Every finding on record at Westport Rehabilitation and Nursing Center

Based on observation, resident interview, and facility document review, the facility staff failed to promote resident's dignity for one of 6 residents in the survey sample, Resident #3. The findings include:For Resident #3 (R3), the facility staff failed to provide privacy for the catheter collection bag (1). R3 was admitted to the facility with diagnoses that included but were not limited to uropathy (2). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/07/2025, R3 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. Section H Bladder and Bowel code R3 as having an indwelling catheter (3). On 02/03/2026 at approximately 2:40 p.m. an observation of R3's from the facility hallway revealed R3's catheter collection bag hanging on the left side of the bed (hallway side) with urine in the bag. The physician's order for R3 documented in part, Foley catheter #16/10 (16 French (4)/ 10 cubic centimeters) due to Obstructive & reflux Uropathy. Order Date: 12/18/2025. The comprehensive care plan for R3 dated 05/05/2025 documented in part, Focus. Catheter: resident requires a urinary 16Fr (French) 5-10cc (five to ten cubic centimeter) balloon catheter related to: obstructive neurogenic bladder. Created on: 05/05/2025 Revision on: 09/08/2025. Under Interventions it documented in part, Maintain catheter privacy bag Created on: 05/05/2025. On 02/03/2026 at approximately 2:50 p.m. an interview was conducted with R3. When asked if she was aware that the catheter collection bag did not have a privacy cover and was in full view from the hallway she stated she was not aware that the bag was not covered. R3 stated I don't like that, it's not dignified. On 02/04/2026 at approximately 9:40 a.m. an interview was conducted with LPN (licensed practical nurse) #5, unit manager. When asked to describe how a resident's catheter collection bag should be presented when it is hung on the side of a bed, she stated that it should be placed in a privacy bag or covered so the contents cannot be seen. When informed of the observation regarding R3 catheter collection bag she stated that the bag should have been covered for privacy and to protect the resident's dignity. On 02/05/2026 at approximately 12:05 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #4, regional director of clinical services, and ASM #5, assistant director of nursing, were made aware of the above findings. No further information was provided prior to exit. References:(1) Urine drainage bags collect urine. Your bag will attach to a catheter (tube) that is inside your bladder. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000142.htm. (3) One that is left in the bladder. Most often, the catheter is inserted through the urethra. This is the tube that carries urine from the bladder to the outside of the body. This information was obtained from the website: https://medlineplus.gov ency article (2) A condition in which the flow of urine is blocked This information was obtained from the website: https:// medlineplus.gov/ency/article/000507.htm. (4) The number 16-French refers to the size of the catheter, with higher numbers indicating larger sizes. This information was obtained from the website: https://balumed.com/en/medical-dictionary/16-french-foley-catheter.

Based on observation, resident interview, and facility document review, the facility staff failed to follow the comprehensive care plan for one of 6 residents in the survey sample, Resident #3. The findings include:Resident #3 (R3), the facility staff failed to follow the comprehensive care plan to provide a privacy bag for the catheter collection bag (1). R3 was admitted to the facility with diagnoses that included but were not limited to uropathy (2). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/07/2025, R3 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. Section H Bladder and Bowel code R3 as having an indwelling catheter (3). On 02/03/2026 at approximately 2:40 p.m. an observation of R3's from the facility hallway revealed R3's catheter collection bag hanging on the left side of the bed (hallway side) with urine in the bag. The physician's order documented in part, Foley catheter #16/10 (16 French (4)/ 10 cubic centimeters) due to Obstructive & reflux Uropathy. Order Date: 12/18/2025. The comprehensive care plan for R3 dated 05/05/2025 documented in part, Focus. Catheter: resident requires a urinary 16Fr (French) 5-10cc (five to ten cubic centimeter) balloon catheter related to: obstructive neurogenic bladder. Created on: 05/05/2025 Revision on: 09/08/2025. Under Interventions it documented in part, Maintain catheter privacy bag Created on: 05/05/2025. On 02/04/2026 at approximately 9:40 a.m. an interview was conducted with LPN (licensed practical nurse) #5, unit manager. When asked to describe the purpose of a resident's comprehensive care plan she stated that it provided instructions for a resident's care. After reviewing R3's comprehensive care plan for maintaining a catheter privacy bag she stated that the care plan was not being followed. On 02/05/2026 at approximately 12:05 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #4, regional director of clinical services, and ASM #5, assistant director of nursing, were made aware of the above findings. No further information was provided prior to exit. References:(1) Urine drainage bags collect urine. Your bag will attach to a catheter (tube) that is inside your bladder. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000142.htm. (3) One that is left in the bladder. Most often, the catheter is inserted through the urethra. This is the tube that carries urine from the bladder to the outside of the body. This information was obtained from the website: https://medlineplus.gov ency article (2) A condition in which the flow of urine is blocked This information was obtained from the website: https:// medlineplus.gov/ency/article/000507.htm. (4) The number 16-French refers to the size of the catheter, with higher numbers indicating larger sizes. This information was obtained from the website: https://balumed.com/en/medical-dictionary/16-french-foley-catheter.

Based on observations, staff interview, resident interview, clinical document and facility document review, it was determined that the facility staff failed to provide a safe environment for two of 17 residents in the survey sample, Resident #9 (R9) and Resident #5 (R5). For Resident #9, the facility staff left the resident unattended, in an unsafe position, with the bed in the high position on 3/24/25. R9 rolled off the bed and suffered a hematoma. The resident was sent to the emergency room and found to have an occipital condyle fracture (1) thus causing harm to the resident.The findings include: 1. For R9, the facility staff left the resident, unattended, in an unsafe position, with the bed in the high position, causing the resident to fall out of the bed, which resulted in an occipital condyle fracture thus causing harm to the resident on 3/24/25. R9 was admitted to the facility on [DATE] with diagnosis that included but were not limited to CVA (cerebrovascular accident – stroke), hemiplegia and hemiparesis. The most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of 6/28/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being partial to moderate assist for bathing/transfer/dressing/toileting and set up for eating. A review of the 2/24/25 Medicare 5-day MDS GG0170. Mobility: A. Roll left and right: The ability to roll from lying on back to left and right side, return to lying on back on the bed. Coded as substantial/max assist. Fall occurred on 3/24/25 and on 3/28/25 MDS GG0170. Mobility: A. Roll left and right: was coded as dependent. A review of the baseline care plan dated 2/20/25 revealed, FOCUS: FALLS: resident is at risk for falls related to muscle weakness related to poor balance, related to psychoactive medications, related to recent hospitalization and high-risk medication use. INTERVENTIONS: place common items within reach of the resident. remind the resident to use their call light to ask for assistance with ADLS (activities of daily living). Care plan was revised on 4/9/25 with added intervention of 1 person assists with bed mobility, assistance may vary. A review of RN (registered nurse) #3's progress note dated 3/24/25 at 7:48 AM revealed, Description of the fall/V/S (vital signs)/injuries if any: Writer heard a loud noise from resident room and upon entering room resident was found on the floor with the face down. Hematoma and bleeding noted on the resident's forehead. Complete head to assessment conducted, V/S at baseline, ROM (range of motion) WNL (within normal limits). Oxycodone (2) 5mg (milligrams) and Tylenol (2) 650mg administered for c/o pain. Site cleansed with normal saline, ice cube applied to site, and compression bandage in place. RP (responsible party)/NP (nurse practitioner) notified. What Interventions were in place at the time of the fall? Fall mats, Staff education on calling for assistance when changing resident, gather supplies before changing resident. What are the risk factors that could have contributed to the fall? Staff education on calling for assistance. A review of the progress note dated 3/24/25 at 9:00 AM revealed, Resident out at hospital, NP aware, RP aware. A review of the progress note dated 3/24/25 at 1:00 PM revealed, Resident returned to facility from hospital with documentation, discharge paperwork, states resident has unspecified occipital condyle fracture, paperwork states he does not recommend a C- collar or any surgical interventions and will be supportive care with pain management and outpatient follow-up PCP (primary care practitioner). Resident has laceration to left forehead and left check. Treatment orders in place, pain regimen reviewed and updated by NP. NP visited resident during shift. Resident accompanied by brother. Resident noted resting in bed, bed in lowest position. A review of the progress note dated 3/24/25 at 9:15 PM revealed, Skilled Nursing Focus: Resident alert and verbal, resident skilled for PT(physical therapy)-OT(occupational therapy), resident c/o (complained of) back neck pain, medicated with PRN (as needed) meds (medications) with positive effect, resident verbalizes needs to staff, resident tolerates whole meds in apple sauce, resident x2 person assist with ADL care, day 1/3 post fall on the floor, ROM WNL, discoloration remains to forehead, bed in lowest position, call bell, within reach. A review of the progress note dated 3/24/25 10:21 PM revealed, LATE ENTRY: Situation: Date and time the fall occurred: 03/24/2025 6:30 AM. Background: Circumstances of the fall: Resident rolled off the bed and landed face down on the floor. Assessment (RN)/Appearance (LPN): Current status of the resident's injuries or reports of pain from the fall: Sustained a bleeding hematoma & discoloration to his face. Recommendation: Interventions currently in place to prevent additional falls: common items within reach, use call bell, 2 person (sic) with bed mobility, use pillows for parameters. Resident's response to new interventions: accepting. A review of the 3/24/25 NP note revealed, Fall: Provider in morning received a call from nursing staff, that patient had a fall and was facedown (sic) on floor with a hematoma and forehead was bleeding. Resident sent to the ER. Resident states he was rolled onto his side and being changed when he rolled out of bed, did not lose consciousness. Seen by neurosurgeon in the emergency room. Recommend by neurosurgeon that he does not need any C-collar or any surgical treatment at this time. He will need pain management and supportive care at this time. Posttraumatic changes involving soft tissue overlying the left frontal bone. A review of the facility's Employee Corrective Action form for CNA (certified nursing assistant) #3, dated 3/26/25 and signed by the Director of Nursing, revealed Describe specific facts: Staff failed to verify bed mobility for Resident. Resident states staff member left the room to get more supplies and that resulted in resident falling. Staff member called on 3/25/25 and made them aware of suspension pending investigation. CNA #3 resigned from facility on 4/26/25 and was not available to be interviewed. A review of the March 2025 ADL record for R9 revealed bed mobility coded as dependent 36 out of 62 shifts. On 3/23/25 day shift coded as dependent on 3/23/25 night shift (till 7AM 3/24/25) coded as partial/moderate assist. On 10/21/25 at 11:00 AM an interview was conducted with R9. When asked if he remembered the fall, R9 stated, Oh yes, the aide turned me on my side to clean me up and left the room to get more supplies, I fell off of the bed and broke my glasses. When asked if there were fall mats, R9 stated yes, there were. When asked what position the bed was in, R9 stated, It was raised, but I could not tell you exactly how high. On 10/21/25 at 12:00 PM an interview was conducted with ASM (administrative staff member) #1, the director of nursing. When asked what substantial / max assist (assistance) means, ASM #1 stated, it means a minimum of two staff. If the care plan does not identify number of staff to care for the resident, the CNAs (certified nursing assistants) use the Kardex and the number of staff should be designated on the Kardex. ASM #1 stated, they should ask and not do care until they have an answer as to how many staff are needed. ASM #1 was asked for the Kardex for March 2025, ASM #1 stated that facility if unable to pull Kardex past 30 days. On 10/22/25 at 7:15 AM an interview was conducted with RN (registered nurse) #3. When asked to describe the R9's fall on 3/24/25, RN #3 stated, I was out in the hall and doing meds, heard a loud sound in the room and rushed in. The resident mentioned that the aide was trying to clean him up and turned him on his side, the resident stated that the aide had stepped out of the room to get some supplies, the aide was not in the room when I entered. The resident had fall mats on both sides and the bed was not in the lowest position. I am not sure how high the bed was. The resident was partially on the floor mat and partially on the floor, he was angled on the floor mat. I had told the CNA to ask for help as she floats for the most part and did not work on that unit all the time After the fall, when I was talking with the CNA, I told her again that she could have yelled for help or to get supplies. I really saw there was remorse in the aide after the fall but the harm had happened at that point. I believe the resident was substantial / max assist. On 10/22/25 at 8:20 AM an interview was conducted with ASM #1, the director of nursing. RELIAS online education was provided for CNA #3. Fall education was documented. ASM #1 provided the Therapy notes for R9 and stated, it is documented on the OT Discharge summary dated [DATE] Patient is maintaining sit-stand-transfer at Min-Mod A with no further progress this reporting period. Goal met to highest practical level. When asked what the baseline dated 4/1/25 substantial/maximal assistance indicates, ASM (administrative staff member) #1, the DON (director of nursing) was not sure, but I will have OT or PT come talk with you. On 10/22/25 at 9:00 AM an interview was conducted with OSM (other staff member) #5, the physical therapy assistant. When shown R9's OT/PT discharge summary and asked to describe it, OSM #5 stated, we generate the STG (short term goals) and LTG (long term goals). Baseline heading and date underneath reflects the status that the resident was on the evaluation date of 4/1/25. He was substantial / max assistance. It is implied as a 1 person assist. Min-Mod A designation means varied assistance from minimum to moderate. We had not seen him before 4/1/25. On 10/22/25 at 2:55 PM, ASM (administrative staff member) #1, the director of nursing, ASM #2, the administrator and (registered nurse) #1, the assistant director of nursing, were made aware of the concern for harm for R9. According to the facility's Fall Management Program policy which revealed, The center considers all patients to be at risk for falls and provides an environment as safe as practicable for all patients. The center utilizes a systematic approach to a falls management program that facilitates an interdisciplinary approach with evidence-based interventions to develop individual care strategies. Discuss fall risks and interventions with patient and/or responsible party. Incorporate any identified interventions into the care plan as applicable. No further information was provided prior to exit. References: 1. Occipital condylar fractures are uncommon injuries usually resulting from high-energy blunt trauma. They are considered a specific type of basilar skull fracture. mostly occur in the setting of high-energy trauma fall from a significant height: This information was obtained from the following website: Occipital condyle fracture | Radiology Reference Article | Radiopaedia.org. 2. Oxycodone is used to relieve severe pain. Oxycodone is in a class of medications called opiate (narcotic) analgesics. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682132.html. 3. Tylenol (acetaminophen) Acetaminophen is used to relieve mild to moderate pain from headaches, muscle aches, menstrual periods, colds and sore throats, toothaches, backaches, reactions to vaccinations (shots), and to reduce fever. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a681004.html

