residents competently. Identify, assess, care plan for appropriate interventions, and monitor residents with needs and behaviors which might lead to conflict or neglect. II. Resident #41 A. Resident status Resident #41, over the age of 65, was admitted on [DATE]. According to the February 2024 computerized physicians orders (CPO), diagnoses included Parkinson's disease, spinal stenosis, history of falling and muscle weakness. The 11/15/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She had no behaviors and did not reject care. The resident required supervision or touching assistance with dressing, transfers and bathing. She was independent with eating and personal hygiene. B. Resident interview Resident #41 was interviewed on 2/27/24 at 9:13 a.m. Resident #41 said licensed practical nurse (LPN) #2 hurt her mouth and teeth when he administered the medications because he broke the capsule of the medication creating a lot of pieces of the capsule in her mouth. She said the capsule was not supposed to be broken because it was an extended-release medication. Resident #41 did not recall water being put in her mouth and said she was upset that LPN #2 broke the capsule because the pieces of the capsule caused pain in her gums and teeth. She said she reported her concern to the provider the following morning. Cross-reference F610 for failure to investigate alleged abuse. C. Record review A 2/13/24 provider visit note documented the following in pertinent part; At the end of my encounter, nursing stepped out to attend to a call bell, during which time the resident reported that the previous shift (night shift) care was 'rough' and 'hurt my lips and my teeth, I'm surprised I could eat breakfast'. It also said that concerns over rough nursing care were reported to the social services director (SSD). -The facility investigation was requested. However, the NHA stated they had not reported or investigated the allegation (see interviews below). The NHA provided a statement from the SSD dated 2/13/24. It read in pertinent part, Resident stated that she is hard to wake when she is sleeping. Nurse was attempting to give her medication and she believes she was in a deep sleep. They put a syringe of water to moisten her mouth. The SSD provided her handwritten note from her initial interview on 2/13/24 with Resident #41. It read in pertinent part, Alleged night nurse woke her up pressing on her shoulder last night. Nurse proceeded to put a pillow over her face and syringe in her mouth telling her to take and swallow. Maybe did not associate it with medicine. Collar was wet. Pushed water into mouth. -Review of the State Agency portal for February 2024 failed to reveal the allegation had been reported. III. Staff interviews The SSD was interviewed on 2/26/24 at 4:23 p.m. The SSD said she did not interview the staff that might have been involved because the director of nursing (DON) or the nursing home administrator (NHA) handled that part of abuse allegations. She said she only talked to the residents about their concerns or allegations. She said Resident #41 was a heavy sleeper and it was probably hard to wake her. The NHA was interviewed on 2/26/24 at 4:39 p.m. The NHA said when she received complaints about resident care she interviewed the resident to see if they felt safe. She reviewed the reporting manual to see if the concern fit the guidelines for reporting. When the complaint fit the guidelines for reporting she made sure the resident was safe and reported the event. She said if the complaint met the requirements for reporting she would interview the staff, however, she did not feel Resident #41's complaint met the requirements so the staff was not interviewed. She said the water was not forced into the resident's mouth in this situation and that it was pushed. The SSD was interviewed a second time on 2/26/24 at 4:45 p.m. The SSD said she believed the complaint should have been reported and thoroughly investigated. She said she was very concerned about the report of water being put in Resident #41's mouth while she was sleeping as that would be an aspiration risk. Licensed practical nurse (LPN) #3 was interviewed on 2/26/24 at 4:55 p.m. LPN #3 said nothing should be administered to a resident unless they were completely awake. He said if a resident was not able to be awakened to receive medication he would not give it at all. He said it was not acceptable to push or place water in a resident's mouth when they were not fully awake as this could cause aspiration. LPN #2 was interviewed on 2/26/24 at 5:25 p.m. LPN #2 said he did not remember the night or the complaint in question. However, he then said Resident #41 was asleep when he initially went in to give her medications so he left the room and came back an hour later. At that time she was awake and he gave the medications and offered a cup of water with a straw. He said he held the cup of water while she took a sip.

