Every finding on record at Windmill Village Rehabilitation & Care Center

Based on interviews and record reviews, the facility failed to treat residents with respect, dignity, and care in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality for 11 of 11 confidential residents in that: The facility failed to ensure staff were not utilizing their personal cell phones while providing care, which included assisting residents with their showers and performing peri-care. The deficient practice could place residents at risk for diminished quality of life, loss of dignity and self-worth. Findings include:At an undisclosed date and time eleven confidential residents stated the use of cell phones by CNAs while performing care made them feel ignored, not a priority, embarrassed, concerned that the CNA could make a mistake due to distraction by the cell phone conversation, and, most of all, their privacy was violated. The eleven confidential residents stated the use of cell phones by CNAs occurred on every shift. The confidential residents stated staff utilized their cell phones while performing showers, when performing care in resident rooms, and while performing peri-care. The confidential residents stated the staff texted and talked on their phones while walking down hallways, at the nurses' stations, and while in the dining area during meals. The confidential residents stated the phone calls occurred through earpieces. The eleven residents stated they did not know the names of the CNAs who utilized their cell phones while performing care. The confidential residents stated cell phone usage of the CNAs while performing care happened in the facility often, and every CNA in the facility utilized their cell phone while performing care. During an interview on 07/09/26 at 12:25pm, the DON stated residents should be provided with privacy during resident care; the staff should provide residents with their full attention, and HIPAA rules should be followed. She stated all staff were trained in privacy, resident rights, dignity, and cell phone usage during orientation and through continuous education by department heads and the DON. She stated staff were monitored by rounds completed by the DON, ADON, and the ADM. She stated cell phones should never be used in patient care areas; cell phones should only be used in the break room. She stated the potential negative outcome would be residents losing dignity and mistakes could be made the staff member. During an interview on 07/09/2026 at 1:05pm, the ADM stated staff should never be distracted by cell phones while providing care; the residents should receive the attention of the staff performing care. The ADM stated she and the DON were responsible for training staff on resident rights, cell phone usage, and dignity. She stated the staff were trained at least every 90 days on resident rights, cell phone usage, and dignity. She stated cell phones should only be used during breaks; cell phones should be kept in breakroom lockers. Staff were monitored for cell phone use by rounding completed by the ADON, DON, and the ADM. The ADM stated the potential negative outcome for residents, if staff are using their cell phones, was residents could feel embarrassed and they could suffer from a loss of dignity. Record review of the facility policy dated October 2022 titled Resident Rights revealed the following: Policy: Employees shall treat Residents with kindness, respect, and dignity. Policy Interpretation and ImplementationA dignified existence:Privacy and confidentiality;Be free of abuse, neglect, misappropriation of property, and exploitation

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: The facility failed to ensure the fryer was free of build up and grime. The facility failed to ensure the toaster was free of build-up and grime. The facility failed to ensure the wall behind the dishwashing station was free of build-up and grime.The facility failed to ensure hot holding pans/cookie sheets were free of build-up and grime.The facility failed to ensure all canned food items had expiration or use-by dates. The facility failed to ensure all pantry food items had expiration or use-by dates. The facility failed to ensure prepared gravy had an expiration or use-by date. The facility failed to ensure prepared pureed chicken had an expiration or use-by date. These failures could place residents who received meals and/or snacks from the kitchen at risk of food contamination and food borne illness.Findings included: During the initial tour and observation of the kitchen on 07/07/2026 at 9:15 AM the following were revealed: The fryer in the kitchen area was observed to be soiled with a thick coating of grease and grime on both sides of the outside of the fryer.The toaster oven was observed to be soiled with a thick layer of grime and grease throughout the machine. The wall behind the dishwashing station contained a yellow layer of grease and grime, and a layer of hardwater stains. Hot holding trays/cookie sheets were observed with a thick layer of black and brown grease build-up, coating the entirety of the pans. 3 cans of tomato soup, 3 cans of chicken noodle soup, and 2 cans of cream of mushroom soup were observed without use-by dates. A container of prepared gravy was observed without an expiration or use-by date. 10 individual containers of prepared pureed chicken were observed in the refrigerator without an expiration or use-by date. During an observation of the kitchen on 07/08/2026 at 10:00 AM revealed the following:The fryer in the kitchen area was observed to be soiled with a thick coating of grease and grime