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care and services to promote a resident's highest level of wellbeing for one of twelve residents, Resident #112 (R112).The findings include: The facility failed to monitor sexual / inappropriate behaviors for a resident who is listed on the sex offender registry. R112 was admitted to the facility on [DATE] with diagnosis that included but were not limited to ischemic cardiomyopathy, CHF (congestive heart failure), atrial fibrillation and LVAD (left ventricular assist device).The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 11/8/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring supervision for bathing/transfer/dressing/toileting and independent for eating.A review of the comprehensive care plan dated 10/3/24 revealed, FOCUS: Resident has behaviors refuses cardiac clinic appointments. Resident refuses daily weights. Encourage compliance with routine weight monitoring. INTERVENTIONS: assure the resident they are safe if they become distressed. Contact clinic and see if can do facility visit.During a complaint investigation regarding admission of residents on the VSP (Virginia State Police) Sex Offender Registry, R112 was found to be on the registry, dated 8/21/24.An interview was conducted on 12/17/25 at 10:45 AM with ASM (administrative staff member) #2, the DON (director of nursing). When asked the admissions process, ASM #2 stated, they do a sex offender check. The facility administrators until 4/21/25 allowed sex offenders in the facility. Asked the process for admitting sex offenders, ASM #2 stated, we find out if the resident is mobile, is the offense recent, nature of offense (virtual or physical). Asked how staff and residents are protected, ASM #2 stated, we would monitor behavior, and if there is an incident- separation of resident, investigation, if sexual in nature- evaluation in ED (emergency department) and call the police. When asked where this would be monitored, ASM #2 stated, on the MAR-TAR (medication administration record, treatment administration record). Asked for evidence of this monitoring for R112, ASM #2 stated, there is no monitoring. On 12/17/25 at 11:50 AM, an interview was conducted with OSM (other staff member) #1, the social worker. Asked, what is the process for residents on the sex offender registry, OSM #1 stated, We previously had accepted these residents, we do not anymore. I'll pass information along to case worker or parole officer. Asked if sexual / inappropriate behaviors should be monitored, OSM #1 stated, Yes, his behaviors should be monitored. On 12/17/25 at 2:00 PM ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, RN (registered nurse) #3, the assistant director of nursing, RN #4, the assistant director of nursing, were made aware of the concerns.According to the facility's Behavioral Assessment/Behavior Monitoring policy, which revealed, Behaviors will be assessed and monitored. Factors influencing behaviors, as well as management interventions will be evaluated and care planned.No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to protect a resident's right to consent to receiving a psychoactive medication for one of 17 residents in the survey sample, Resident #14.The findings include:For Resident #14 (R14), the facility staff failed to obtain consent from the resident prior to administering Ativan (1) on 3/1/25.A review of the MDS (minimum data set) immediately prior to 3/1/25, an annual assessment with an ARD (assessment reference date) of 2-15-25, revealed R14 was coded as having no cognitive impairment, having scored 15 out of 15 on the BIMS (brief interview for mental status).A review of R15's clinical record between 2/15/25 and 3/1/25 revealed no evidence of a change in R14's cognitive status. Multiple entries in the record named R14 as her own RP (responsible party).Further review of R15's clinical record revealed the following progress notes: 3/1/2025 15:05 (3:05 p.m.) Behavior Note.Type of Behavior: Agitation, outward expressions of anger, Striking staff with room phone x 2, attempting to strike staff with fists. Threatening roommate.Non-pharmacological intervention: redirection, removing pt to quiet area, Effect: Pt (patient) continued to scream, yell, attempt to strike staff. Social worker present, called daughter.PRN (as-needed) Medication: Order obtained for PRN Ativan [tablet], pt refused to accept. 3/1/25 14:51 (4:51 p.m. Note Text: Writer reached out to [name of nurse practitioner] for patients (sic) continued aggression/agitation and continued physical strikes to staff members despite all intervention and redirection. Provider prescribed Ativan Injection Solution 2 MG/ML (Lorazepam) stat (immediate) dose one time. Writer attempted to call daughter as well as son again. VM (voicemail) left for both x 2. Ativan IM (intramuscular injections) administered as ordered and effective.A review of R15's clinical record revealed no evidence that R14 was given the opportunity to consent to the Ativan injection she received on 3/1/25.On 10/21/25 at 1:25 p.m., LPN (licensed practical nurse) #3, a unit manager, was interviewed. She stated any medication that is administered to a resident must first be ordered by a provider. She explained that once the provider writes and signs the order, the resident (if the resident is named as their own responsible party) and/or the RP are notified prior to administering the medication. She stated every resident has the right to refuse any medication or treatment. She stated that even is a resident is exhibiting behaviors, there is always an alternative to administering a medication without the resident's consent. These include non-pharmacological interventions and sending the resident to the hospital as a last resort. She added that even if a resident is confused, if the resident does not agree to receiving a medication, the facility can not administer it.On 10/21/25 at 2:07 p.m., ASM (administrative staff member) #1, the director of nursing and RN (registered nurse) #1, the assistant director of nursing, were interviewed. ASM #1 stated that a resident has a right to refuse a medication unless the resident is posing a risk to themselves or to other residents. RN #1 stated the purpose of administering Ativan to R14 was to calm the resident down, and that non-pharmacological interventions were attempted prior to the resident's receiving the Ativan injection. She stated the resident was offered the opportunity to refuse the Ativan by mouth, and when the resident refused, the facility staff administered the Ativan by injection. She stated there was no evidence that the resident was given the opportunity to refuse the injection.On 10/22/25 at 10:10 a.m., ASM #1, ASM #2, the administrator, and RN #1 were informed of these concerns.A review of the facility policy, Refusal of Medication/Treatment/Care, revealed, in part: All patients have the right to refuse medication(s) and/or care; however, a licensed nurse is responsible for providing education to patient and/or the responsible party regarding the risk for negative outcomes.No additional information was provided prior to exit.Reference(1) Lorazepam (brand name Ativan) is used to relieve anxiety. Lorazepam is in a class of medications called benzodiazepines. It works by slowing activity in the brain to allow for relaxation. This information is taken from the website https://medlineplus.gov/druginfo/meds/a682053.html.

Based on observation and staff interview, the facility staff failed to accommodate a resident's need by placing the call bell within reach for one of 12 residents in the survey sample, Resident #103. The findings include:For Resident #103 (R103), the facility staff failed to place the call bell (a device with a button that can be pushed to alert staff when assistance is needed) within reach. R103 was admitted to the facility with a diagnosis that included by not limited to difficulty walking. The most recent comprehensive MDS (minimum data set) was not due at the time of the survey. The facility's admission Assessment for R103 dated 12/10/2025 documented in part, 1. Cognitive State. a) cognitively impaired. 16. admission Narrative Note: resident presents to facility by medical transport is a manual wheelchair. alert and oriented to self with confusion to time, place, and situation. pleasant affect. On 12/16/2025 at approximately 10:40 a.m. an observation of R103 in his room revealed he was sitting in his wheelchair next to the right side of the bed. When asked if he was able to locate the call bell, R103 looked around his bed and stated he did not know where it was. Observation of the call bell revealed it was draped over the left side of the headboard. After pointing out the location of the call bell to R103, he was asked if he was able to access it. Observations revealed R103 propelling his wheelchair to the opposite of the bed but unable to mauver the wheelchair alongside the left side of the bed to reach the call bell. R103 stated that he could not reach the call bell. On 12/16/2025 at approximately 10:55 a.m. an observation revealed LPN (licensed practical nurse) #5 enter R103's room, remove the call bell from the head of the bed and clip it to R103's shirt while he was sitting in his wheelchair. On 12/16/2025 at approximately 10:57 a.m. an interview was conducted with LPN # 5. When asked about the purpose of a call bell for residents she stated that it was used to call for assistance. She further stated that R103's call bell was not within his reach and should have been where R103 could access it. On 12/17/2025 at approximately 2:00 p.m. ASM (administrative staff member) # 1, administrator, and ASM #2, director of nursing, were made aware of the above findings. No further information was provided prior to exit.

Based on observations and staff interview, facility staff failed to maintain a clean environment for one of 12 resident rooms observed, resident room [ROOM NUMBER]. The findings include:For resident room [ROOM NUMBER], facility staff failed to maintain the PTAC (packaged terminal air conditioner) unit vents in a clean manner. On 12/16/2025 at approximately 12:45 p.m. an observation of the PTAC in resident room [ROOM NUMBER] revealed the vents to have a black, greasy substance coating them. On 12/16/2025 at approximately 3:36 p.m. an observation of the PTAC unit in resident room [ROOM NUMBER] and interview with OSM (other staff member) #7 was conducted. After observing the vents on the PTAC unit he agreed that they were not clean. When asked about maintaining the vents in a clean manner he stated that PTAC units are checked every two weeks and that this one was overlooked. On 12/17/2025 at approximately 2:00 p.m. ASM (administrative staff member) # 1, administrator, and ASM #2, director of nursing, were made aware of the above findings. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to implement their abuse policy to report an allegation of abuse in the required timeframe for one of 17 residents in the survey sample, Resident #4.The findings include: The facility policy Reporting Requirements/Investigations effective 2/5/2023 documented in part, .Immediately upon notification of any alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, the Administrator will immediately report to the State Agency, but not later than 2 hours after the allegation is made, if the events that caused the allegation involves abuse or results in serious bodily injury .Review of the facility synopsis of events documented an event for Resident #4 (R4) dated 1/27/2025 which documented in part, .Report Date: 1/27/2025. Incident Date: 1/27/2025. Resident alleged that his nurse hit him on his arm today in his room, nurse denied hitting him but that the resident attempted to strike at her and there was a witness to collaborate he attempted to strike at the nurse. Upon notification of the allegation the nurse was suspended. The Administrator interviewed the resident, assessed the skin area where he stated he was hit, there were no obvious bruises, swelling, abrasions or reddened areas. Resident was transferred to the hospital for AMS (altered mental status) today around 1:45 pm . Review of the fax transmittal confirmation of the event to the state agency documented the report sent 1/28/2025 at 10:54 AM.The progress notes for R4 documented in part, 01/27/2025 13:12 (1:12 p.m.) Note Text: Resident has been yelling throughout the shift today related to roommates' mats on floor and bedside table. Writer arranged room to accommodate resident's needs, but resident was still yelling. Writer went to check resident's BS (blood sugar) and explained to resident that he will be getting 10 units of Humalog (insulin). Resident started yelling at nurse that he is allergic to Humalog. Nurse apologized to resident and stated that I did not mean Humalog but Admelog (another brand of insulin). Resident started cursing and yelling I'm allergic to Humalog. Writer attempted to show Insulin pen to resident, when writer showed insulin pen to resident, resident attempted to grab pen from writer and then attempted to hit resident (sic). Writer backed up and walked out of room. After leaving resident's room he came out of his room and stated that nurse hit me twice. Writer went to inform ADON (assistant director of nursing) of situation.On 10/21/2025 at 2:24 PM, an interview was conducted with administrative staff member (ASM) #1, the director of nursing, who stated that R4 had alleged that the nurse had hit them. She stated that the former administrator had taken over the investigation due to her personal relationship with the accused nurse. ASM #1 stated that when there was any allegation of abuse the staff member is suspended, a pain and skin assessment is completed, a trauma screening is completed by social services, and they notified the physician and responsible party. She stated that abuse allegations were reported within two hours and the event for R4 would qualify as required to report in two hours because it was an allegation of abuse. On 10/22/2025 at 10:09 AM, ASM #1 and ASM #2, the administrator were made aware of the concern.No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to report an allegation of abuse in the required timeframe for one of 17 residents in the survey sample, Resident #4.The findings include: Review of the facility synopsis of events documented an event for Resident #4 (R4) dated 1/27/2025 which documented in part, .Report Date: 1/27/2025. Incident Date: 1/27/2025. Resident alleged that his nurse hit him on his arm today in his room, nurse denied hitting him but that the resident attempted to strike at her and there was a witness to collaborate he attempted to strike at the nurse. Upon notification of the allegation the nurse was suspended. The Administrator interviewed the resident, assessed the skin area where he stated he was hit, there were no obvious bruises, swelling, abrasions or reddened areas. Resident was transferred to the hospital for AMS (altered mental status) today around 1:45 pm . Review of the fax transmittal confirmation of the event to the state agency documented the report sent 1/28/2025 at 10:54 AM.The progress notes for R4 documented in part, 01/27/2025 13:12 (1:12 p.m.) Note Text: Resident has been yelling throughout the shift today related to roommates' mats on floor and bedside table. Writer arranged room to accommodate resident's needs, but resident was still yelling. Writer went to check resident's BS (blood sugar) and explained to resident that he will be getting 10 units of Humalog (insulin). Resident started yelling at nurse that he is allergic to Humalog. Nurse apologized to resident and stated that I did not mean Humalog but Admelog (another brand of insulin). Resident started cursing and yelling I'm allergic to Humalog. Writer attempted to show Insulin pen to resident, when writer showed insulin pen to resident, resident attempted to grab pen from writer and then attempted to hit resident(sic). Writer backed up and walked out of room. After leaving resident's room he came out of his room and stated that nurse hit me twice. Writer went to inform ADON (assistant director of nursing) of situation.On 10/21/2025 at 2:24 PM, an interview was conducted with administrative staff member (ASM) #1, the director of nursing, who stated that R4 had alleged that the nurse had hit them. She stated that the former administrator had taken over the investigation due to her personal relationship with the nurse. ASM #1 stated that when there was any allegation of abuse the staff member is suspended, a pain and skin assessment is completed, a trauma screening is completed by social services, and they notified the physician. She stated that abuse allegations were reported within two hours and the event for R4 would qualify as required to report in two hours because it was an allegation of abuse. The facility policy Reporting Requirements/Investigations effective 2/5/2023 documented in part, .Immediately upon notification of any alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, the Administrator will immediately report to the State Agency, but not later than 2 hours after the allegation is made, if the events that caused the allegation involves abuse or results in serious bodily injury .On 10/22/2025 at 10:09 AM, ASM #1 and ASM #2, the administrator were made aware of the concern.No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, the facility staff failed to complete an accurate MDS assessment for one of 17 residents in the survey sample, Resident # 1. The findings include: For Resident #1, the facility staff failed to complete an accurate quarterly MDS (minimum data set) assessment. R1 was admitted to the facility on [DATE] with diagnosis that included but were not limited to paraplegia, ASCVD (atherosclerosis cardiovascular disease) and neuromuscular dysfunction of bladder. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 9/27/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for bed mobility, transfer, hygiene and supervision for eating. A review of MDS Section: GG0115. Functional Limitation in Range of Motion- B. Lower extremity coded 0 = no impairment. MDS Section: GG0170. Mobility: I. Walk 10 feet: coded as 88 = not attempted due to medical condition or safety concerns. A review of the comprehensive care plan dated 1/13/25 and revised 9/27/25 revealed, FOCUS: Resident is at risk for falls related to muscle weakness, related to poor balance, related to psychoactive medications. INTERVENTIONS: ensure the resident wears shoes when ambulating, place common items within reach of the resident, remind the resident to use their call light to ask for assistance with ADLS (activities of daily living).R1 had been transferred to hospital on [DATE] and was not in facility during the survey. On 10/21/25 at 7:14 AM, an interview was conducted with LPN (licensed practical nurse) #2. When asked what she remembered about R1, LPN #2 stated he could not walk and used a wheelchair. On 10/21/25 at 7:25 AM, an interview was conducted with LPN #10, the MDS coordinator. When asked to review R1's, 9/27/25 MDS functional limitations in range of motion and mobility sections and asked if there was an error in what was coded, LPN #10 stated yes, there is. When asked what standard is followed to complete the MDS, LPN #10 stated the RAI (resident assessment instrument) manual. On 10/22/25 at 10:15 AM, ASM (administrative staff member) #1, the director of nursing, ASM #2, the administrator and RN (registered nurse) #1, the assistant director of nursing, were made aware of the findings. According to the RAI (resident assessment instrument) MDS Section GG0170: Code based on the resident's performance.No further information was provided prior to exit.