Based on record review and interviews, the facility failed to thoroughly investigate an allegation of physical abuse involving two (#41 and #21) of two residents reviewed for abuse out of 38 sample residents. Specifically, the facility failed to: -Investigate allegations of physical and/or emotional abuse reported by Resident #41 to a provider; and, -Conduct an investigation of a bump and bruising (injuries of unknown origin) to Resident #21. Cross-reference F609 failure to report an allegation of abuse to the State Agency. Findings include: I. Facility policy The Abuse Prevention policy, reviewed on 7/18/23, was provided by the nursing home administrator (NHA) on 2/27/24 at 5:47 p.m. It documented in pertinent part, It is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation. Identify, correct and intervene in situations in which abuse, neglect, exploitation. and or misappropriation of resident property is more likely to occur to include trained and qualified. registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms, if any. Assure that residents are free from neglect by having the structures and processes to provide needed care and services to all residents, which includes, but is not limited to, the provision of a facility assessment to determine what resources are necessary to care for its residents competently. Identify, assess, care plan for appropriate interventions, and monitor residents with needs and behaviors which might lead to conflict or neglect. II. Resident #41 A. Resident status Resident #41, over the age of 65, was admitted on [DATE]. According to the February 2024 computerized physicians orders (CPO), diagnoses included Parkinson's disease, spinal stenosis, history of falling and muscle weakness. The 11/15/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She had no behaviors and did not reject care. The resident required supervision or touching assistance with dressing, transfers and bathing. She was independent with eating and personal hygiene. B. Resident interview Resident #41 was interviewed on 2/27/24 at 9:13 a.m. Resident #41 said Licensed practical nurse (LPN) #2 hurt her mouth and teeth when he administered the medications because he broke the capsule of the medication creating a lot of pieces of the capsule in her mouth. She said the capsule was not supposed to be broken because it was an extended-release medication. Resident #41 did not recall water being put in her mouth and said she was upset that LPN #2 broke the capsule because the pieces of the capsule caused pain to her gums and teeth. C. Record review A 2/13/24 provider visit note documented the following in pertinent part At the end of my encounter, nursing stepped out to attend to a call bell, during which time the resident reported that the previous shift (night shift) care was 'rough' and 'hurt my lips and my teeth, I'm surprised I could eat breakfast'. It also said that concerns over rough nursing care were reported to the social services director (SSD). -The facility investigation was requested. However, the NHA stated they had not reported or investigated the allegation (see interviews below). The NHA provided a statement from the SSD dated 2/13/24. It read in pertinent part, Resident stated that she is hard to wake when she is sleeping. Nurse was attempting to give her medication and she believes she was in a deep sleep. They put a syringe of water to moisten her mouth. The SSD provided her handwritten note from her initial interview on 2/13/24 with Resident #41. It read in pertinent part, Alleged night nurse woke her up pressing on her shoulder last night. Nurse proceeded to put a pillow over her face and syringe in her mouth telling her to take and swallow. Maybe did not associate it with medicine. Collar was wet. Pushed water into mouth. D. Staff interviews The SSD was interviewed on 2/26/24 at 4:23 p.m. The SSD said she did not interview the staff that might have been involved because the director of nursing (DON) or the NHA handled that part of abuse allegations. She said she only talked to the residents about their concerns or allegations. She said Resident #41 was a heavy sleeper and it was probably hard to wake her. The NHA was interviewed on 2/26/24 at 4:39 p.m. The NHA said when she received complaints about resident care she interviewed the resident to see if they felt safe. She reviewed the reporting manual to see if the concern fit the guidelines for reporting. When the complaint fit the guidelines for reporting she made sure the resident was safe and reported the event. She said if the complaint met the requirements for reporting she would interview the staff, however, she did not feel Resident #41's complaint met the requirements so the staff was not interviewed. The SSD was interviewed a second time on 2/26/24 at 4:45 p.m. The SSD said she believed the complaint should have been