on both sides of the outside of the fryer.The toaster oven was observed to be soiled with a thick layer of grime and grease throughout the machine. The wall behind the dishwashing station contained a yellow layer of grease and grime, and a layer of hardwater stains. Hot holding trays/cookie sheets were observed with a thick layer of black and brown grease build-up, coating the entirety of the pans. 3 cans of tomato soup, 3 cans of chicken noodle soup, and 2 cans of cream of mushroom soup were observed without use-by dates. A box of fig [NAME] bars were observed without use-by dates. A box of individual ritz crackers were observed without use-by dates. During an interview on 07/07/2026 at 11:00 AM, DA A stated all dietary staff were responsible for ensuring the kitchen area was kept clean. DA A stated the dietary staff followed a cleaning schedule to ensure all surface areas were maintained. DA A stated all staff were responsible for putting up food storage in the pantry area. DA A stated they received regular training on food storage and all food items had to be labeled and dated. DA A stated all food stored in the dry pantry was supposed to be labeled with a received date or use-by date. DA A stated all prepared food items were supposed to be labeled with a prepared date or a use-by date. DA A stated it was important for the kitchen to be maintained and clean for the health of the residents. DA A stated it was important to label and date all food items to ensure residents did not get sick from eating expired food. During an interview on 07/09/2026 at 10:40 AM, DA B stated all staff were responsible for putting away food items when they received their inventory. DA B stated she was primarily responsible for the walk-in refrigerator and freezer. DA B stated she was also responsible for labeling and dating food items in the dry storage any time she went into the dry storage and saw something undated. DA B stated they have received numerous trainings on labeling and storage, and all staff were aware all food items should be labeled or dated. DA B stated she was not aware of the unlabeled/undated canned items or snacks in the dry storage. DA B stated she was not aware of the unlabeled container of gravy. DA B stated she was aware of the unlabeled pureed chicken, and she stated she thought since one item was labeled the other items were considered labeled, although they were wrapped individually. DA B stated she was trained to label/date each food item as it was prepared and stored. DA B stated the dietary manager usually made rounds to double check that everything was labeled and dated. DA B stated the dietary manager was on leave. DA B stated it was important to ensure all food items were labeled and dated to prevent expired food from being served to the residents. DA B stated residents could get sick if they ate old food. DA B stated all dietary staff were responsible for cleaning and maintaining the kitchen area. DA B stated they usually had a cleaning schedule to complete deep cleaning tasks. DA B stated she did not know where the cleaning schedule was. DA B stated the dietary staff tried to deep clean the kitchen area twice a month, depending on how busy they were. DA B stated she was not aware of the grease and grime build up on the hot holding pans/cookie sheets, the toaster oven, the fryer, or the oven. DA B stated she was not aware of the grease and grime build up or hardwater stains on the wall behind the dishwashing station. DA B stated all dietary staff were responsible for deep cleaning equipment in the kitchen. DA B stated it was important to ensure the kitchen was clean and maintained to ensure residents did not get sick. DA B stated if the kitchen were not kept clean residents could get sick, and it was the dietary staff's goal to prevent that from happening. During an interview on 07/09/2026 at 10:55 AM, DA C stated all dietary staff were responsible for labeling and dating food items when they were received and as they were prepared and stored. DA C stated all dietary staff took turns putting up food items as they were received. DA C stated the dietary manager also helped with this task and double checked to ensure all food items were labeled and dated. DA C stated she was not aware of the unlabeled/undated canned foods or unlabeled/undated snacks in the dry storage. DA C stated she was not aware of the unlabeled/undated gravy and pureed chicken. DA C stated she did not know why these items were not labeled or dated. DA C stated staff received regular training on labeling and dating food items and all dietary staff were responsible for ensuring all food items were labeled and dated. DA C stated if food items were not labeled or dated residents could be served expired food, causing them to get sick. DA C stated all staff were responsible for cleaning and maintaining the kitchen. DA C stated the dietary manager assigned deep cleaning tasks regularly, but she did not know where the schedule was. DA C stated she was not aware of the grease and grime build up on the hot holding pans/cookie sheets, the toaster oven, the fryer, or the oven. DA C stated she was not aware of the grease and grime build up or hardwater stains on the wall behind the dishwashing station. DA C stated it was important to ensure the kitchen was clean and maintained to ensure the kitchen was sanitary, and to prevent residents from getting sickDuring an interview on 07/09/2026 at 11:40 AM, the ADM stated the dietary manager was out of the country. The dietary manager was unavailable for interview. The ADM stated all dietary staff were responsible for food storage. The