Based on observations, staff interview facility document review and clinical record review, it was determined the facility staff failed to develop/implement the care plan for one of twelve residents in the survey sample, Resident #112 (R112).The findings include: The facility staff failed to develop the comprehensive care plan for sexual / inappropriate behavior monitoring for R112.R112 was admitted to the facility on [DATE] with diagnosis that included but were not limited to ischemic cardiomyopathy, CHF (congestive heart failure), atrial fibrillation and LVAD (left ventricular assist device).The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 11/8/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring supervision for bathing/transfer/dressing/toileting and independent for eating.A review of the comprehensive care plan dated 10/3/24 revealed, FOCUS: Resident has behaviors refuses cardiac clinic appointments. Resident refuses daily weights. Encourage compliance with routine weight monitoring. INTERVENTIONS: assure the resident they are safe if they become distressed. Contact clinic and see if can do facility visit.During a complaint investigation regarding admission of residents on the VSP (Virginia State Police) Sex Offender Registry, R112 was found to be on the registry.On 12/17/25 at 10:45 AM, an interview was conducted with ASM (administrative staff member) #2, the DON (director of nursing). Asked if monitoring sexual / inappropriate behaviors should be on the care plan for a resident who is listed on the sex offender registry, ASM #2 stated, It should be on the care plan. I would expect it to be there.On 12/17/25 at 2:00 PM ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, RN (registered nurse) #3, the assistant director of nursing, RN #4, the assistant director of nursing was made aware of the concerns.According to the facility's Care Planning policy, which revealed, A licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan for each patient in order to provide effective, person-centered care, and the necessary health-related care and services to attain or maintain the highest practical physical, mental and psychosocial well-being of the patient.According to the facility's Behavioral Assessment/Behavior Monitoring policy, which revealed, Behaviors will be assessed and monitored. Factors influencing behaviors, as well as management interventions will be evaluated and care planned.No further information was provided prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to review and revise the care plan for two of 17 residents in the survey sample, Residents #5 and #1.The findings include:1. For Resident #5 (R5), the facility staff failed to review and revise the care plan after a fall. On the following dates and times, R5 was observed lying on his back in bed; there were no fall mats to either side of the bed: 10/20/25 at 2:26 p.m. and 3:48 p.m.; 10/21/25 at 9:26 a.m. A review of R5's care plan dated 4/26/25 and most recently revised on 8/22/25 revealed no information regarding the implementation of fall mats to prevent injury to R5 in case of a fall. A review of R5's clinical record revealed the following progress note dated 3/30/2025: 03:38 (3:38 a.m.) Fall Note Description of the fall.Writer was called to Resident's room because CNA (certified nursing assistant) found the resident on the floor. Resident was laying (sic) on the floor on the right side of the bed. He has a small skin tear on the left side of his forehead. Resident is suspected to have had a seizure prior to fall. Resident still showed on and off jerking spells/seizure-like movements. What interventions were in place at the time of the fall? Bed in low position, call light within reach.What are the risk factors that could have contributed to the fall? History of seizures, nonverbal -- unable to call for help.What new interventions were implemented in response to the fall? Fall mat placed, neurochecks initiated, sent to ER (emergency room). On 10/21/25 at 12:02 p.m., ASM (administrative staff member) #1, the director of nursing, stated she could not find any evidence that the facility staff reviewed or revised R5's care plan following the fall on 3/29/25. She admitted that the care plan should have been reviewed, as the care plan gives the staff directions about how to care for the resident. She added: He had a fall so it should have been reviewed. On 10/21/25 at 12:37 p.m., CNA #4 was interviewed. He stated when he arrives at work, he receives report from the nurse. If there have been changes to a resident's care plan, including interventions to prevent injuries from falls, the nurse will usually tell him. He stated he also has access to the Kardex, which takes interventions from the care plan and puts them in a format that CNAs can see on the computer kiosk. He stated he was not aware that R5 needed floor mats, although he could see how they would be helpful for the resident. On 10/21/25 at 2:42 p.m., LPN (licensed practical nurse) #4, a unit manager, was interviewed. She stated if a floor nurse determines floor mats are needed as an intervention following a resident's fall, the nurse should update the care plan, alert all the staff, and place the mats by the resident's bed. She stated that any floor nurse has the ability to update a resident's care plan at any time. On 10/22/25 at 10:10 a.m., ASM #1, ASM #2, the administrator, and RN #1 were informed of these concerns. A review of the facility policy, Care Planning, revealed, in part: Care plans will be updated on an ongoing basis as changes in the patient occur, and reviewed quarterly with the quarterly assessment. No additional information was provided prior to exit. 2. The facility failed to revise the comprehensive care plan for fall interventions for R1. R1 was admitted to the facility on [DATE] with diagnosis that included but were not limited to paraplegia, ASCVD (atherosclerosis cardiovascular disease) and neuromuscular dysfunction of bladder. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 9/27/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for bed mobility, transfer, hygiene and supervision for eating. A review of MDS Section: GG0115. Functional Limitation in Range of Motion- B. Lower extremity coded 0 = no impairment. MDS Section: GG0170. Mobility: I. Walk 10 feet: coded as 88 = not attempted due to medical condition or safety concerns. A review of the comprehensive care plan dated 1/13/25 and revised 9/27/25 revealed, FOCUS: Resident is at risk for falls related to muscle weakness, related to poor balance, related to psychoactive medications. INTERVENTIONS: ensure the resident wears shoes when ambulating, place common items within reach of the resident, remind the resident to use their call light to ask for assistance with ADLS (activities of daily living). R1 had been transferred to hospital on [DATE] and was not in facility during the survey. On 10/20/25 at 2:35 PM, an interview was conducted with LPN (licensed practical nurse) #1. When asked if she remembered R1, LPN #1 stated, yes, he could not walk and he had a foley. I changed his foley and foley bag when the NP (nurse practitioner asked me to, it was before he went to the hospital. His sister was visiting that day. When asked the purpose of the care plan, LPN #1 stated, it is to describe the care each resident needs and what interventions we are to implement to meet those needs. When asked if the care plan for R1 included an intervention of ensure the resident wears shoes when ambulating was the care plan correct, LPN #1 stated, no, because he did not walk. When asked if the care plan should be revised, LPN #1 stated, yes. On 10/21/25 at 7:14 AM, an interview was conducted with LPN #2. When asked what she remembered about R1, LPN #2 stated he could not walk and used a wheelchair. On 10/22/25 at 10:15 AM, ASM (administrative staff member) #1, the director of nursing, ASM #2, the administrator and (registered nurse) #1, the assistant director of nursing, were made aware of the findings. No further information was provided prior to exit.

Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to follow professional standards of practice to promote residents highest level of well-being for two of 17 residents in the survey sample, Resident #10 and Resident #4.The findings include: 1. For Resident #10 (R10), the facility staff failed to follow professional standards of practice during medication administration.On 10/20/2025 at 10:19 AM, an observation was made of licensed practical nurse (LPN) #5 preparing medication for R10. LPN #5 was observed removing one tablet of Folic Acid from a house stock bottle that was labeled Folic Acid 400mcg (microgram) and placing it in a medication cup and administered it to R10.Review of the physician orders for R10 documented in part, Folic Acid Oral Tablet 1 MG (milligram) (Folic Acid) Give 1 tablet by mouth one time a day for supplement. Order Date: 04/03/2025. Start Date: 04/04/2025.On 10/20/2025 at 2:15 PM, an interview was conducted with LPN #5 who stated that during medication administration she verified the resident, right medication, right dosage, right quantity, right time, and right preferences for taking the medication. She retrieved the bottle of Folic Acid 400mcg from the medication cart and reviewed the physicians order and stated that she administers one-quarter of the tablet to R10 to equal the 1mg dosage. LPN #5 stated that it was not the correct dosage and it was hard using the stock medications when the nurses had to calculate the dosages.The facility policy General Guidelines for Medication Administration revised 08/2020, documented in part, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to administer . Check #1: Select the medication, check the label, container, and contents for integrity, and compare the medication against the Medication Administration Record (MAR) by reviewing the 5 Rights. Check #2: Prepare the dose by removing the dose from the container and verifying it against the label and the MAR by reviewing the 5 Rights. c. Check #3: Complete the preparation of the dose and re-verify the label against the MAR by reviewing the 5 Rights .On 10/22/2025 at 10:09 AM, administrative staff member (ASM) #1, the director of nursing and ASM #2, the administrator were made aware of the concern.No further information was provided prior to exit.2. For Resident #4 (R4), the facility staff failed to A) document behaviors, a change in condition and resident-initiated hospital transfer and B) clarify physician orders for insulin.A) Document behaviors/change in condition and resident-initiated hospital transfer:The progress notes for R4 documented in part,- 01/27/2025 13:12 (1:12 p.m.) Note Text: Resident has been yelling throughout the shift today related to roommates' mats on floor and bedside table. Writer arranged room to accommodate resident's needs, but resident was still yelling. Writer went to check resident's BS (blood sugar) and explained to resident that he will be getting 10 units of Humalog (insulin). Resident started yelling at nurse that he is allergic to Humalog. Nurse apologized to resident and stated that I did not mean Humalog but Admelog (another brand of insulin). Resident started cursing and yelling I'm allergic to Humalog. Writer attempted to show Insulin pen to resident, when writer showed insulin pen to resident, resident attempted to grab pen from writer and then attempted to hit resident. Writer backed up and walked out of room. After leaving resident's room he came out of his room and stated that nurse hit me twice. Writer went to inform ADON (assistant director of nursing) of situation.- 01/27/2025 23:13 (11:13 p.m.) Note Text: Resident returned to facility from [Name of hospital]. No new orders noted at this. No new areas noted to skin. Will continue with plan of care.Review of the facility synopsis of events documented an event dated 1/27/25 which documented in part, Resident alleged that his nurse hit him on his arm today in his room, nurse denied hitting him but that the resident attempted to strike at her and there was a witness to collaborate he attempted to strike at the nurse. Upon notification of the allegation the nurse was suspended. The Administrator interviewed the resident, assessed the skin area where he stated he was hit, there were no obvious bruises, swelling, abrasions or reddened areas. Resident was transferred to the hospital for AMS (altered mental status) today around 1:45 pm . On 10/21/2025 at 11:55 AM, administrative staff member (ASM) #1, the director of nursing stated that the former unit manager had taken over for the nurse who was suspended on 1/27/25 and she no longer worked at the facility. She stated that she had been informed that R4 went outside and called 911 themselves and initiated the hospital transfer themselves. On 10/21/2025 at 1:26 PM, an interview was conducted with licensed practical nurse (LPN) #3 who stated that she was called to go check on R4 because the other unit manager had taken over for the nurse sent home. She stated that she was told that R4 had been having behaviors and had gone outside to the edge of the road. LPN #3 stated that when she got out there with R4 she tried to get the resident to return to the building but R4 was upset and confused. She stated that she had called R4's family member and tried to get R4 to talk with her but they refused. She stated that R4 used his personal cell phone to call 911 and when the police arrived they tried to get the resident to go back inside but R4 still refused. LPN #3 stated at that time she went back inside but she heard that R4 ended up going to the hospital because he tried going down the street. She stated that she witnessed R4 being put in the back of the ambulance and the police were there as well. She stated that the former administrator was outside at the time. LPN #3 stated that there was supposed to be documentation in the medical record and even if the resident called 911 themselves the staff should put in some type of note documenting the incident and notify the physician and the responsible party. [NAME] and Perry's Fundamentals of Nursing, 7th Edition, page 231 documents the following statements: Assessment is the deliberate and systematic collection of data to determine a client's current and past health status .The purpose of the assessment is to establish a database . Page 243 documents: If you do not record an assessment finding or problem interpretation, it is lost and unavailable to anyone else caring for the client .Observation and recording is a legal and professional responsibility.B) Clarify physician orders for insulin:Review of the physician orders for R4 documented in part,- Admelog SoloStar 100 UNIT/ML (milliliter) Solution pen-injector, Inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units ; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units, subcutaneously before meals and at bedtime for Type 1 DM (diabetes mellitus). Order Date: 01/22/2025. Start Date: 01/22/2025.- Insulin Lispro 100 UNIT/ML Solution Inject as per sliding scale: if 150 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10 Call MD [medical doctor] for BS [blood sugar] >400mg/dl (milligram per deciliter), subcutaneously before meals related to type I Diabetes Mellitus with other specified complication. Inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units Call MD for BS >400mg/dl, subcutaneously three times a day for DM. Order Date: 06/24/2024. Start Date: 06/24/2024.Review of the electronic medication administration record (eMAR) for R4 dated 1/1/2025-1/31/2025 documented R4 receiving the Lispro sliding scale insulin as ordered through 11:30 AM on 1/24/2025. The eMAR documented the Admelog scheduled to start on 1/22/2025 at 6:30 AM but not administered until 4:30 PM on 1/24/2025. The eMAR notes for the missed doses 1/22/2025-1/24/2025 of Admelog documented that they were waiting for clarification by the nurse practitioner.On 10/21/2025 at 10:24 AM, an interview was conducted with licensed practical nurse (LPN) #7 who stated that if a medication was not administered they let the physician or nurse practitioner know and if there were questions about a medication they called them to clarify the medication. On 10/22/2025 at 10:09 AM ASM #1 stated that they did not have any evidence that the Admelog order was clarified with the nurse practitioner prior to 1/24/2025. On 10/22/2025 at 10:09 AM, administrative staff member (ASM) #1, the director of nursing and ASM #2, the administrator were made aware of the concern.No further information was provided prior to exit.