reported and thoroughly investigated. She said she was very concerned about the report of water being put in Resident #41's mouth while she was sleeping as that would be an aspiration risk. LPN #3 was interviewed on 2/26/24 at 4:55 p.m. LPN #3 said nothing should be administered to a resident unless they were completely awake. He said if a resident was not able to be awakened to receive medication he would not give it at all. He said it was not acceptable to push or place water in a resident's mouth when they were not fully awake as this could cause aspiration. LPN #2 was interviewed on 2/26/24 at 5:25 p.m. LPN #2 said he did not remember the night or the complaint in question. However, he then said Resident #41 was asleep when he initially went in to give her medications so he left the room and came back an hour later. At that time she was awake and he gave the medications and offered a cup of water with a straw. He said he held the cup of water while she took a sip. 46851 III. Resident #21 A. Resident status Resident #21, age greater than 65, was admitted on [DATE]. According to the February 2024 CPO, diagnoses included dementia, anxiety disorder and major depression disorder. According to the 12/26/23 MDS assessment, the resident was severely cognitively impaired with a BIMS score of one out of 15. She was dependent on staff for toileting, showering and putting on footwear. She needed extensive assistance with dressing, hygiene and eating. The resident used a wheelchair for mobility. The assessment indicated the resident did not exhibit any behaviors during the assessment period. B. Record review An 8/17/23 nursing progress note documented an unknown certified nurse aide (CNA) reported a bump and bruise on Resident #21's left forehead and eye. The unknown CNA noticed the injuries when she transferred the resident out of bed. The CNA reported the injuries to the nurse. The progress note indicated the DON would do the investigation. The Abuse/Adverse Event investigation, dated 8/17/23, documented the resident had a fall with injury. Resident #21 had two prior falls on 11/2/22 and 7/29/23. The incident was not witnessed. Resident #21's daughter was interviewed and agreed the bruise was from the clutter in the resident's room. The daughter was not present at the time of the event. The daughter said there was a small dresser in the room that she may have bumped into. The dresser was removed from the room since it was at eye level. -Several sections of the investigation event were not completed, including the section on what had occurred, the chronological timeline and interviews from staff. The staff interview section documented the resident moved while in her bed and had caused multiple injuries. -The investigation did not indicate who was interviewed. There were no behavioral issues documented in the progress notes before the incident. C. Staff interviews CNA #1 was interviewed on 2/27/24 at 8:50 a.m. CNA #1 said she would report any bruises or injuries to the nurse and document them in the resident's chart. CNA #1 said reporting injuries of unknown origin was important so an investigation could occur. CNA #1 said Resident #21 would squirm in her bed and checking on her regularly to prevent her from falling was essential. CNA #1 said she was not working in the facility during the incident. Registered nurse (RN) #1 was interviewed on 2/27/24 at 9:05 a.m. RN #1 said she would start an incident report and report bruises of unknown origins to the DON once she was made aware of them. RN #1 said the administration would perform investigations of injuries of unknown origin to rule out abuse. RN #1 said Resident #21 did not get restless often. RN #1 said a dresser in the resident's room next to her bed was at eye level and was three inches from the bed. RN #1 said the resident had wedges on her bed to keep her from falling. RN #1 said she could not remember the incident on 8/17/23. The NHA was interviewed on 2/27/24 at 9:56 a.m. The NHA said staff should report bruises of unknown origins to the nurse and she would notify the DON and administration. The NHA said staff should immediately report injuries of unknown origin. The NHA said the administration would investigate to ensure there was no abuse and that the investigation would depend on staff and environmental factors. The NHA said the staff interviews were not documented in the 8/17/23 investigation. The NHA acknowledged the blank spaces in the investigation and said during a huddle held in the resident's room they decided the resident did not fall. The NHA said the resident turned in her bed and bumped her head and no further investigation was done. The NHA said she talked to staff but did not document what they said. The NHA said the resident had anxiety before the incident occurred and that was what led to the bump and bruise on her forehead and eye.