ADM stated all dietary staff received regular training on food storage and they were trained to label and date all prepared and stored food items. The ADM stated she was not aware there were items in the dry storage [NAME] were not labeled or dated. The ADM stated it was her expectation that the dietary staff labeled and dated all prepared and stored food items. The ADM stated if residents were served something out of date, they had the potential to get sick The ADM stated all dietary staff were also responsible for cleaning and maintaining the kitchen area and equipment. The ADM stated it was her expectation that the kitchen area was clean and sanitary. The ADM stated residents could potentially get sick from a build up of bacteria if the kitchen was not maintained. Record review of the facility's policy titled, Sanitation, dated October 2008, revealed the following: Policy Statement:The food service area shall be maintained in a clean and sanitary manner.Policy Interpretation and Implementation:1- All kitchens, kitchen area and dining areas shall be kept clean, free from litter and rubbish and protected f1om rodents, roaches, flies, and other insects.2. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions,, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges, and fasteners will be kept in good repair.16. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime.17. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. Record review of the facility's policy titled, Food Receiving and Storage, dated October 2017, revealed the following: Policy Statement:Foods shall be received and stored in a manner that complies with safe food handling practices.Policy Interpretation and Implementation:l. Food Services, or other designated staff, will maintain clean food storage areas at all times.6. Dry foods that are stored in bins will be removed from original packaging, labeled, and dated ( use by date). Such foods will be rotated using a first in - first out system.7. All foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date).

Based on observation, interview, and record review the facility failed to ensure that its medication error rate was less than 5 percent. The facility had a medication error rate of 15.38 percent based on 4 errors out of 26 opportunities, which involved 2 (Resident #107 and Resident #45) of 3 residents reviewed for medication administration.-MA A failed to give Resident #107's dose of the medication Metoprolol Tartrate at the ordered time, resulting in a late dose. -MA A failed to give Resident #45's dose of the medication Levetiracetam at the ordered time, resulting in a late dose. -MA A failed to give Resident #45's medication Lisinopril according to physician's orders when she administered the medication outside the ordered vital sign parameters. -MA A failed to verify the correct dosage for Resident #45's medication Pantoprazole prior to administering the medication, resulting in Resident #45 being underdosed. These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and a decline in health.Findings included: Resident #107Record review of Resident #107's admission Record dated 07/07/2026 revealed a [AGE] year-old female with an original admission date of 08/14/2025. Resident #107 had diagnoses which included: metabolic encephalopathy (brain dysfunction caused by an underlying systemic illness), cognitive communication deficit (difficulty with communication caused by disrupted thinking skills), and hypertension (high blood pressure). Record review of Resident #107's Quarterly MDS assessment, dated 04/07/2026, revealed a BIMS score of 10 indicating the resident had moderate cognitive impairment. Record review of Resident #107's current physician's orders, dated 07/08/2026, revealed an order with a start date of 06/02/2026 for Metoprolol Tartrate oral tablet 12.5 mg. Give one tablet by mouth two times a day for hypertension. Record review of Resident #107's July 2026 MAR revealed Metoprolol Tartrate oral tablet 12.5 mg was ordered to be administered at 8:00 AM. During a medication administration observation on 07/08/2026 at 9:35 AM for Resident #107, MA A dispensed one Metoprolol 12.5 mg tablet and administered the medication to Resident #107. Resident #45Record review of Resident #45's admission Record dated 07/07/2026 revealed a [AGE] year-old female with an admission date of 03/04/2025. Resident #45 had diagnoses which included: unspecified convulsions (sudden, uncontrollable, involuntary shaking), cerebral infarction (stroke), Gastro-esophageal reflux disease (a digestive disorder that occurs when stomach acid repeatedly flows back up into the esophagus, causing irritation), and hypertension (high blood pressure). Record review of Resident #45's Annual MDS assessment, dated 02/24/2026, revealed a BIMS score of 12 indicating the resident had moderate cognitive impairment. Record review of Resident #45's current physician's orders, dated 07/08/2026, revealed the following orders:-Levetiracetam Oral Tablet 500 mg. Give 500 mg by mouth two times a day for seizure activity related to unspecific convulsions. -Lisinopril Oral Tablet 10 mg. Give 10 mg by mouth one time a day related to hypertension. Hold if blood pressure is less than 100/60 or if heart rate is less than 55. -Pantoprazole Sodium Oral Tablet Delayed Release. Give 30 mg by mouth one time a day related to Gastro-esophageal reflux disease. Record review of Resident #45's July 2026 MAR revealed Levetiracetam oral tablet 500 mg was ordered to be administered at 8:00 AM During a medication administration observation on 07/08/2026 at 9:49 AM for Resident #45, MA A dispensed one Levetiracetam 500 mg tablet, one Lisinopril 10 mg tablet, and one Pantoprazole 20 mg tablet into a dispensing cup and took the cup into Resident #45's room. MA A placed a wrist blood pressure cuff on the right wrist of Resident #45 and obtained the following vital sign readings: blood pressure 99/72; pulse 69. MA A administered the medications from the dispensing cup to Resident #45 and exited the room. During an interview on 07/08/26 at 12:23 PM, MA A stated it was the responsibly of the MAs and nurses to ensure medications were given on time, and at the correct dosage, according to physician's orders. MA A stated she was trained on accurate medication administration during her MA training and through ongoing training at the facility. She stated the pharmacy consultant conducted medication pass observations during the onsite visits. MA A reopened her MAR and reviewed the medications for Resident #107 and Resident #45. She stated she administered Resident #107's 8:00 AM dose of Metoprolol and Resident #45's 8:00 AM dose of Levetiracetam late due to running behind on medication pass and having to look for the correct dosage of a medication in the medication room. MA A stated medication could be given one hour before and up to one hour after the ordered time of administration. MA A stated she gave Resident #45's Lisinopril medication outside the ordered parameters for blood pressure. She stated she should have held the medication, based on the resident's blood pressure reading. MA A stated she usually double checked any parameters before administering a medication, but she got in a hurry and was nervous and failed to check it again prior to administering the medication. MA A stated she administered the incorrect dose of Resident #45's Pantoprazole medication when she gave a 20 mg dose instead of the ordered 30 mg dose. She stated the dosage must have recently changed and she failed to compare the dose on the card with the dose on the MAR. MA A stated the protocol when a medication error was made was to report the error to the charge nurse or DON so the doctor could be notified of the error. MA A stated a potential negative outcome for failure to administer medications according to physician's orders was that a resident could die. During an interview on 07/09/2026 at 12:57 PM, the DON stated she was made aware by staff of medication errors made during the medication pass observation on 07/08/2026. She stated all staff were trained on accurate medication administration upon hire and through ongoing facility training. The DON stated the facility utilized rounds and competency checks for training and monitoring of accurate medication administration. She stated nursing administration was responsible for ensuring accurate and timely medication administration. She stated the pharmacy consultant conducted monthly competency checks for medication administration. She stated medication errors were reported to the provider and noted in the health record. The DON stated the provider was notified of the errors made during the medication pass observation on 07/08/2026 and a dosage order was verified and updated in the health record. The DON stated Resident #107 and Resident #45 were monitored following the medication errors without any adverse events. The DON stated a potential negative outcome for failure to follow physician's orders during medication administration was that a resident could become sick or have an adverse reaction to a medication. During an interview on 07/09/2026 at 1:13 PM, the ADM stated she was made aware by the DON of medication errors made during the medication pass observation on 07/08/2026. She stated nursing administration was responsible to ensure staff were administering medications accurately and according to physician's orders. The ADM stated all nursing staff and MAs were trained on accurate medication administration upon hire and through ongoing facility training. The ADM stated the system for monitoring the accuracy of medication administration was through monthly competency checks by the pharmacy consultant and through reports generated by the electronic medical record regarding timeliness of medication administration. She stated her expectation of staff for medication administration was that orders were followed and medications were given according to ordered timeframes. The ADM stated a potential negative outcome for failure to administer medications according to physician's orders was medication errors and missed doses. During a telephone interview on 07/10/2026 at 1:27 PM, the Medical Director stated his expectation for ordered medication was that the medication was given within one hour prior to or one hour following the scheduled administration time. He stated he was made aware of medication errors made during the medication pass observation and orders were verified by facility staff. He stated a potential negative outcome for failure to administer medications according to physician's orders would depend on the medication, but it was important to follow the orders for timing and accuracy of all medications. Record review of the facility policy titled Administering Oral Medications Level III (revised October 2010) revealed: PurposeThe purpose of this procedure is to provide guidelines for the safe administration of oral medications. Steps in the Procedure .6. Check the label on the medication and confirm the medication name and dose with the MAR.8. Check the medication dose. Re-check to confirm the proper dose. 9. Prepare the correct dose of medication.13. Perform any pre-administration assessments.