Based on resident/staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide ADL (activities of daily living) care for dependent residents for one of twelve residents, Resident #104 (R104).The findings include: The facility staff failed to provide ADL (activities of daily living) specifically turning/repositioning, incontinence care and feeding R104.R104 was admitted to the facility on [DATE] with diagnosis that included but were not limited to quadriplegia, spinal stenosis and TIA (transient ischemic attack).The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 10/9/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as dependent for bathing/transfer/dressing/toileting and eating; Section H-Bladder and Bowel coded the resident as bowel always incontinent, urinary indwelling catheter. A review of the comprehensive care plan dated 8/1/24 revealed, FOCUS: LONG TERM CARE: the resident requires assistance with ADLS relate to weakness, Quadriplegic and hand contractures. FOLEY CATHETER: resident requires a urinary 18 FR Coude' catheter 10cc balloon related to: obstructive neurogenic bladder. INTERVENTIONS: Assist of one with ADLS, resident dependent with feeding for meals, 2 person assist with bed mobility. Observe for signs and symptoms of infection such as dark or cloudy urine or blockage and notify md as indicated. Provide catheter care Q shift.A review of the October, November and December 2025 ADL forms reveal missing documentation on the following dates and shifts:-Turning/repositioning: Day shift: 11/28, 12/3 and Night shift: 10/29, 10/31, 11/25, 11/30 and 12/11.-Incontinence care: Day shift: 11/28, 12/3, 12/4 12/14 and Night shift: 10/26, 10/29, 10/31,11/25, 11/30 and 12/12.-Feeding: Day shift (breakfast/lunch): 11/28, 12/3 and Night shift (supper) 10/29, 10/31, 11/25, 11/30 and 12/12.On 12/15/25 at 2:00 PM an interview was conducted with CNA (certified nursing assistant) #1. When asked where documentation of specifically turning/repositioning, incontinence care and feeding would be located, CNA #1 stated, we document it in PCC (point click care) on the ADL form. When asked if the documentation is not present, would there be evidence of the care, CNA #1 stated, no, there would not be any evidence of the care. They are to document all care given in the ADL form.On 12/17/25 at 2:00 PM ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, RN (registered nurse) #3, the assistant director of nursing, RN #4, the assistant director of nursing was made aware of the concerns.According to the facility's Nursing Care and Services policy, which revealed, The center will utilize Mosby's Textbook for Long-Term Care Assistants by Kostelnick and/or Clinical Nursing Skills & Techniques by [NAME], [NAME] and Ostendorff, as a reference for nursing services and skills not otherwise provided in the Policies and Procedures Manuals. Turning and repositioning the person- record and document your observations.No further information was provided prior to exit.

Based on staff/resident interview, facility document review and clinical record review, it was determined that the facility staff failed to provide treatment and services for an indwelling catheter for one of twelve residents in the survey sample, Resident #104 (R104).The findings include: The facility failed to evidence treatment and services for Resident 104's (R105's) indwelling catheter.R104 was admitted to the facility on [DATE] with diagnosis that included but were not limited to quadriplegia, spinal stenosis and TIA (transient ischemic attack).The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 10/9/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as dependent for bathing/transfer/dressing/toileting and eating; Section H-Bladder and Bowel coded the resident as bowel always incontinent, urinary indwelling catheter. A review of the comprehensive care plan dated 8/1/24 revealed, FOCUS: LONG TERM CARE: the resident requires assistance with ADLS relate to weakness, Quadriplegic and hand contractures. FOLEY CATHETER: resident requires a urinary 18 FR Coude' catheter 10cc balloon related to: obstructive neurogenic bladder. INTERVENTIONS: Assist of one with ADLS, resident dependent with feeding for meals, 2 person assist with bed mobility. Observe for signs and symptoms of infection such as dark or cloudy urine or blockage and notify md as indicated. Provide catheter care Q shift.A review of the physician orders dated 6/20/25 revealed, FOLEY CATH : Catheter Output every day and night shift for foley monitoring.A review of the physician orders dated 11/6/25 revealed, Foley catheter and Suprapubic catheter: Flush with 60ml of Normal Saline 1x/daily while patient is lying in bed. one time a day for UTI prophylaxis. Suprapubic catheter: Provide foley catheter care every day and night shift for Obstructive Neurogenic bladder.A review of the physician orders dated 11/10/25 revealed, Suprapubic catheter: Flush with 10cc NS (normal saline) as needed for sluggish urine AND every day and night shift.A review of the October, November and December 2025 MAR-TAR (medication administration record-treatment administration record) revealed missing evidence of treatment provided:-Catheter Output every day and night shift for foley monitoring: Day shift: 10/21, 10/24 and Night shift: 10/24, 10/25, 11/9, 11/19.-Flush with 60ml of Normal Saline 1x/daily: Day shift: 11/11.-Suprapubic catheter: Provide foley catheter care every day and night shift: Day shift: 10/24, 11/24 and Night shift: 10/24, 11/9, 11/24.-Flush with 10cc NS (normal saline) as needed for sluggish urine AND every day and night shift: Day shift: 11/11.On 12/16/25 at 1:05 PM an interview was conducted with LPN (licensed practical nurse) #4, asked where evidence of catheter care would be documented, LPN #4 stated, it would be documented on the MAR-TAR. When asked if there is no evidence of care being documented- the care been done, LPN #4 stated, no, if it is not documented it was not done. On 12/17/25 at 2:00 PM ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, RN (registered nurse) #3, the assistant director of nursing, RN #4, the assistant director of nursing was made aware of the concerns.According to the facility's Urinary Catheterization policy, which revealed, Licensed nurses will irrigate catheter, if indicated, per provider's order. Perform catheter care every shift and document in the medical record.No further information was provided prior to exit.

Based on observation, resident interview, staff interview and clinical record review, it was determined that the facility staff failed to provide food at a palatable temperature for one of twelve residents, Resident #104 (R104).The findings include: The facility staff failed to provide food at a palatable temperature for R104 during lunch on 12/15/25. R104 was admitted to the facility on [DATE] with diagnosis that included but were not limited to quadriplegia, spinal stenosis and TIA (transient ischemic attack).The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 10/9/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as dependent for bathing/transfer/dressing/toileting and eating. A review of the comprehensive care plan dated 8/1/24 revealed, FOCUS: LONG TERM CARE: the resident requires assistance with ADLS relate to weakness, Quadriplegic and hand contractures. INTERVENTIONS: Assist of one with ADLS, resident dependent with feeding for meals.A test tray was done on Unit 1 for lunch on 12/15/25. 12:10 PM lunch trays arrived in cart on Unit 1, 12:14 PM, first tray taken off of cart. R104 was in the last room on the right of Unit 1 Hall. R104 received his tray at 12:43 PM. Temperatures of test tray: fish 118.6 degrees, noodles 122.8 degrees, zucchini and tomatoes 120.0.An interview was conducted on 12/15/25 at 12:52 PM with OSM (other staff member) #3, the dietary manager. When asked about the temperatures on the lunch test tray, OSM #3 stated, No, the food should be warmer. I get a lot of complaints about food temperatures. The staff do not deliver them to residents quickly enough. On 12/15/25 at 1:10 PM an interview was conducted with R104, when asked about his lunch food temperatures, R104 stated, it was warm at best, but it was not good to eat at that temperature.On 12/17/25 at 2:00 PM ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, RN (registered nurse) #3, the assistant director of nursing, RN #4, the assistant director of nursing was made aware of the concerns.According to the facility's Timely Meal Service policy, which revealed, Food will be delivered promptly to assure safe, palatable and high-quality food served at the proper temperature. Food will be served at preferable temperatures as discerned by the patients/residents and customary practice.No further information was provided prior to exit.

Based on clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to maintain an accurate clinical record for one of five residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to maintain an accurate clinical record documenting transfer to the emergency room. The progress notes for R1 documented in part, - Effective Date: 04/13/2025 08:31 (8:31 a.m.) Type: eINTERACT SBAR (situation, background, assessment, recommendations) Summary for Providers. Late Entry. Situation: The Change in Condition/s reported on this CIC Evaluation are/were: Shortness of breath . Nursing observations, evaluation, and recommendations are: Resident observed has SOB (shortness of breath), distress. Full Head to Toe assessment was performed. VS (vital signs) 137/76 (blood pressure)-20 (respirations)-97.6 (temperature)-72% (oxygen saturation). Both lungs coarse upon Auscultation, 2 L (liters) of oxygen administered, MD notified. EMT (emergency medical technician) notified, arrived and resident sent to [Name of hospital], ER (emergency room) . - Effective Date: 04/13/2025 08:31 (8:31 a.m.) Type: eINTERACT SBAR Summary for Providers. Late Entry. Situation: The Change in Condition/s reported on this CIC Evaluation are/were: Shortness of breath . Nursing observations, evaluation, and recommendations are: Resident was laboring or difficulties breathing and secretions coming out of his mouth, medical emergency was call to transfer to ER for further evaluation . - Effective Date: 04/13/2025 10:00 Type: Evaluation Note. Note Text: Respiratory Evaluation: Temp: T (temperature) 98.0 - 4/13/2025 10:00 Route: Forehead (non-contact) Pulse ox: O2 97.0 % - 4/13/2025 10:00 Method: Trach Complains of shortness of breath? - No. Exhibits new or different cough? - No. Progress Note: #4 shiley (tracheostomy) patent and intact. Red capping trial with goal of de-cannulation continues. Remains on room air with no SOB. Lungs clear with diminished bases. No cough or SOB noted. No suction required. Review of the clinical record failed to evidence documentation that R1 went to the ER on [DATE]. On 5/8/25 at 9:35 a.m., an interview was conducted with RN (registered nurse) #1 who stated that they worked with R1 on 4/13/25 and often when they were on the specialty care unit and had the tracheostomy. She stated that they had worked with R1 through the capping trial, and he had progressed to have the tracheostomy tube removed and was doing well. RN #1 stated that she had never sent R1 to the hospital when he was on her unit and the saturations had never gone below the high 80's with exertion. RN #1 stated that the nurse who wrote the change in condition note on 4/13/25 never worked on their unit and that it was not accurate because R1 did not go to the hospital that day. On 5/8/25 at 10:53 a.m., an interview was conducted with LPN (licensed practical nurse) #1 who stated that they had written the change in condition notes on 4/13/25 for R1. She stated that she did not work on the specialty care unit and had not worked with R1 until after the tracheostomy tube was removed and they moved to their current unit. She stated that she worked with them on 4/20/25 when they went out to the hospital and had documented the notes as late entries and had mistakenly put the wrong date in. LPN #1 stated that she had multiple patient issues that day and had not been able to document until later and when she went to enter the note she typed in the wrong date and had just left the notes in because she was not sure what to do. The facility provided policy, Clinical Nursing Skills & Techniques, 11th edition, [NAME] & Potter documented on page 57, .The information within a recorded entry or a report must be complete, containing appropriate and essential information . On 5/8/25 at 1:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional director of clinical services were made aware of the concern. No further information was provided prior to exit.