Based on observations, record review and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater. Specifically, the facility medication administration observation error rate was 7.14% or two errors out of 28 opportunities. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 606-607, retrieved on 2/28/24, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: the right medication, the right dose, the right patient, the right route, the right time, the right documentation and the right indication. II. Facility policy and procedure The Administration of Medications policy, revised 7/14/21, was provided by the nursing home administrator (NHA) on 2/7/24 at 12:37 p.m. It read in the pertinent part, Medication Error - means the observed or identified preparation or administration of medications or biologicals which is not in accordance with: 1.The prescriber's order; 2.Manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological; or 3.Accepted professional standards and principles which apply to professionals providing services. Accepted professional standards and principles include the various practice regulations in each State, and current commonly accepted health standards established by national organizations, boards, and councils. III. Observations On 2/26/24 at 9:49 a.m., licensed practical nurse (LPN) #1 was observed preparing and administering medications to Resident #183. The resident's physician's order was for: Gabapentin capsule 100 mg (milligrams). Give one capsule by mouth three times a day for pain. Scheduled for 8:00 a.m., 2:00 p.m. and 7:00 p.m. -LPN #1 was unable to locate the medication for the resident and therefore did not administer the medication to Resident #183. On 2/26/24 at 9:57 a.m., LPN #1 was observed preparing and administering medications to Resident #80. The resident's physician's order was for: Pantoprazole Sodium oral tablet delayed release 40 mg. Give 40 mg by mouth one time a day for gastroesophageal reflux disease (GERD). Scheduled for morning administration. -LPN #1 was unable to locate the medication for the resident and therefore did not administer the medication to Resident #80 III. Staff interviews LPN #1 was interviewed on 2/26/24 at 9:59 a.m. LPN #1 said she was unable to locate the ordered medications. She said she did send a request to the pharmacy for the gabapentin for Resident #183 and this was the third request sent to the pharmacy. The NHA was interviewed on 2/26/24 at 11:08 a.m. The NHA said she would look into the medications that were not administered. She said LPN #1 was fairly new to the facility and may not have been aware of the emergency medications that were available to administer in the event a medication was unavailable in the medication cart. IV. Facility follow up On 2/26/24 at 11:28 a.m., the NHA said she was able to find Resident #183's gabapentin in another location in the medication cart and LPN #1 administered the medication to the resident. -However, the gabapentin had been scheduled for 8:00 a.m. Therefore, the late administration of the medication was still a medication error. The NHA said the order for pantoprazole sodium had a standing order (an order authorized by a prescriber) to substitute with omeprazole (another medication used to treat GERD). The NHA said she updated the order in Resident #80's medical record, educated LPN #1 and LPN #1 gave the medication to the resident. -However the pantoprazole sodium had been scheduled for the morning administration. Therefore, the late administration of the medication was still a medication error.

Based on record review and staff interviews, the facility failed to develop and implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for one (#140) of one resident out of 38 sample residents. Specifically, the facility failed to: -Ensure clinical signs and symptoms of an infection were identified for Resident #140 prior to administering antibiotics; and, -Ensure a urinalysis with a culture (laboratory test to identify bacteria) and sensitivity (a laboratory test used to determine what medication/antibiotic will work best to treat an infection) (C&S) were obtained, according to a physician's order, prior to administering antibiotics for Resident #140. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC), The Core Elements of Antibiotic Stewardship for Nursing Homes, Appendix B, retrieved online on 3/6/24 from https://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship-appendix-b.pdf, Incomplete assessment and documentation of a resident's clinical status, physical exam or laboratory findings at the time a resident is evaluated for infection can lead to uncertainty about the rationale and/or appropriateness of an antibiotic. Ongoing audits of antibiotic prescriptions for completeness of documentation, regardless of whether the antibiotic was initiated in the nursing home or at a transferring facility, should verify that the antibiotic prescribing elements have been addressed and recorded. II. Facility policy and procedure The Antibiotic Stewardship policy and procedure, reviewed May 2023, was provided by the nursing home administrator (NHA) on 2/21/24 at 10:00 a.m. It revealed in pertinent part, The antibiotic stewardship program promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance. This means that the antibiotic prescribed for the correct indication, dose, and duration to appropriately treat the resident while also attempting to reduce the development of antibiotic-resistant