Based on observation, interview, and record review, the facility failed to follow their own established smoking policy for 1 of 3 residents reviewed for smoking. (Resident #1)The facility failed to ensure staff followed the smoking policy and took residents out to smoke in designated smoking area. This failure could place residents at risk of injury or harm.Findings included:Record review of Resident #1's face sheet undated revealed she was [AGE] years old and admitted to the facility on [DATE]. Resident #1 had diagnoses which included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), emphysema (lung condition that causes shortness of breath), hypertension (high blood pressure), shortness of breath, anxiety (feeling of fear and worry), and tobacco use.Record review of Resident #1's quarterly MDS assessment dated [DATE], revealed she had a BIMS score of 12, which indicated she had moderate cognitive impairment. The MDS indicated Resident #1 needed supervision or touching assistance for most ADLs. The MDS did not indicate Resident #1 was using tobacco at the time of the assessment.Record review of Resident #1's Care Plan Report revealed she had a problem attempting to smoke and asking others to take her to smoke. Resident #1 had been educated by ADON and DON that this was a nonsmoking facility dated 10/14/25. Interventions included caregivers to provide opportunities for positive interaction, attention, to stop and talk with him/her as passing by, explain all procedures to the resident before starting, intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention, and remove from situation and take to alternate location as needed. The care plan further revealed observe and report behavior episodes and attempt to determine underlying causes, consider location, time of day, persons involved, and situations and document behavior and potential causes.Record review of Resident #1's Safe Smoking assessment dated [DATE] revealed Resident #1 was determined to be a safe smoker.Record review the facility's provided undated Smoker List revealed two resident names and Resident #1 was not listed. Smoke schedule 0900, 1400, 1900 and smoke area outside of the dining room.During an interview on 10/14/25 at 09:30 am with the ADM, she stated during her investigation of the fire, CNA A admitted to taking Resident #1 out on the patio at the end of Hall 300 to smoke between 12:00 pm and 1:00 pm. She stated Resident #1 was not a smoker and when admitted was told the facility was a nonsmoking facility. She stated the facility had two residents that were still allowed to smoke in the designated smoking area outside the dinner room.An observation on 10/14/25 at 09:33 am of the patio at the end of Hall 300 revealed the door to patio was keypad locked on inside and outside. The gazebo was located at back right side of patio approximately 25ft. from facility door. The patio railing at the back on the right side and the support post are burnt. A flower planter box located on the back right corner was burnt. There was no observation of ash trays, a fire extinguisher, or red trash can.During an interview on 10/14/25 at 09:35 am with LVN B, she stated they occasionally took residents out on the patio to help with their behaviors. She stated the designated smoking area was located by the dining room. She stated they would occasionally take residents out on the patio at the end of Hall 300 to smoke at night because the lighting was better. She stated they always took the cigarette butts to the red can located in the designated smoking area outside of the dining room.During an interview on 10/14/25 at 01:20 pm with the ADM, she stated CNA A took Resident #1 outside to smoke. She stated CNA A was not aware that Resident #1 was not on the list of smokers. She stated the facility had two residents that were allowed to smoke. She stated when she interviewed Resident #1, Resident #1 stated she had put her cigarette out in the planter box on the patio at the end of Hall 300. She stated CNA B was making rounds and seen flames out at the patio. CNA B got the fire extinguisher, put the fire out and 911 was called. She stated the designated smoking area was located outside of the dining room. She stated the smoking area was for resident-use only.During an observation on 10/14/25 at 01:30 pm, the smoking area outside dining room had an ash tray, red can, and fire extinguisher.During an interview on 10/14/25 at 02:13 pm with CNA A, she stated on Tuesday 10/07/25 Resident #1 asked to go outside on the patio to warm up because