Based on observation, staff interview, and facility document review, the facility staff failed to prepare and serve food in a sanitary manner in one of one facility kitchen. The findings include: The facility staff failed to prepare and serve food in a sanitary manner for the lunch meal on 3/10/25. On 3/10/25 at 11:35 a.m., observation was made of the facility kitchen. OSM (other staff member) #4, a dietary aide, was observed obtaining holding temperatures of food on the steam table, ready for serving to residents. As OSM #4 took temperatures, she failed to sanitize the thermometer between foods. Instead of using an alcohol wipe, she used the same paper towel repeatedly. OSM #5, a dietary aide, was observed pushing a cart of clean silverware from the dish room. The silverware was visibly wet, and most utensils had water dripping from them. OSM #5, wearing gloves, touched the eating end of every utensil and put the still-dripping utensils upside down in a silverware container. OSM #5 began loading meal trays on to the serving line. Wearing the same gloves, he placed the same utensils, one by one, on trays. Most all the utensils still contained water droplets. OSM #5's long braids were observed outside of his hair net; these braids hung over the food trays as OSM #5 put the utensils on the trays. OSM #6, a dietary aide, was observed bagged turkey and cheese sandwiches on several trays. OSM #6 was observed to have a goatee but was not wearing a beard guard. Each of these bags contained a turkey and cheese sandwich on white bread. A serving size mayonnaise packet was in each bag and was in direct contact with a piece of the white bread. At 12:46 p.m., additional spaghetti noodles were poured into the steam table container. OSM #4 served these noodles without first obtaining a holding temperature. At 12:43 p.m., additional green beans were poured into the steam table container. OSM #4 served these green beans without first obtaining a holding temperature. At 1:03 p.m., additional meatballs and sauce were poured into the steam table container. OSM #4 served these items without first obtaining a holding temperature. OSM #4 wore gloves throughout the entire lunch service. Wearing these gloves, she touched each meal ticket, moving it from a pile behind the serving line to each individual's meal tray. As part of her serving the meal, she reached multiple times into a bag of hot dog buns and touched the buns with the same gloved hands that had been in contact with the residents' individual meal tickets. On 3/10/25at 2:29 p.m., OSM #4, the dietary director, was interviewed. She stated the dining staff hair nets should cover all hair. She stated braids should not be outside of the hairnet, and beard guards should cover all facial hair. She stated the facility had previously been putting the mayonnaise packets in direct contact with the sandwich bread, but she understood the concern. She stated alcohol wipes should be used to sanitize the thermometer between foods while obtaining holding temperatures. She stated this prevents cross contamination. She stated the purpose of obtaining holding temperatures is to make sure the food has reached a safe temperature prior to serving it. She stated any time a new food is added to the tray line, a holding temperature should be obtained to assure it is safe. She stated the silverware should have been completely dried before being placed in the holders or on the food tray. She stated OSM #5 should not have touched the meal tickets then touched the hot dog buns. She stated: This is an issue of contamination. On 3/10/25 at 4:10 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Bare Hand Contact with Food and Use of Plastic Gloves, revealed, in part: Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed, and hands must be washed. A review of the facility policy, Taking Accurate Temperatures, revealed, in part: To take hot food temperatures, insert the thermometer at a 45-degree angle to the middle of the food item .Wait for the thermometer to use the maximum temperature, read and record the temperature and then remove the thermometer from the food item and immediately clean and sanitize. A review of the facility policy, Employee Sanitary Practices, revealed, in part: Wear hair restraints to prevent hair from contacting exposed food. No additional information was provided prior to exit.

Based on observations, staff/resident interviews, facility document review and clinical record review, it was determined the facility staff failed to implement the care plan for one of 16 residents in the survey sample, R208. The findings include: The facility staff failed to implement the comprehensive care plan for CPAP for R208. Observed R208's CPAP machine in his room at approximately 12:00 PM on 3/10/25. R208 was admitted to the facility on [DATE] with diagnosis that included but were not limited to chronic respiratory failure, COPD (chronic obstructive respiratory disease) and Parkinson's Disease. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/14/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing and set-up for eating. Section O: oxygen: yes. A review of the comprehensive care plan dated 11/29/24 revealed, FOCUS: RESPIRATORY: the resident is at risk for respiratory complications secondary to sleep apnea, COPD, respiratory failure. INTERVENTIONS: CPAP as ordered. A review of the physician's order dated 7/31/23 revealed, BIPAP/CPAP Specify settings: 4 *Use sterile water only* every night shift for Sleep Apnea Check CPAP/BIPAP for proper placement AND every day shift for Sleep Apnea. Wash mask daily with soap and warm water, rinse thoroughly with warm water &allow to dry AND every day shift for Sleep Apnea. Wash headgear(strap) & tubing weekly on Wed with mild soap and warm water, rinse with warm water & allow to air dry AND every evening shift for Sleep Apnea. No Evidence on MAR (medication administration record) of CPAP settings, noted to be placed on 3/10/25 on MAR starting with night shift. An interview was conducted on 3/10/25 at 12:00 PM with R208, when asked if he used his CPAP machine, R208 stated, yes, at night. It helps me sleep. An interview was conducted on 3/10/25 at 2:15 PM with LPN (licensed practical nurse) #1. When asked the purpose of the care plan, LPN #1 stated, to address the residents' needs and have interventions for the needs. When asked if there were no evidence for the intervention of CPAP as ordered, would the care plan have been implemented, LPN #1 stated, no. On 3/10/25 at 3:10 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing was made aware of the concerns. A review of the facility's Care Planning policy revealed, A licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan for each patient in order to provide effective, person-centered care, and the necessary health-related care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being of the patient. No further information was provided prior to exit.

Based on observations, staff /resident interviews facility document review and clinical record review, it was determined the facility staff failed to provide respiratory care services for one of 16 residents, R208. The findings include: The facility staff failed to provide evidence of respiratory care services for R208. Observed R208's CPAP machine in his room at approximately 12:00 PM on 3/10/25. R208 was admitted to the facility on [DATE] with diagnosis that included but were not limited to chronic respiratory failure, COPD (chronic obstructive respiratory disease) and Parkinson's Disease. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/14/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing and set-up for eating. Section O: oxygen: yes. A review of the comprehensive care plan dated 11/29/24 revealed, FOCUS: RESPIRATORY: the resident is at risk for respiratory complications secondary to sleep apnea, COPD, respiratory failure. INTERVENTIONS: CPAP as ordered. A review of the physician's order dated 7/31/23 revealed, BIPAP/CPAP Specify settings: 4 *Use sterile water only* every night shift for Sleep Apnea Check CPAP/BIPAP for proper placement AND everyday shift for Sleep Apnea. Wash mask daily with soap and warm water, rinse thoroughly with warm water &allow to dry AND everyday shift for Sleep Apnea. Wash headgear(strap) & tubing weekly on Wed with mild soap and warm water, rinse with warm water & allow to air dry AND every evening shift for Sleep Apnea. No Evidence on MAR (medication administration record) of CPAP settings, noted to be placed on 3/10/25 on MAR starting with night shift. An interview was conducted on 3/10/25 at 12:00 PM with R208, when asked if he used his CPAP machine, R208 stated, yes, at night. It helps me sleep. An interview was conducted on 3/10/25 at 2:15 PM with LPN (licensed practical nurse) #1. When asked where the evidence of following BIPAP/CPAP settings as ordered would be, LPN #1 stated we document those on the MAR (medication administration record). When ask if there was no evidence, were the orders being followed, LPN #1 stated, no. On 3/10/25 at 3:10 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing was made aware of the concerns. A review of the facility's Respiratory Care and Oxygen Equipment policy revealed, Oxygen therapy will be administered per provider's order, according to current standards of practice and equipment will be maintained and stored in a safe and appropriate manner. CPAP, BiPAP, APAP require provider or respiratory therapy orders for settings. No further information was provided prior to exit.

Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to prevent an avoidable accident for one of six residents in the survey sample, Resident #1. This accident resulted in a fractured pelvis and intractable pain for Resident #1, constituting harm. The facility presented a plan of correction with an allegation of compliance date prior to survey entrance. The facility presented credible evidence that the plan of correction had been implemented, resulting in a finding of past noncompliance. The findings include: For Resident #1 (R1), the facility staff failed to correctly use the mechanical lift, resulting in a fall with a fractured pelvis for R1. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/14/24, R1 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). She was coded as being completely dependent on facility staff for transfers from bed to chair. A review of R1's clinical record revealed the following Fall Note dated 11/29/24: Description of the fall .Resident was found on floor next to bed. CNA's (certified nursing assistants) present. Per Unit Manager writer was told to go call 911. Writer did as instructed and printed paperwork and met EMS (emergency medical services) at nursing station. Writer was told that Resident slid out of Hoyer lift to the floor. What interventions were in place at the time of the fall: CNAs instructed on proper use of lift equipment .What new interventions were implemented in response to the fall: Instructing CNAs to always have two aides that have been properly trained on of lift equipment when transferring residents. This fall note was written by RN (registered nurse) #1, who was unavailable for interview during the survey. Further review of R1's clinical record revealed the following progress notes: 11/29/2024 20:51(8:51 p.m.) Resident returned from emergency room via stretcher .She has a Sacral Fracture. 11/29/24 21:45 (9:45 p.m.) Nursing observations, evaluation, and recommendations are: Resident - post fall this morning. She returned from ER (emergency room) with Sacral Fracture per hospital discharge paper work. Resident is grimacing and moaning when transferred and turned in bed from Transport Stretcher. Oxycodone medication is given by mouth. Resident is to be sent to emergency room for Sacral Fracture and unmanaged pain per provider. On 12/3/23 at 2:04 p.m., ASM (administrative staff member) #2, the director of nursing, and ASM #3, the assistant administrator, were interviewed. ASM #2 stated the facility had a plan of correction related to this incident. ASM #2 stated two CNAs were present in the room when R1 fell from the Hoyer lift. ASM #2 stated: They were using the sling correctly when the resident slid out. When asked why a plan of correction was needed if the Hoyer lift had been used correctly, ASM #2 stated she always does a plan of correction for a resident fall with fracture. She stated the plan of correction centered around re-education of the staff on how to correctly use a Hoyer mechanical lift. ASM #2 stated the CNAs in the room at the time of R1's fall were CNA #1 and CNA #2. On 12/3/24 at 2:35 p.m., LPN (licensed practical nurse) #1was interviewed. She stated she was the charge nurse when R1 experienced a fall on 11/29/24. She stated she was not in the room when the fall happened. She stated she heard screaming as she was leaving the supervisor's (RN #1's) office, and she ran to R1's room. She realized R1 was on the floor and crying hysterically. She stated the Hoyer lift was elevated to a level where the sling seat was just above her head. She stated RN #1 entered the room after she did, and immediately instructed her to call EMS. She stated she never went back in the room until EMS arrived because she was busy preparing paperwork for the EMS staff. She stated she did not know what transpired prior to the resident falling out of the Hoyer lift. She stated she was sure that one of the CNAs in the room at the time of R1's fall was on orientation, and had not yet been trained on the use of the Hoyer lift. On 12/3/24 at 3:01 p.m., CNA #1 was interviewed. She stated she and CNA #2 worked together to place R1 in the sling for the Hoyer lift. She stated she helped CNA #2 secure a couple of the sling straps to the lift frame, but could not remember exactly how this worked. CNA #1 stated she was in control of the lift remote, and asked R1 if she was ready. She began to lift the sling using the remote, and noticed the resident was looking contracted in the sling. She stated: I wasn't sure if that's how she usually looked. She stated the resident then just slid out. She stated she does not think the sling was positioned correctly under the resident's lower body, possibly causing the fall. She added: I think [CNA #2] just didn't notice. CNA #1 stated she is still in orientation, and has not yet been checked off in safe use of the lift. On 12/3/24 at 3:20 p.m., CNA #2 was interviewed. She stated R1 had asked to be moved from the wheelchair to her bed. She stated she does not normally care for R1, so was not sure how the Hoyer lift normally functioned for R1. She stated she tugged on all the connections to make sure they were secure, and attached the sling to the lift frame. She stated she CNA #1 began to lift the resident using the sling. As CNA #2 was attempting to make her way around the resident to guide her into the bed, the resident fell out. She stated R1 fell and hit her buttocks hard on the floor. She stated the resident fell from a level just below her (CNA #2's) chest. She stated the resident did not hit her head on the floor. When asked what went wrong, she stated she is still trying to figure out what happened. When asked if she was aware at the time that CNA #1 had not been signed off on the use of Hoyer lifts, she stated she had not worked with CNA #1 before, but she asked her about her Hoyer lift experience. CNA #1 told her she had used the lift in previous facilities. On 12/3/24 at 3:32 p.m., Resident # 4 (R4), R1's roommate, was interviewed. She stated she was awake and aware at the time of the fall, but was not able to see how the resident was positioned in the mechanical lift. On 12/4/24 at 9:41 a.m., R1 was interviewed. She stated she returned from the hospital after supper on 12/3/24. She stated she fell out of the sling because the sling was not positioned correctly. She stated the sling was not positioned all the way down to her knees, but was only positioned just a little below her buttocks. She stated she has no feeling on the left side of her body, so she was unaware of the sling positioning. She said she did not think either CNA was paying very close attention when the accident happened. She stated CNA #1 jerked the lift twice in an effort to move it from over the wheelchair towards the bed, and these jerking motions caused her to slip out of the sling. On 12/4/24 at 11:13 a.m., ASM #2 was interviewed. She agreed that if the Hoyer lift had been used correctly, the resident should not have sustained a fall. On 12/4/24 at 2:00 p.m., ASM #1, the administrator, ASM #2, and ASM #3 were informed of these concerns. A review of the facility's plan of correction revealed, in part: Problem: Fall with major injury/Transfer - Mechanical Lift .Problem: Resident sustained a fall with a major injury during a 2 person assist with mechanical lift. Immediate Response - what was done at the time: Fall assessment and sent to ER for evaluation. IDT (interdisciplinary team)/DON (director of nursing) Risk meeting to discuss and review the facility fall prevention program and a 4-point plan initiated on 2 person assist/mechanical lift to maintain safety while transfer to reduce falls or major injury. How to Identify other residents that might be impacted: Audit by DON or designee on residents to verify with 2 person assist/mechanical lift. What Measures were put in place to prevent reoccurrence: The DON or designee will educate the licensed nurses and CNAs on approaches to managing residents with 2 person assist/transfer - mechanical lift to maintain safety such as adjusting Hoyer lift pad and maintain contact guard and prevent falls with or without injury. How to monitor to ensure the problem does not reoccur: The UM (unit manager) or designee will audit weekly X 4 on resident with change of condition or new admitted residents who are identified as 2 person assist for mechanical lift. The results will be reported to the monthly Quality Committee for review and discussion to ensure substantial compliance. Once the QA Committee determines the problem no longer exists, then review will be completed on a random basis. Date of Compliance: 12/2/24. The facility presented credible evidence, including audits and staff education, that this plan was implemented as described and completed by 12/2/24. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide clinical services for a resident experiencing bowel dysfunction for one of 12 residents in the survey sample, Resident #7, resulting in harm. The findings include: The facility staff failed to identify Resident #7's (R7's) lack of a bowel movement for 10 days, and failed to administer a physician-ordered suppository to treat the lack of bowel movements. The resident developed an ileus (By definition, ileus is an occlusion or paralysis of the bowel preventing the forward passage of the intestinal contents, causing their accumulation proximal to the site of the blockage. 1), which required transfer to a local hospital. On the most recent MDS (minimum data set), a quarterly/discharge no return anticipated assessment with an ARD (assessment reference date) of 5/12/22, R7 was coded as being moderately impaired for making daily decisions, having scored 12 out of 15 on the BIMS (brief interview for mental status). The resident was coded as requiring the extensive assistance of staff for bed mobility, and for all activities of daily living, including eating. A review of R7's point of care documentation completed by CNAs (certified nursing assistants) revealed the resident was not documented to have a bowel movement from the evening shift (3:00 p.m. - 11:00 p.m.) on 4/27/22 until the day shift (7:00 a.m. - 3:00 p.m.) on 5/8/22. A review of R7's physician's orders revealed the following orders: 2/3/22 Polyethylene Glycol (Miralax) Powder 17 gm/scoop (grams per scoop). Give one scoop orally in the morning for bowel management. Mix in 6-8 ounces of liquid. 2/3/22 Docusate sodium capsule (stool softener) 100 mg (milligrams) Give 1 capsule orally two times a day for bowel management. 2/3/22 Bisacodyl suppository 10 mg (milligrams) Insert 1 suppository rectally as needed daily for constipation. A review of R7's MAR (medication administration record) for April and May 2022 revealed the resident received Miralax and docusate sodium as ordered, however the resident failed to receive a Bisacodyl suppository between 4/28/22 and 5/8/22. A review of R7's progress notes for April and May 2022 failed to reveal any evidence that any staff member notified a provider (either a nurse practitioner or the attending physician) that the resident had not had a bowel movement between 4/28/22 and 5/8/22. A review of a progress note written by the NP (nurse practitioner) on 5/6/22 revealed, in part: Chief Complaint: Recertification visit to review medications, diagnoses, labs (laboratory results), vital signs and current plan of care. Pt (patient) is new to our medical practice, this is our initial patient encounter and all previous medical records reviewed. Pt seen for abnormal lab results review .review of systems .Gastrointestinal negative .Physical examination .Abdomen: Soft; BS (bowel sounds) X4 (in all four quadrants) heard .Assessment and Plan .severe protein calorie malnutrition .weight loss noted, dietician following .pt reports adequate appetite .chronic pain, per pt not controlled, d/c (discontinue) oxycontin (an opioid medication for pain) .start Morphine ER (extended release) (an opioid medication for pain) 15 mg q 12h (every 12 hours) .supportive care .FULL CODE. This NP was not available for interview during the survey. A review of R7's May 2022 MAR revealed the resident received the Morphine twice a day as ordered. A review of a dietary progress note dated 5/9/22 revealed, in part: Quarterly/Significant Weight Loss Assessment .PO (by mouth) intake: Varies - 25 - 50%. A review of progress notes dated 5/11/2022 revealed, in part: 10:02 a.m .Note Text: Resident refused all morning meds, resident states 'the medicines makes me sicker.' 12:28 p.m .Note Text: Resident vomited x1, noted with distended abdomen, very weak in appearance, NP .at bedside, new order in place for sodium chloride 0.9% for 2 days, stat (immediate) KUB (abdominal X-ray) in place. NACL (sodium chloride) 0.9% infusing at 100cc/hr (cubic centimeters per hour) to left lower arm, at this time, resident tolerating well, resident is own RP (responsible party), this writer attempted to reach resident's daughter via phone. 1442 (2:42 p.m.) .Note Text: Chief Complaint: Pt seen per nursing request for tachycardia (rapid heartbeat) and abdominal distention .Review of symptoms .Gastrointestinal: Nausea/vomiting; abdominal pain; Other: abd (abdominal distention) .Physical examination: Abdomen: Distended. BS X4 heard .Assessment and Plan .abdominal distention/nausea/vomiting X 2 days per pt, start PIV (peripheral intravenous fluids) .stat KUB. A review of the radiology report for R7 dated 5/11/22 at 7:20 p.m. revealed, in part: History: Nausea/Vomiting .Findings: Moderate stool column is seen in the left to the level of the hepatic flexure. Dilated small bowel is seen in the mid abdomen. Impression: Large amount of rectal stool needs evacuation and there appears to be a small bowel ileus. Follow-up is suggested. A review of R7's progress notes dated 5/12/22 revealed, in part: 0244 (2:44 a.m.) .Radiology review; abnormal results .vomiting X 1 and abdominal distention .Report: stool up to hepatic flexure, large amount of stool in rectum; small bowel ileus, patient seen with nurse. Patient c/o (complains of) shortness of breath and having no appetite. States he would take his constipation meds (medications) .Give Bisacodyl suppository 10 mg pr (by rectum) X 1 dose. This note was written by a physician who provided a telehealth visit. 4:20 a.m .Note Text: Resident sent out 911 to [name of local hospital] for evaluation due to change in condition. Resident observed with hypoxia (low oxygen) and tachycardia (rapid heart rate). A review of R7's care plan dated 2/3/22 revealed, in part: [R7] has bowel elimination alteration; constipation related to lack of exercise, medications .Administer medications per physician order .Report signs and symptoms of constipation such as abdominal cramping, diarrhea, nausea/vomiting, no bowel movement for three days. On 1/31/23 at 9:37 a.m., LPN (licensed practical nurse) #2 was interviewed. When asked how she evaluates a resident for bowel movements, she stated she can look at the point of care records on the EMR (electronic medical record), can ask the CNA taking care of the resident, and, if the resident is a reliable historian, can ask the resident. She stated she tries every day to evaluate each resident for whether or not they have had a bowel movement in the last couple of days. She stated if a resident is on narcotics/opioids or antibiotics, it is especially important to evaluate for bowel movements, as both of these types of medications can be constipating. She stated if a resident has not had a bowel movement in the last three days, she would call the provider. She stated if a resident has an as-needed order for an oral laxative or suppository, she would also administer that medication. After reviewing R7's point of care records and R7's order for an as-needed suppository, she stated: I would have given the suppository, and I still would have called [the provider]. She stated a resident who has not had a bowel movement in 10 days is at high risk for bowel rupture. On 1/31/23 at 9:55 a.m., CNA #4 was interviewed. She stated she took care of R7 for most of the time he spent at the facility. She stated: I kept [the resident] turned and changed. (R7) lost a lot of weight while he was here. She stated she remembered the resident's steep decline, but that the resident had never been placed on comfort care. She stated: At the end, even bowel movements were just liquid. When asked to elaborate, she stated R7 was always incontinent of both bowel and bladder and always needed to be changed. She stated the last couple of times she cared for the resident, the bowel movements were nothing more than water. She stated the last time she took care of the resident, the resident was nauseated and vomiting. She stated she informed the nurse of the liquid bowel movements. A review of R7's point of care records revealed CNA #4's signature on day shift on 5/8/23 and 5/11/23. On these dates, CNA #4's documentation indicated the resident had a medium sized bowel movement, was incontinent, and required the extensive of staff to be cleaned. On 1/31/23 at 11:32 a.m., LPN #6, R7's unit manager, was interviewed. She stated the facility's bowel protocol is for the provider to be notified if a resident has not had a bowel movement in three days. She stated an alert appears on the clinical dashboard of the resident's EMR alerting the staff of this. She stated the nurse should go to the resident and/or the CNA to determine if the resident might have had a bowel movement, but the staff was unaware. If the resident and/or the CNA confirms the lack of a bowel movement in the last three days, the nurse should contact the provider to alert the provider, and to request a new intervention. She stated if a resident has a prn (as-needed) order for an additional bowel agent, the nurse should offer that to the resident, and still contact the provider. She stated nurses should be looking at bowel movement frequency every day. She stated: They have the capability to look every day. They can to the [point of care] records. And they can certainly ask the patient while they are passing meds. After reviewing R7's bowel records, orders, and MARs, she stated: I can't see we did anything. I will go look. When asked if R7 was ever considered for palliative care or hospice services, she stated: He wanted everything done. On 1/31/23 at 12:05 p.m., LPN #3 was interviewed. When asked if the facility had a protocol for monitoring the frequency of residents' bowel movements, she stated, If it's been longer than five days, you are supposed to notify the doctor. She stated the doctor might order an additional bowel agent. She stated I would ask the aides to let me know about the bowel movements, and continue to check on the resident. On 1/31/23 at 12:12 p.m., RN (registered nurse) #2, a nurse practitioner, was interviewed. She stated she never met or took care of R7. When asked the possible effects of switching from Oxycodone to Morphine on a resident's bowels movements, she stated the Morphine is stronger than Oxycodone, and can slow down the bowels even more than Oxycodone. She stated she counters this with the use of stool softeners. She stated the bowels have a naturally fluctuating movement, and this movement is slowed by opioids. She stated when this happens, stool builds up in the bowel, and can turn into an ileus. She stated an ileus is lack of movement in the bowels. She stated if an ileus is not treated, a bowel can continue to grow larger in diameter, with a possibility of rupturing. When asked if the facility had a bowel protocol, she stated to her understanding, everyone is on Miralax, which is a gentle laxative. She stated symptoms of an ileus can include abdominal discomfort, cramping, nausea, vomiting, and abdominal pain. She stated some residents may also have a moderate amount of loose, watery stool, but nothing that is formed. She stated nurses should be monitoring residents every shift for bowel movements. She stated: I want to be notified after two days of a resident not having a bowel movement. After reviewing R7's bowel movement records and physician's orders, she stated: I would have wanted to have been notified sooner that he had not had a bowel movement. We would have started something else. On 1/31/23 at 12:55 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, and ASM #4, the regional director of clinical services, were informed of the concern for harm for R7. On 1/31/23 at 1:20 p.m., LPN #6 stated: I can't find anything to say we did something for [R7]. On 1/31/23 at 2:03 p.m., LPN #4 was interviewed. She stated if a resident has not had a bowel movement in three days, she would do an abdominal assessment and let the provider know so the provider could put something in place. On 1/31/23 at 3:48 p.m., ASM #2, the director of nursing stated she had spoken to R7's attending physician (ASM #6) who was in charge of the resident's care until 5/6/22. She stated ASM #6 was going to be unavailable by phone for a while, but had told her that he was aware the resident had not had a bowel movement. She stated ASM #6 could provide copies of studies showing it is not abnormal for elderly people to go seven days without having a bowel movement. ASM #2 stated ASM #6 told her he was aware, and there were interventions. ASM #2 was asked to provide documentation of ASM #6's awareness. ASM #2 stated she wanted to address the point of care records regarding frequency of bowel movements. She stated there were no clinical alerts for the staff on the EMR because on some of the shifts, the CNAs had charted not applicable. She stated a clinical alert is only generated if there is no bowel movement charted at all. When asked if she could find any evidence in the clinical record that the staff notified the provider that the resident did not have a bowel movement or that the staff had given the resident a suppository as ordered, she stated: No, not in the documentation we have. On 1/31/23 at 4:32 p.m., ASM #5, the facility's current medical director, was interviewed. ASM #5 stated: I never saw this patient. I took over a week before everything happened. From what I was told the patient had an ileus at the end. He was sent out, and unfortunately passed away. We had him on a stool softener. I believe we did everything right. When ASM #5 was asked if the staff should have notified him or the NP about the resident's lack of bowel movements, he asked: There is nothing charted at all? He added: He was not eating at all. If he is eating less than 25%, he is not going to have a bowel movement. On 1/31/23 at 4:40 p.m., LPN #6 stated she had located a text message that she sent to ASM #6. She provided a screen shot of the text exchange. The text exchange documented the following on 5/4/23 at 12:10 p.m.: LPN #6: [R7's first initial and last name] - no BM in 72 hrs (hours). Colace Bio (sic) and supp (suppository) prn. ASM #6: Ok. LPN #6 was asked if she ordinarily used text messages to communicate with providers about specific residents. She said: Yes, it's how we notify physicians. When asked if the information she texted to ASM #6 was correct regarding the number of days without a bowel movement. LPN #6 again reviewed R7's bowel records, and stated: No. I told [ASM #6] it had only been three days, when it really had been six days. When asked what she understood ASM #6's ok to mean, she stated: He meant to continue with the stool softener and suppository. When asked if she administered a suppository to R7 at that time, she stated she did not. She stated: I told the nurse to give it. But it was not signed off. She added: You can lead a horse to water, but you can't make them drink. When asked if there was any evidence that R7 had received the suppository, she stated: With it not being signed off, we can't say it was given. There is no signature or note that day about the suppository. LPN #6 stated she did not document her text conversation with ASM #6 in the medical record. On 1/31/23 at 5:00 p.m., ASM #2 was asked to review R7's point of care records regarding meal percentages consumed during May 2022. ASM #2 stated the following meal percentages for R7 (B=breakfast, L=lunch, D=dinner): May 1 B=0; L=0; D=51-75 May 2 = nothing all day May 3 B=76-100; L=26-50; D=26-50 May 4 B 26-50; L 26-50; D=0 May 5 = nothing all day May 6 = nothing all day May 7 B=76-100; L 36-50; D26-50 May 8 B=51-75; L 51-75; D=0 May 9 B=76-100; L 76-100; L=0 May 10 = nothing all day May 11 B, L=0; D=51-75 May 1 through May 11 - R7 was offered and accepted a bedtime snack each evening. When asked if ASM #5 was accurate in saying R7 was not eating anything, ASM #2 stated: Some days, yes. Some days, no. She stated: It's not like he totally quit eating. Yes, he was eating some. But some days he wasn't. She added that the record only documented that evening snacks were offered and accepted by the resident. There was no documentation regarding how much of the snack the resident consumed. A review of the facility policy, Constipation Prevention, revealed, in part: Nurse will routinely review to determine patients in need of intervention to facilitate bowel movement .Document bowel movements in the clinical record. Contact physician for any needed orders .The plan for prevention of constipation will be documented on the comprehensive care plan. No further information was provided prior to exit. (1) This information is taken from the National Institutes of Health website https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5569564./ Ileus is a temporary lack of the normal muscle contractions of the intestines Other causes include drugs, especially opioid analgesics and anticholinergic drugs .The symptoms of ileus are abdominal bloating and pain caused by a buildup of gas and liquids, nausea, vomiting, severe constipation, loss of appetite, and cramps. People may pass watery stool .Treatment: Temporary restriction of food and fluids by mouth, Fluids given by vein, Suction via nasogastric tube. This information is taken from the website https://www.merckmanuals.com/home/digestive-disorders/gastrointestinal-emergencies/ileus.