organisms and/or other adverse events. The program will be managed and overseen by the infection preventionist. Assessment of residents suspected of having an infection: the facility will utilize the McGeer Criteria when considering initiation of antibiotics. Antibiotic time out: at 72 hours after antibiotic initiation or first dose in the facility, each resident should be reassessed for consideration of antibiotic need. At this time, laboratory testing results, response to therapy and resident condition will be considered. Tracking: process measures for tracking antibiotic stewardship track how and why antibiotics are prescribed. Process measures include review of SBAR's (situation, background, assessment and review) and other clinical documentation during clinical meetings and ongoing reviews of the completeness of prescribing documentation to include dose, route, duration and indication for use. III. Resident #140 A. Resident status Resident #140, age 67, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included hemiplegia (complete paralysis affecting one or more extremities on one side of the body) and hemiparesis (partial weakness affecting one or more extremities on one side of the body) following a cerebral infarction (stroke) affecting the right dominant side. B. Record review The February 2024 CPOs documented the following physician order: Keflex (antibiotic) oral capsule 500 mg (milligrams) - give one capsule by mouth two times a day for a UTI (urinary tract infection). Please do not start until urinalysis and urine culture has been collected, ordered 2/21/24. The February 2024 medication administration record (MAR) documented that the resident was administered Keflex starting on 2/21/24 until 2/26/24. -A review of the resident's medical record did not reveal documentation that a urinalysis had been completed with a urine culture per the physician's orders. -It did not include documentation indicating what symptoms Resident #140 exhibited to warrant an antibiotic being ordered. IV. Staff interviews The infection preventionist (IP) and the NHA were interviewed on 2/26/24 at 4:33 p.m. The IP said the facility followed a specific criterion when an infection was suspected. She said, in order for a lab test to be ordered, the resident had to meet all criteria. The IP said she had researched Resident #140's use of Keflex. She said she was only able to find documentation that the resident had experienced dysuria (painful urination), but no other symptoms. She said the dysuria alone did not meet the criteria for the resident to be administered an antibiotic. The IP said she was unable to find documentation that a urinalysis with a culture had been completed as ordered by the physician. She said the medication should not have been administered until the results of the laboratory with the culture had returned. She said she contacted the laboratory and confirmed a urinalysis had not been obtained. She said she called the physician and recommended the antibiotic be discontinued. She said since the resident did not meet the criteria and the facility did not follow the physician's order, the resident was administered the antibiotic unnecessarily. The IP said she was responsible for the antibiotic stewardship program at the facility. She said she had not reviewed Resident #140's use of the antibiotic prior to 2/26/24, during the survey process.

Based on observations and interviews the facility failed to establish and maintain infection control designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections for two of three units. Specifically, the facility failed to: -Ensure residents were offered hand hygiene prior to eating for room trays; and, -Ensure staff perform hand hygiene between residents during room tray delivery. I. Professional reference The Hand Hygiene guidance, updated 1/30/2020, retrieved on 12/28/22, from: https://www.cdc.gov/handhygiene/providers/guideline.html, documented in part, Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: after touching a patient or patients immediate environment and immediately after glove removal. II. Facility policy and procedure The Hand Hygiene for Residents, Families, and Visitors policy, dated 6/7/22, received from the Nursing home administrator (NHA) on 12/29/22 at 12:52 p.m. revealed in pertinent part, to decrease the risk of transmission of infection by enabling residents to perform appropriate hand hygiene. Staff should encourage and assist the resident as needed to ensure proper hand hygiene through hand washing or use of alcohol based hand rub. Hand hygiene should be offered/performed: prior to handling and/or consumption of food or beverage. The Hand Hygiene policy, dated 7/15/22, received from the NHA on 12/29/22 at 12:52 p.m. revealed in pertinent part, hand washing and hand hygiene is generally considered the most important procedure in preventing nosocomial infections. The purpose is to decrease the risk of transmission of infection by appropriate hand hygiene. Facility to provide education to associates on hand hygiene, associates are to perform hand hygiene before and after contact with a resident, after contact with objects in resident's rooms. III. Observations Certified nurse aide (CNA) #1 observed on 12/28/22 at 12:05 p.m. passing trays on the North unit. She passed a meal tray to room [ROOM NUMBER]-1 there was no resident present in the room, she left the tray on the bedside table. No hand sanitizing wipe was on the meal tray. She