she was cold. She stated she went back inside to get another resident and when she returned to the patio Resident #1 was down at the gazebo smoking. She stated she did not think anything about it because they occasionally took residents outside on patio to smoke. She stated Resident #1 put the cigarette out in pot inside of planter box and had the top part of cigarette in her hand when she went back inside facility. She stated she was not sure where Resident #1 got the cigarette and lighter. She stated she told the receptionist that Resident #1 went outside and smoked. She stated the receptionist told her Resident #1 was not supposed to smoke and the receptionist notified the ADON and DON. She stated she was not aware Resident #1 was not supposed to smoke.During an interview on 10/14/25 at 02:26 pm with the DON, she stated CNA A worked Hall 300. She stated the receptionist reported to her Resident #1 went out on the patio at the end of Hall 300 and smoked with CNA A. She stated CNA A stated she did not know Resident #1 was going to smoke. She stated she did not know where Resident #1 got cigarettes and lighter. She stated someone had to bring them to her. She stated the only designated smoking area was outside by the dining room. She stated the facility was non-smoking and currently had two residents who were grandfathered in, and once those residents were no longer at the facility, they will be 100% non-smoking. She stated all staff were aware of the designated smoking area. She stated Resident #1 told her she did not have any more cigarettes in her room. She stated Resident #1 did not allow staff to look through her belongings. She stated the purpose of the designated smoking area was so the residents had everything they needed, and a safe place to smoke to prevent fires and be monitored. She stated all staff have been trained where the location of the designated smoking area was and the smoking policy. She stated the potential negative outcome could be a fire.During an interview on 10/14/25 at 02:35 pm with the ADON, she stated it was reported to her and the DON that Resident #1 went outside on the patio at the end of Hall 300 and smoked. She stated when they went to Hall 300 Resident #1 was back in her room. She stated CNA A stated she took her outside on the patio at the end of Hall 300 to smoke. She stated CNA A did not know Resident #1 was not supposed to smoke or the location of designated smoking area. She stated she was trained on the smoking policy and designated smoking area. She stated Resident #1 stated she had cigarettes in her room, but no one ever took her outside to smoke. She stated Resident #1 did not have a lighter and would not tell them who lit her cigarette. She stated the policy was for residents to only smoke in designated smoking areas. She stated the designated smoking area was located outside the dining room. She stated all staff had been in-serviced on the smoking policy and designated area. She stated the potential negative outcome could be a fire.During an interview on 10/14/25 at 02:45 pm with Resident #1, she stated she asked the staff to take her outside to smoke. She stated CNA A took her outside to smoke and lit her cigarette. She stated she did not know the code to get out on the patio or get back into facility. She stated she was not aware she could not smoke outside on the patio at the end of Hall 300. She stated when she was on Hall 100, she would see people smoking outside her window. She stated she had no cigarettes or lighter in her room.During an interview on 10/14/25 at 03:15 pm with the ADM, she stated the purpose of the designated smoking area was to take the residents there, so they were monitored and safe. She stated she was not aware the staff were taking residents out on the patio at the end of Hall 300 to smoke. She stated all staff have been in-serviced on the smoking policy and the location of the designated smoking area. She stated her expectation was for all staff to follow the smoking policy. She stated the charge nurse was responsible for monitoring staff who took residents out to smoke. She stated the potential negative outcome could be a fire.Review of the facility's policy titled Smoking Policy - Residents revised 03/08/23 revealed the following:Policy Statement - This facility should establish and maintain safe resident smoking practices .2. Smoking is only permitted in designated smoking areas, which are located outside of the building.4. Ensure that fireproof or compatible containers are available in smoking areas.