Based on observation, staff interviews, interviews with local health-department staff, review of facility documents, and clinical record review, it was determined, that the facility staff failed to ensure the implementation of infection control practices and precautions, to prevent the spread of infection, and communicable disease during an identified outbreak of Coronavirus (COVID 19) for three of 37 residents residing on the 300 Unit, (Residents, #2, #4, and #5). The facility staff failed to implement standard and droplet precautions to prevent the spread of COVID 19* to residents that had tested negative for COVID-19, and who resided in the same room with a COVID 19 positive roommate on the 300 unit. The facility staff failed to pull privacy curtains the full length of the bed in three of three resident rooms in which COVID-19 positive and negative residents resided together in the same room, for Residents, #1, #2, #3, #4, #5 and #6. Cohorting COVID-19 positive and negative residents together and failing to pull privacy curtains the full length of the bed and to implement droplet precautions created the likelihood of residents being exposed to and contracting COVID-19. At the time of the survey, there had already been nine deaths of residents, who had contracted COVID 19. Review of the facility LTC (Long Term Care) Respiratory Surveillance List (for COVID-19 Outbreaks), submitted by the facility for review by fax on [DATE], revealed the facility census was 130 current residents, 81 residents had tested positive for the COVID-19 virus and nine had expired, (Residents #7, #8, #9, #10, #11, #12, #13, #14 and # 15). This failure resulted in Immediate Jeopardy. The State Agency informed the facility on [DATE] at 6:18 p.m. of the Immediate Jeopardy situation. On [DATE] at 11:59 a.m., the Immediate Jeopardy was abated and lowered to a level II isolated. The findings include: On [DATE] at 5:08 p.m., the survey team conducted an onsite, abbreviated, remote FICS (focused infection control survey) at the facility. As a part of the survey process, the survey team conducted observations and interviewed facility staff members and staff from the local health department. On [DATE] at 5:25 p.m., an observation was conducted of resident rooms on the 300 hall of the facility. Observation of the resident room shared by Residents #1 (COVID-19 positive) and #2 (COVID-19 negative) revealed, both residents lying in single beds. The curtain between the two beds was open (drawn back to the wall allowing visualization of both residents from the doorway). Observation of room shared by Residents #3 (COVID-19 positive) and #4 (COVID-19 negative) revealed the two residents lying in single beds. The curtain between the two beds was observed open. An isolation cart containing gloves, gowns and linen bags was observed outside of the doorway of Resident #3 and Resident #4's room. Observation of the room shared by Residents #5 (COVID-19 negative) and #6 (COVID-19 positive) revealed a semi-private room and a resident lying in the bed closest to the doorway, and the second resident sitting in a wheelchair in the center of the room between the two beds wearing a facemask. The curtain between the two beds was observed open behind the resident in the wheelchair. Further observation of the 300 hall revealed seven vacant rooms. On [DATE] at 4:57 p.m. through 6:11 p.m., an onsite visit and observation was completed. The long-term care supervisor was notified of the survey team's observations and a conference call was completed with two additional supervisors and the survey team. On [DATE] at 9:11 a.m., a telephone interview was conducted with CNA (certified nursing assistant) # 3 who worked on the 300 hallway. When asked if they were aware of any residents in the same room, where one resident was COVID-19 positive and the other resident COVID-19 negative CNA # 3 stated, Yes, we do have positive and negative together. When asked what procedure they follow to prevent the spread of [MEDICAL CONDITION] from the COVID-19 positive resident to the COVID-19 negative resident CNA # 3 stated, I take care of negative resident first, change all of my PPE (personal protective equipment) then do care for the positive resident. When asked about the cubicle curtain CNA # 3 stated that the curtain was to be pulled between the residents. On [DATE] at 9:22 a.m., a telephone interview was conducted with CNA # 4 who worked on the 300 hallway. When asked if they were aware of any residents in the same room, where one resident was COVID-19 positive and the other resident COVID-19 negative CNA # 4 stated, Yes, we do have positive and negative in the same room. When asked what procedure they follow to prevent the spread of [MEDICAL CONDITION] from the COVID-19 positive resident to the COVID-19 negative resident CNA # 4 stated, Put all of PPE gear on first, then I take care of negative person first, then change PPE gear, wash hands Put on new PPE and poncho. When asked about the cubicle curtain CNA # 4 stated that the curtain was to be pulled between the residents. On [DATE] at 9:35 a.m., a telephone interview was conducted with OSM # 7, nurse supervisor of (Name of City) health department and OSM # 8, epidemiologist. OSM # 7 and OSM # 8 had been in contact with (name of facility) and OSM # 7 was last on site on [DATE]. OSM #7 and #8 were asked about any recommendations they had made to the facility. OSM # 7 and OSM # 8 stated that they made recommendations after recent testing at the facility and finding some residents testing positive for COVID-19 and other resident residing in the same rooms, who tested negative for COVID-19. OSM #8 and #7 stated they recommended to the facility that the facility shelter the resident's in-place because the roommate who was negative, was already exposed to the COVID-19 virus and moving the residents to separate them could spread [MEDICAL CONDITION]. On [DATE] at 11:00 a.m., a telephone interview was conducted with ASM (administrative staff member) # 1, facility administrator and ASM # 2, interim director of nursing and infection control coordinator. When asked how facility staff knows which residents are COVID-19 positive or negative ASM # 2 stated they notify the staff each morning, there is a list at the units and it is reflected on their 24-hour report. ASM #2 was asked what they were doing to reduce the spread of COVID-19 within the facility when there is COVID-19 positive and negative residing in the same room. ASM # 2 stated the CNAs (certified nursing assistants) provide care to the negative resident first, change their PPE (personal protective equipment), wash their hands, put on new PPE before providing care the COVID-19 positive resident, the resident's beds are six feet apart and the curtain is pulled between the beds. ASM # 1 and ASM # 2 further stated that they had an outbreak on the 300 hall. They stated that 21 of the 37 residents on the 300 hall tested positive for COVID-19, 13 were negative, two test results were pending and one resident refused to be tested . When asked if they had been in contact with OSM # 7 and OSM # 8 and if they had discussed any recommendations ASM # 2 stated yes, that they were in contact with OSM # 7 by telephone and that they recommended the facility shelter the resident's in place. When asked what explanation was provided for not moving a resident who tested positive for COVID-19 or a resident who tested negative for COVID-19 who were residing in the same room, ASM # 1 and ASM # 2 stated that they were told the more they try to move the residents around [MEDICAL CONDITION] will spread. When asked if there was discussion about pulling the privacy curtains to divide the residents in the room ASM # 1 and ASM # 2 stated that OSM # 7 and OSM # 8 did not say anything about it. When asked if they had received written documentation about the sheltering the residents in place ASM # 1 and ASM # 2 stated no. A remote review of the clinical records for Residents #1, #2, #3, #4, #5, and #6, revealed the following: Remote review of Resident #1's clinical record revealed, Resident # 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident # 1's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of [DATE], coded Resident # 1 as scoring a four on the brief interview for mental status (BIMS) of a score of 0 - 15, four - being severely impaired of cognition for making daily decisions. Resident # 1 was coded as requiring extensive assistance of one staff member for activities of daily living. The comprehensive care plan for Resident #1 dated [DATE] documented in part, Focus. I am at risk for psychosocial well-being concern r/t (related to) medically imposed restrictions r/t COVID-19 precautions. I am at risk for s/sx (signs and symptoms). Positive for COVID-19 (,[DATE]) ([DATE]). Revision on: [DATE]. Under Interventions it documented in part, Observe for s/s of COVID-19/document and promptly report s/sx: fever, coughing, sneezing, soar (Sic.) throat, respiratory issues. Date Initiated: [DATE]. The nurse's note for Resident # 1 dated [DATE] documented in part, 22:32 (10:32 p.m.) COVID-19 results pending. Remains asymptomatic (4). The nurse's note for Resident # 1 dated [DATE] documented in part, 04:41 (4:41 a.m.) Continues on droplet precautions (5) for COVID-19. At 11:48 a.m., the nurse's note documented in part, COVID test for resident was positive, MD/NP (medical director/Nurse Practitioner) made aware .RP (responsible party) called made aware of COVID test results . Remote review of Resident #2's clinical record revealed, Resident # 2 was admitted to the facility on [DATE] and a readmission on [DATE] with [DIAGNOSES REDACTED]. Resident # 2's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of [DATE], coded Resident # 2 as scoring a 10 on the brief interview for mental status (BIMS) of a score of 0 - 15, 10 - being moderately impaired of cognition for making daily decisions. Resident # 2 was coded as requiring extensive assistance of one staff member for activities of daily living. The comprehensive care plan for Resident #2 dated [DATE] documented in part, Focus. I am at risk for psychosocial well-being concern r/t (related to) medically imposed restrictions r/t COVID-19 precautions. I am at risk for s/sx (signs and symptoms). Negative for COVID-19 (,[DATE]) ([DATE]). Revision on: [DATE]. Under Interventions it documented in part, Observe for s/s of COVID-19/document and promptly report s/sx: fever, coughing, sneezing, soar Sic. throat, respiratory issues. Date Initiated: [DATE]. The Physician/Practitioner Progress Note note for Resident # 2 dated [DATE] documented in part, 13:07 (1:07 p.m.) COVID-19 test pending. Resident is asymptomatic today. The Physician/Practitioner Progress Note note for Resident # 2 dated [DATE] documented in part, 12:35 p.m., Assessment/Plan: COVID-19 test negative. At 2:46 p.m., the Physician/Practitioner Progress Note documented in part, Telephoned the resident's RP, (Name of RP) to discuss the resident's recent negative COVID-19 test results from ,[DATE] ([DATE]). Remote review of Resident #3's clinical record revealed, Resident # 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident # 3's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of [DATE], coded Resident # 3 as scoring a two on the brief interview for mental status (BIMS) of a score of 0 - 15, two - being severely impaired of cognition for making daily decisions. Resident # 3 was coded as requiring extensive assistance of one staff member for activities of daily living. The comprehensive care plan for Resident #3 dated [DATE] documented in part, Focus. I am at risk for psychosocial well-being concern r/t (related to) medically imposed restrictions r/t COVID-19 precautions. I am at risk for s/sx (signs and symptoms). Positive for COVID-19 (,[DATE]) ([DATE]). Revision on: [DATE]. Under Interventions it documented in part, Observe for s/s of COVID-19/document and promptly report s/sx: fever, coughing, sneezing, soar Sic. throat, respiratory issues. Date Initiated: [DATE]. The nurse's note for Resident # 3 dated [DATE] documented in part, 22:35 (10:35 p.m.) COVID-19 results pending. The nurse's note for Resident # 3 dated [DATE] documented in part, 15:04 (3:05 p.m.), COVID results positive, resident has not had any sx (symptoms), N/V/D (nausea/vomit/diarrhea), sob (shortness of breath), or cough, MD/NP (medical director/Nurse Practitioner) and RP (responsible party) aware. Remote review of Resident #4's clinical record revealed, Resident # 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident # 4's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of [DATE], coded Resident # 4 as scoring a three on the brief interview for mental status (BIMS) of a score of 0 - 15, three - being severely impaired of cognition for making daily decisions. Resident # 4 was coded as requiring extensive assistance of one staff member for activities of daily living. The comprehensive care plan for Resident #4 dated [DATE] documented in part, Focus. I am at risk for psychosocial well-being concern r/t (related to) medically imposed restrictions r/t COVID-19 precautions. I am at risk for s/sx (signs and symptoms). Negative for COVID-19 (,[DATE]) ([DATE]). Revision on: [DATE]. Under Interventions it documented in part, Observe for s/s of COVID-19/document and promptly report s/sx: fever, coughing, sneezing, soar Sic. throat, respiratory issues. Date Initiated: [DATE]. The Physician/Practitioner Progress Note for Resident # 4 dated [DATE] documented in part, 14:40 (2:40 p.m.) Assessment/Plan: COVID-19 test pending. The nurse's note for Resident # 4 dated [DATE] documented in part, 00:08 (12:08 a.m.), Remains on droplet precautions related to COVID-19. The Physician/Practitioner Progress Note for Resident # 4 dated [DATE] documented in part, 12:41 (12:41 p.m.), COVID-19 test negative. At 14:55 (2:55 p.m.), the Physician/Practitioner Progress Note documented, Resident's RP (responsible party) (Name of RP-relationship), notified this afternoon of the resident's negative COVID-19 test results. Remote review of Resident #5's clinical record revealed, Resident # 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident # 5's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of [DATE], coded Resident # 5 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Resident # 5 was coded as requiring limited assistance of one staff member for activities of daily living. The comprehensive care plan for Resident #5 dated [DATE] documented in part, Focus. I am at risk for psychosocial well-being concern r/t (related to) medically imposed restrictions r/t COVID-19 precautions. I am at risk for s/sx (signs and symptoms). Negative for COVID-19 (,[DATE]) ([DATE]). Revision on: [DATE]. Under Interventions