completed hand hygiene on exit with alcohol based rub. She then proceeded to pass the meal tray to room [ROOM NUMBER]-1, there was not a hand sanitizing wipe on the tray. She failed to offer hand hygiene to the resident and complete hand hygiene on exit of the resident's room. She then collected the tray for room [ROOM NUMBER]-1. The meal tray contained a hand sanitizing wipe which, was placed on the meal tray by CNA #7. She delivered the meal tray to the resident but failed to offer assistance with hand hygiene. She exited the residents room without performing hand hygiene. She then delivered a meal tray to room [ROOM NUMBER]-2. There was no hand sanitation wipe on the meal tray. She failed to offer hand hygiene to the resident and the CNA failed to perform hand hygiene on exit. CNA #5 was observed at 12:22 p.m. passing room meal trays on the North unit. She passed a meal tray to room [ROOM NUMBER]-1. There was no hand sanitizing wipe on the meal tray. The CNA failed to offer hand hygiene to the resident. The CNA touched resident personal items on the bedside table in order to place the meal tray down. She then exited the room without performing hand hygiene. She proceeded to pass a meal tray to room [ROOM NUMBER]-1. There was no sanitizing wipe on the meal tray, and no hand hygiene was offered to the resident. She failed to perform hand hygiene on exit of the residents room. She then delivered a meal tray to room [ROOM NUMBER]-2. The CNA applied gloves without performing hand hygiene prior, collected the meal tray, a hand sanitizing wipe was not on the meal tray. She failed to offer hand hygiene to the resident. The CNA removed her gloves and exited the resident room, she failed to perform hand hygiene and returned to the meal cart. The resident was in isolation for extended spectrum beta-lactamase (ESBL, a type of infection) in urine. At 12:30 p.m. the dietary aide (DA) transported the meal tray cart to the South wing. She then placed sanitizing hand wipe on top of every tray for the South wing. CNA #4 was observed to be passing the meal trays on the South wing at 12:31 p.m. He passed to room [ROOM NUMBER], where he failed to perform hand hygiene before and after entering the room. He did not offer hand hygiene to the resident. He then passed a meal tray to room [ROOM NUMBER]. He removed the hand sanitizing wipes off of the meal tray. He failed to perform hand hygiene before and after passing the tray. He failed to offer hand hygiene to the resident. He passed a meal tray to room [ROOM NUMBER]. He failed to perform hand hygiene prior to entering the resident room. He placed a clothing protector for the resident, removed the cover from the dish, cut up the food and checked for condiments. He failed to offer hand hygiene to the resident and there was not a sanitizing wipe on the tray. He failed to perform hand hygiene on exit of the residents room. He went to the meal cart and touched the cart to check for additional meal trays. CNA #3 was observed to be delivering meal trays on the South wing at 12:36 p.m. She delivered to room [ROOM NUMBER] where she failed to perform hand hygiene prior to entering the room and failed to offer hand hygiene to the resident. She delivered a meal tray to 209. She failed to perform hand hygiene prior to entering the room. III. Staff interviews CNA #1 was interviewed on 12/28/22 at 12:37 p.m. She said this was her second shift at this facility and she had not seen hand sanitizing wipes being offered for any meals. She said there were none yesterday or this morning with breakfast. Staff should wash their hands between residents if they touch any personal items in their rooms or the residents. CNA #5 was interviewed on 12/28/22 at 12:37 p.m. She said sanitizing wipes were to be provided to residents with every meal and staff should perform hand hygiene between tray delivery especially if we touch the residents personal items. CNA #6 was interviewed on 12/28/22 at 1:40 p.m. She said the process for meal delivery was when trays arrive on the floor, read the ticket for drinks, then deliver to residents and assist with tray set up. Hand hygiene was offered to each resident with each meal, after restroom breaks and when their hands appeared to be dirty. Staff were to perform hand hygiene between residents, during meals if staff touch personal items in resident rooms or the residents themselves. The NHA and the infection preventionist (IP) #1 and #2 were interviewed on 12/29/22 at 11:15 a.m. The NHA said residents were to be offered hand hygiene either with soap and water or be provided with a hand sanitizing wipe before meals. The NHA said staff were to perform hand hygiene before and after resident cares and after touching resident personal items either soap and water or alcohol based hand rub may. 47350