Based on interviews, and record review, the facility failed to incorporate recommendations from a PASRR level II determination and the PASRR evaluation report for 1 of 5 residents (Resident #1) reviewed for PASRR. The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within 20 days after the IDT meeting. This failure could cause residents with mental health disorders and psychiatric conditions to have a delay in services or not receive specialized services or equipment that may be needed for a better quality of life.Record review of Resident #1's face sheet dated 08/28/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: paranoid schizophrenia (a disorder that affects the ability to think, feel and behave clearly), mild intellectual disabilities, cognitive communication deficit (inability to communicate effectively due to cognitive impairments), intermittent explosive disorder (a mental disorder characterized by explosive outbursts of anger or violence), Type 2 diabetes mellitus (a condition in which the body does not use insulin properly), cerebral infarction (stroke) and generalized muscle weakness. Record review of Resident #1's annual MDS assessment dated [DATE] revealed a BIMS score of 07, indicating the resident had severe cognitive impairment. The MDS also revealed Resident #1 had a psychiatric disorder and was dependent in eating, toileting and hygiene. Record review of Resident #1's comprehensive care plan, initiated 04/11/25 and revised on 05/18/25, revealed the resident as PASRR positive related to IDD. Further review revealed an IDT PASRR meeting was held on 04/28/25. Record review of a Care Plan Conference document dated 04/28/25 revealed the care plan meeting was held due to Other: PASRR. Attendees included: MDS Nurse, Social Services, Dietary, a staff nurse, Resident #1's family member, a COTA and a PASRR habilitation coordinator. Record review of Resident #1's PCSP dated 04/28/25 revealed a recommendation for a CMWC and coordination of habilitative therapy services of PT and OT. In an interview on 08/28/25 at 2:34 PM with the MDS Nurse, she stated she was responsible for LTC PASRR assessments. She stated Resident #1 was PASRR positive and recommendations had been made at the initial IDT meeting on 04/28/25, but she had issues with being able to upload the OT evaluation. She stated the facility reached out to the caseworker but did not receive a response and she was not able to enter anything due to the resident's information not populating in the system. The MDS Nurse stated a second IDT meeting was held in June to extend the deadline due to not being able to enter the information. She stated she had attended PASRR training and had performed PASRR assessments for many years. She stated it was her responsibility to assure proper PASRR assessments were submitted timely and to submit NFSS through the LTC portal. The MDS Nurse stated she knew Resident #1 qualified for services and was not receiving services, but she had not been able to fix the problem so far. In an interview on 08/29/25 at 9:48 AM with the HHSC PASRR Unit Program Specialist, she stated if PASRR specialized services were recommended at the IDT meeting but were not initiated within 20 business days following the date the services were agreed to, the resident would not receive a PASRR specialized service. She stated the facility was given an additional specific timeframe to submit the NFSS request, but the facility did not meet that timeframe in addition to the previous 20 business days that were allowed. In an interview on 08/29/25 at 2:57 PM, Resident #1 stated he occasionally attended his own care plan meetings, but his family member usually took care of his business. He stated he was aware of the fact that he could have a new wheelchair, and he was waiting to get it. He stated his current wheelchair was functioning fine but was missing a brake on one side. Resident #1 stated he was not interested in doing therapy. In an interview on 08/29/25 at 3:04 PM, the DOR stated he was not in his current position when the IDT meeting for Resident #1 took place. He stated the OT evaluation was completed and the CMWC had been measured and ordered and was awaiting PASRR approval. In an interview on 08/29/25 at 4:07 PM, the Regional LIDDA Director stated Resident #1 was recommended for a CMWC and habilitative OT and PT. She stated the facility submitted partial information on 05/20/25 which was processed by HHSC on 05/23/25. She stated all the required documentation was not submitted under the supplier acknowledgment tab and was lacking documentation for PT and OT services, which caused the process to be delayed beyond the 20-day timeline. She stated it was the responsibility of the facility to follow-up on the portal process and assure timely submission and acceptance of documentation. In an interview on 08/29/25 at 4:43 PM, the ADM stated the process when a PASRR positive resident is identified was to hold an IDT meeting with PASRR workers to establish what services were needed. She stated it was the responsibility of the MDS Nurse to assure the NFSS was entered into the LTC portal timely and follow up on the process. She stated the monitoring system to assure timely entry of PASRR information was for the MDS Nurse to report any issues to the ADM. The ADM stated a potential negative outcome for failure to process PASRR information timely was that residents may miss services that they were qualified for. Record review of the facility's document titled Preadmission and Screening Resident Review (PASRR) Rules, revised 03/15/23 revealed: GuidelineIt is the intent of [named company] to meet and abide by all state and federal regulations that pertain to resident Preadmission and Screening Resident Review (PASRR) rules.RulesThe intent of this guideline is to identify residents with Mental Illness (MI), Intellectual Disability (ID) or Developmental Disability (DD)/Related Conditions (RC) and to ensure they are properly placed, whether in community or in a Nursing Facility (NF) and to ensure they receive the services they require for their MI, or ID/DD. ProcedurePost IDT Meeting ResponsibilitiesOnce the IDT/PCSP makes its determinations about specialized care, the facility will;.2. The facility will initiate the request for specialized services within 20 business days of the IDT/PCSP meeting, implement Specialized Services therapy within 3 business days after receiving approval from HHSC in the online portal and order CMWC and/or DME within 5 business days of receiving approval from HHSC in the online portal-.