it documented in part, Observe for s/s of COVID-19/document and promptly report s/sx: fever, coughing, sneezing, soar Sic. throat, respiratory issues. Date Initiated: [DATE]. The Physician/Practitioner Progress Note for Resident # 5 dated [DATE] documented in part, 14:30 (2:30 p.m.) Screen for COVID-19. The nurse's note for Resident # 5 dated [DATE] documented in part, 14:29 (2:49 p.m.) RP (responsible party): left message in reference to COVID-19 testing, Awaiting return call. The nurse's note for Resident # 5 dated [DATE] documented in part, 17:17 (5:17 p.m.), COVID results were negative, call placed to RP, message left on answering machine. Remote review of Resident #6's clinical record revealed, Resident # 6 was admitted to the facility on [DATE] and a readmission on [DATE] with [DIAGNOSES REDACTED]. Resident # 6's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of [DATE], coded Resident # 6 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Resident # 6 was coded as requiring extensive assistance of one staff member for activities of daily living. The comprehensive care plan for Resident #6 dated [DATE] documented in part, Focus. I am at risk for psychosocial well-being concern r/t (related to) medically imposed restrictions r/t COVID-19 precautions. I am at risk for s/sx (signs and symptoms). Positive for COVID-19 (,[DATE]) ([DATE]). Revision on: [DATE]. Under Interventions it documented in part, Observe for s/s of COVID-19/document and promptly report s/sx: fever, coughing, sneezing, soar Sic. throat, respiratory issues. Date Initiated: [DATE]. The nurse's note for Resident # 6 dated [DATE] documented in part, 14:46 (2:46 p.m.) RP (responsible party) notified in reference to COVID-19 testing with consent, MD (medical director) notified. The nurse's note for Resident # 6 dated [DATE] documented in part, 17:19 (5:19 p.m.), COVID results were positive, resident was made aware, call placed to (Name of Relative), message left on answering machine. On [DATE] at approximately 11:52 a.m., ASM (administrative staff member) #1, the administrator, was contacted by telephone and asked for the standard used for sheltering residents in place (COVID 19 positive and negative in the same room). On [DATE] at 1:05 p.m., ASM # 1 provided this surveyor with the following email, The conversation was had with the DOH (Department of Health) about sheltering in place on Wing 3 was on Friday [DATE] until all of the Residents were tested and results in. The decision was based on the concerns that there was a widespread outbreak and even those that would be negative would already have been exposed and all would be treated as presumed positive. (Name of OSM # 7) provided this: · Have a plan for how residents in the facility who develop COVID-19 will be handled (e.g., transfer to single room, implement use of Transmission-Based Precautions, prioritize for testing, transfer to COVID-19 unit if positive). · Residents in the facility who develop symptoms consistent with COVID-19 could be moved to a single room pending results of [DIAGNOSES REDACTED]-CoV-2 testing. They should not be placed in a room with a new admission nor should they be moved to the COVID-19 care unit unless they are confirmed to have COVID-19 by testing. While awaiting results of testing, HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Cloth face coverings are not considered PPE and should only be worn by HCP for source control, not when PPE is indicated. · Have a plan for how roommates, other residents, and HCP who may have been exposed to an individual with COVID-19 will be handled (e.g., monitor closely, avoid placing unexposed residents into a shared space with them). On [DATE] at 1:11 p.m., a telephone conference was conducted with OSM (other staff member) # 9, medical director, deputy director of (Name of City and County) Health District, Long Term Care (LTC) Supervisor and this surveyor. OSM # 9 was asked if they (local health department) talked with or visited the facility. OSM # 9 stated that there were a set of written recommendations provided to the facility. OSM #9 was informed of the observation that was conducted onsite at the facility on [DATE] and of the interview conducted with OSM # 7, nurse supervisor of (Name of City) health department and OSM # 8, epidemiologist on [DATE] at 9:35 a.m., by telephone. OSM #9 was informed of the information the facility provided from the local health department in regards to residents sheltering in place (COVID positive and negative in the same room). OSM # 9 acknowledged this information did not address sheltering in place. OSM #9 stated if there is an even risk of exposure, they (local health department) are on board with putting them (residents) together, i.e. if there are two roommates who have been tested negative but with positive roommates, the two negative roommates can be moved together. OSM # 9 further stated, We can suggest that they move the exposed residents. OSM # 9 stated that she needed to locate the guidance and would send this to the LTC Supervisor and surveyor. On [DATE], at 4:55 p.m., a second telephone conference, was conducted with, OSM #9, the LTC (long term care) Supervisor, Director of OLC (Office of licensure and Certification), Assistant Director of OLC and this surveyor, regarding, CMS (Centers for Medicare & Medicaid Services), regulations and the CDC's (Centers for Disease Control and Prevention's) guidance, for cohorting residents who are positive or negative for COVID-19. OSM #9 stated that they were trying to get a feel from the early [DATE]/,[DATE] CDC guidance, Evaluate and Manage Residents with Symptoms of Respiratory Infection. OSM #9 stated that the [DATE] CDC guidance specifically stated that exposed individuals needed to be moved from the COVID-19 positive residents. OSM #9 stated that because there is an element of judgement involved, that moving the exposed resident out of the room poses more of a danger and more of a shuffling of the residents and could cause more blenderizing. I would say that is why the guidance doesn't say must or will. OSM #9 informed that facilities must ensure that they are complying with all CMS and CDC guidance related to infection control and the [DATE] CDC's guidance, which documents facilities Have a plan for how roommates, other residents and HCP (health care providers) who may have been exposed to an individual with COVID-19 will be handled. OSM #9 was informed that the word plan, on the [DATE], CDC guidance links and connects to the [DATE], CDC guidance, titled, Responding to Coronavirus (COVID-19) in Nursing Homes, Considerations for the Public Health Response to COVID-19 in Nursing Homes. The [DATE], CDC guidance** documents under the header, Resident with new-onset suspected or confirmed COVID-19, in part the following, If the resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit. Exposed residents may be permitted to room share with other exposed residents if space is not available for them to remain in a single room. OSM #9 then stated now, those seven to ten words, yes. A remote review of the Line List for COVID-19 Outbreaks, submitted by the facility for review by fax on [DATE], revealed the facility census was 130 current residents, 81 residents had tested positive for the COVID-19 virus and nine had expired. The remote review of the facility's LTC (Long Term Care) Respiratory Surveillance List (for COVID-19 Outbreaks), and a remote review of clinical records revealed the following documented entries for Residents #7, #8, #9, #10, #11, #12, #13, #14 and # 15. On the line list the following was documented, Name of resident (Resident #7), Unit (number), room(number), Onset Date, [DATE], Fever (Y/N),Y, Cough (Y/N),N, Myalgia (Y/N), Y, Shortness of Breath (Y/N), Y, COV-2 test result (+/-), + (positive), Flu Test Result (+/-).-(dash), Chest Xray (+/-),-(dash), hospitalized (Y/N), Y (yes), died (Y/N), ,[DATE]. Under the section titled Outcome During Outbreak: a handwritten note beside this documented, died in hospital. Remote review of Resident #7's clinical record revealed, Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the most recent MDS (minimum data set), an quarterly assessment with an assessment reference date of [DATE], Resident #7 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). A review of Resident #7's clinical record revealed a physician note dated [DATE] documenting that the resident had test for COVID-19 and was Instructed not to leave his room. RP (responsible party) informed of change in condition. Further review revealed a nurse practitioner note dated [DATE] documenting will transfer resident to hospital for further evaluation and treatment of [REDACTED]. Further review revealed a nurse note dated [DATE] documenting the resident was admitted to the hospital and RP called and updated. On the line list the following was documented, Name of Resident (Resident #8), Unit (number), room(number), Onset Date, [DATE], Fever (Y/N),Y, Cough (Y/N), not noted, Myalgia (Y/N), not noted, Shortness of Breath (Y/N), Y, COV-2 test result (+/-), + (positive), Chest Xray (+/-),-(dash), hospitalized (Y/N), Y (yes), died (Y/N), ,[DATE]. Under the section titled Outcome During Outbreak: a handwritten note beside this documented, admitted to hospital, expired. Remote review of Resident #8's clinical record revealed, Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the most recent MDS, a five (5) day Medicare assessment with an assessment reference date of [DATE], Resident #8 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS. A review of Resident #8's clinical record revealed a nurse's note dated [DATE] documenting that the resident had shortness of breath and oxygen saturations of 85% on 4 liters of oxygen. Resident's sister informed of his condition. Further review revealed a nurse practitioner note on [DATE] Due to resident intermittent respiratory distress/labored breathing, tachypnea, [MEDICAL CONDITION] heart rate, resident will be sent out via 911 to hospital emergency room for further evaluation. Further review revealed a nurse's note dated [DATE] Patient admitted to hospital with [DIAGNOSES REDACTED]. On the line list the following was documented, Name of Resident (Resident #9), Unit (number), room(number), Onset Date, no notation, Fever (Y/N), no notation, Cough (Y/N), no notation, Myalgia (Y/N), no notation, Shortness of Breath (Y/N), no notation, COV-2 test result (+/-), + (positive), Flu Test Result (+/-). No notation, Chest Xray (+/-), no notation, hospitalized (Y/N), Y (yes), died (Y/N), Y (yes). A handwritten note beside this documented, Hospital expired of vascular. Remote review of Resident #9's clinical record revealed, Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the most recent MDS, a 5 day Medicare assessment with an assessment reference date of [DATE], Resident #9 was coded as having no cognitive impairment for making daily decisions, having scored 14 out of 15 on the BIMS. A review of Resident #9's clinical record revealed a nurse's note dated [DATE] documenting that the resident had a change in condition with abdominal pain or [MEDICAL CONDITION], decrease in fluid/food intake and nausea/vomiting with Temperature of 97.1. Further review revealed a nurse's note dated [DATE] documenting Therapy notified nurse of resident left lower extremity feeling cold to the touch. Further review revealed an activities aide note dated [DATE] documenting virtual family visit with resident and son, she was actively engaged in video chat with him. Further review revealed a nurse's note dated [DATE] documenting Resident transferred to medical center. On the line list the following was documented, Name of Resident (Resident #10), Unit (number), room(number), Onset Date, [DATE], Fever (Y/N),Y, Cough (Y/N),N, Myalgia (Y/N), Y, Shortness of Breath (Y/N), Y, COV-2 test result (+/-), + (positive), Flu Test Result (+/-).no notation, Chest Xray (+/-), N, hospitalized (Y/N), N (no), died (Y/N), ,[DATE]. Under the section titled Outcome During Outbreak: COV test pending, admitted to hospital CVOID +, expired in hospital. Remote review of Resident #10's clinical record revealed, Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the most recent MDS, a 5-day Medicare assessment with an assessment reference date of [DATE], Resident #10 was coded as having severe cognitive impairment for making daily decisions, having scored 01 out of 15 on the BIMS. A review of Resident #10's clinical record revealed a nurse practitioner note dated [DATE] documenting that the resident had test for COVID-19 with pending results and fever of 102.8 on [DATE] afebrile since then. Further review revealed a nurse's note dated [DATE] Resident has a low grade temp 99.6 call placed to on call service, unable to contact RP (responsible party) at this time. Further review revealed a social services note dated [DATE] Contacted RP to clarify resident's code status. RP states resident is to be a FULL CODE. Covid droplet precautions remain. Further review revealed a nurse's note dated [DATE] Resident alert but not responding as usual. Oxygen saturation 89% on two liters of oxygen. Resident transported to the hospital for further evaluation. On the line list the following was documented, Name of Resident (Resident #11), Unit (number), room(number), Onset Date, no notation, Fever (Y/N), no notation, Cough (Y/N), no notation, Myalgia (Y/N), no notation, Shortness of Breath (Y/N), no notation, COV-2 test result (+/-), + (positive), Flu Test Result (+/-). No notation, Chest Xray (+/-), no notation, hospitalized (Y/N), Y (yes), died (Y/N), Y (yes). A handwritten note beside this documented, died in hospital. Remote review of Resident #11's clinical record revealed, Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the most recent MDS, a 5-day Medicare assessment with an assessment reference date of [DATE], Resident #11 was coded as having moderately impaired cognition for making daily decisions, having scored 9 out of 15 on the BIMS. A review of Resident #11's clinical record revealed a nurse practitioner note dated [DATE] documenting that the resident recently had been hospitalized for [REDACTED]. Further review revealed a nurse's note dated [DATE] documented Resident in respiratory distress, oxygen saturations at 47% on two liters of oxygen, temp 100.9 BP (blood pressure) ,[DATE]. Oxygen increased to four liters with no increase in oxygen saturation. Nurse Practitioner notified and RP notified. RP wanted resident transferred to the emergency room . Further review revealed a nurse's note dated [DATE] documented emergency room informed that resident was admitted for COVID 19. On the line list the following was documented, Name of Resident (Resident #12), Unit (number), ro (TRUNCATED)