Based on observations, interviews, record review, and facility policy review, it was determined the facility failed to ensure oxygen was administered at the physician-ordered flow rate to prevent potential complications for 1 (Resident #80) of 3 sampled residents reviewed for oxygen therapy. Findings included: Review of a facility policy titled, Oxygen Administration/Safety/Storage/Maintenance, dated as reviewed 10/07/2022, revealed Oxygen will be administered in accordance with physician orders and current standards of practice. Review of an Admission Record revealed Resident #80 had diagnoses including chronic diastolic (congestive) heart failure and obstructive sleep apnea. Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #80 scored 14 on a Brief Interview for Mental Status (BIMS), which indicated the resident was cognitively intact. The MDS indicated the resident required extensive assistance of two or more people with bed mobility and transfers. According to the MDS, the resident had not received oxygen therapy in the 14 days prior to the assessment. Review of a care plan, dated as initiated 07/08/2021, revealed Resident #80 needed oxygen therapy due to shortness of breath from congestive heart failure. A planned intervention was to administer oxygen at 1.5 liters per minute (LPM) continuously. Review of an Order Listing in Resident #80's electronic medical record revealed the resident had a physician's order dated 06/08/2021 for oxygen to be administered continuously at 1.5 LPM via nasal cannula. Observation on 11/07/2022 at 10:30 AM revealed Resident #80 sitting in a wheelchair in their room with a portable oxygen cannister behind the wheelchair. The resident was receiving oxygen via nasal cannula, with the flow rate set at 2.5 LPM, instead of 1.5 LPM as ordered by the physician. Review of a November 2022 Treatment Administration Record indicated Resident #80 was to receive oxygen at 1.5 LPM via nasal cannula and that the nurses were to document the oxygen administration every shift. Further review revealed Registered Nurse (RN) #3 had initialed the oxygen to have been administered as ordered during the day shift on 11/07/2022. Observation on 11/08/2022 at 2:20 PM revealed Resident #80 was receiving oxygen via nasal cannula, with the flow rate on the resident's oxygen concentrator set on 3 LPM, instead of 1.5 LPM as ordered by the physician. During an interview at this time, Resident #80 denied ever having adjusted the oxygen flow and stated the nurses took care of that. The resident indicated they were unsure what the oxygen flow rate should be. Review of the November 2022 Treatment Administration Record revealed RN #3 had initialed the oxygen order to indicate the oxygen was administered as ordered during the day shift on 11/08/2022. Observation on 11/09/2022 at 2:55 PM revealed Resident #80 was sitting in a wheelchair receiving oxygen at 2.5 LPM via nasal cannula connected to a portable oxygen tank. Review of the November 2022 Treatment Administration Record revealed RN #3 had initialed the oxygen order to indicate the oxygen was administered as ordered during the day shift on 11/09/2022. During an interview on 11/09/2022 at 2:55 PM, Licensed Practical Nurse (LPN) #1 revealed RN #3, who was assigned to care for Resident #80, was on lunch break. LPN #1 checked Resident #80's oxygen flow rate and verified it was set at 2.5 LPM. The LPN stated he was not sure what the rate should be. During an interview on 11/10/2022 at 9:10 AM, RN #3 stated nursing staff should check on residents who received oxygen therapy at the beginning of their shift and ensure the resident was wearing the nasal cannula correctly, ensure oxygen tanks were full, and check the flow rate on the oxygen concentrator/tank. RN #3 stated that most of the time, he looked at the physician's orders, but he did not always verify the order when documenting on a resident's TAR. RN #3 stated he thought Resident #80's physician's order for oxygen was 2.5 LPM. He indicated he did not know why he documented the flow rate as 1.5 LPM on 11/07/2022, 11/08/2022, and 11/09/2022. RN #3 stated he kept Resident #80's oxygen at 2.5 LPM and had not informed the physician about the change in flow rate. He stated he did not request an order to change the flow rate but should have. Observation on 11/10/2022 at 8:00 AM revealed Resident #80 lying in bed receiving oxygen at 3 LPM via nasal cannula. Review of the November 2022 Treatment Administration Record at this time revealed staff had not yet initialed the resident's oxygen for day shift on 11/10/2022. During an interview on 11/10/2022 at 8:03 AM, LPN #2 verified Resident #80's oxygen flow rate was set to deliver oxygen at 3 LPM. LPN #2 stated she checked on Resident #80 that morning and that a certified nursing assistant (CNA) obtained the resident's vital signs. She indicated the resident had since been sleeping, and she had not checked the resident's oxygen setting nor physician orders. LPN #2 stated nursing staff should always check residents' physician orders; however, she stated she could not remember the last time she looked at Resident #80's physician orders and could not remember Resident #80's physician-ordered oxygen flow rate. During an interview on 11/10/2022 at 9:23 AM, the Director of Nursing (DON) revealed that if staff needed to increase a resident's oxygen rate, staff should document the need and contact the physician. The DON indicated nursing staff should review the current physician orders when documenting oxygen administration on a resident's Treatment Administration Record. She stated there were probably times when staff knew the correct oxygen flow rate and did not look at the orders. The DON stated she expected staff to ensure residents were receiving oxygen at the flow rate ordered by the physician and to accurately document. The DON confirmed that RN #3 had Resident #80's oxygen set on 2.5 LPM when the order was for 1.5 LPM, and stated RN #3 should have contacted the physician. During an interview on 11/10/2022 at 10:13 AM, the Administrator stated she expected nursing staff to have an order for oxygen administration and for nurses to follow the order.

Based on record review and interviews, the facility failed to ensure the legal representative was notified of changes for one resident (#1) out of three sample residents. Specifically, the facility failed to notify the legal representative of an outside appointment and a new medication order for the resident on [DATE]. Additionally, the facility failed to notify the legal representative of a change of condition and laboratory orders for the resident on [DATE]. Furthermore, the facility failed to timely notify the legal representative of the resident's death on [DATE] (cross-reference F842 medical records). Findings include: I. Facility policy and procedure The Changes in Resident Condition or Status policy, updated [DATE], was provided electronically by the nursing home administrator (NHA) on [DATE] at 4:25 p.m. It read, in pertinent part: This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status. In the case of death of a resident, the resident's physician will be notified immediately by facility staff in accordance with State law. II. Resident #1 A. Resident status Resident #1, age 81, was admitted on [DATE] and passed away on [DATE]. According to the [DATE] computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] minimum data set (MDS) assessment revealed the resident was cognitively impaired with a staff assessment of mental status which revealed short and long term memory problems, severely impaired decision making skills, inattention, disorganized thinking, and altered level of consciousness. He exhibited occasional rejection of care. He required extensive assistance of two staff members with mobility and most activities of daily living (ADLs). B. Record review 1. Neurology appointment and medication change [DATE] A health status note dated [DATE] revealed the resident went to an outside appointment and a new antidepressant medication ([MEDICATION(S)] 10 mg tablet) was ordered. A nursing note dated [DATE] revealed the resident's daughter/guardian was in the facility and requested to review the resident's medication orders. She noticed a new medication which she was unaware of and discovered the resident had gone out to an appointment she did not know about. -Review of the resident's notes contained no evidence the resident representative was notified of the resident having an outside appointment, going to the appointment, or that the new medication had been ordered for the resident. 2. Change of condition [DATE] and resident death [DATE] (cross-reference F842) A nursing note on [DATE] at 5:58 a.m. revealed the registered nurse (RN) writer was called by the licensed practical nurse (LPN) to assess the resident. The resident was found without blood pressure, apical pulse and respirations. The LPN was to make the proper notifications. -Review of the resident record revealed no documentation of the resident's family members being notified of the resident's death. The medical director (MD) who was also the resident's primary physician was interviewed on [DATE] at 2:25 p.m. She stated she had reviewed the resident's medical record and was very familiar with the resident and was very involved with this situation. She stated she received a call on [DATE] in the early afternoon and the nurse who called her reported the resident had been at his baseline earlier in the day and had spoken to his daughter on the phone. Just prior to calling the physician, the resident started to exhibit lethargy and a change in mental status which was sudden. She stated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the samples were collected and sent to the lab and she came to the to assess the resident in person. She stated the resident was very ill at baseline, but upon her assessment his vital signs were within his normal limits and his urine was observed to be a little dark and cloudy, though this was not unusual for the resident with the chronic urinary tract infections he suffered. She stated the nursing staff were checking on him frequently. She stated she received a call from the staff around 6:00 a.m. reporting that he was without vital signs. She stated she was very surprised there was no documentation of the family being notified of the change in condition since the family was very involved but the resident was fully assessed and orders were followed. -Review of the resident record revealed no documentation of the change of condition or any notifications being made to the physician or the family members related to the change. III. Staff interviews LPN #1 was interviewed on [DATE] at 11:00 a.m. He stated if a resident had any change in condition, medication, or treatment the family should be notified as soon as possible. He stated the family should be notified of a resident's death immediately. He stated all notifications should be documented in the resident record with a note explaining the details of the notification. RN #1 was interviewed on [DATE] at 11:10 a.m. He stated when a resident had a change of condition, the physician should be contacted for direction and orders and the family should be notified of any changes. He stated family should be notified immediately of a resident's death. He stated all notifications should be documented in the resident's medical record. The unit manager (UM) was interviewed on [DATE] at 12:24 p.m. She stated the staff should notify the resident responsible party and the physician of all changes in the resident condition and treatments. She stated the resident representative should be notified of a death immediately after the physician pronouncement and should be documented at the time. The director of nursing (DON) was interviewed on [DATE] at 2:55 p.m. She stated she was new to the facility and was not working in the facility at the time of these incidents. She stated the resident responsible party should be notified of any changes in condition, medications, and appointments. She stated all notifications to the physician and the responsible party should be documented. She stated all staff would be educated related to expectations related to notifications and documentation of the notifications.