Based on observation, interview, and record review, the facility failed to ensure the resident's had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents, for 14 of 24 residents (Resident #12, Resident #31 and 12 confidential Residents), reviewed for resident rights. The facility failed to ensure staff performed rounds every two hours on the night shift. 12 of 12 residents who attended Resident Council stated CNAs do not perform rounds every 2 hours at night. Residents stated they have not had access to water due to the lack of rounding. Residents stated they have not had assistance with adjusting the temperature of their rooms and have not had assistance with turning due to the lack of rounding. The facility failed to ensure Resident #12 and #31 were rounded by night shif staff. This failure could place residents including at risk of not receiving needed care and services in a timely manner. The findings were: Record review of Resident #12's face sheet revealed a [AGE] year-old female, who was admitted to the facility on [DATE]. Resident #12 had diagnoses which included: Pain, Cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), Acute and chronic respiratory failure with hypoxia (failure of the respiratory system to adequately supply the body with oxygen, resulting to low oxygen levels in the tissues), Constipation (problem with passing stool), Muscle weakness (a decrease in the strength and ability of muscles to perform their normal functions, often resulting in a reduced ability to move the body), Overactive bladder (a sudden, strong urge to urinate), Anxiety disorder (group of mental health conditions categorized by excessive and persistent fear or worry that significantly impacts daily life), GERD [a condition where stomach acid flows back up into the esophagus (the tube connecting the stomach and mouth), causing heartburn and other symptoms]. Record Review of Resident #12's quarterly MDS dated [DATE], revealed a BIMS score of 14 which indicated the resident was cognitively able to make choices and decisions for herself. Record review of Resident #12's undated Care plan revealed resident at risk for complications related to GERD and interventions required assistance through monitoring for coughing/choking while lying down. Record review of Resident #31's face sheet revealed a [AGE] year-old female, who was admitted to the facility on [DATE]. Resident #31 had diagnoses which included: Abnormal posture, Pressure ulcer stage 2 (Partial-thickness skin loss of both the outermost and inner parts), Pruritus (itching), Acute Nasopharyngitis (common cold), Hypertension (condition where the blood pressure in the arteries is persistently elevated), Muscle weakness (a decrease in the strength and ability of muscles to perform their normal functions, often resulting in a reduced ability to move the body), Anxiety disorder (group of mental health conditions categorized by excessive and persistent fear or worry that significantly impacts daily life), GERD, Difficulty in walking, Hemiplegia and Hemiparesis (are both conditions that can result from a cerebral infarction (stroke), affecting movement and function on one side of the body). Record Review of Resident #31's quarterly MDS dated [DATE], revealed a BIMS score of 15 which indicated the resident was cognitively able to make choices and decisions for herself. Record review of Resident #31's undated Care plan revealed she has a behavior problem related to history of intentional self-harm and intervention required caregivers to provide opportunity for positive interaction, attention. Stop and talk with her as passing by. Observation and interview on 5/18/25 at 12:25p.m., Resident #31seen covered with the blanket on her bed, stated staff (CNAs) do not round at night every 2 hours. They did not come back upon request. Resident #31 requested, One thing I can say is, you need to come here at night unannounced. Resident #31 stated the DON was notified. Observation and interview on 5/18/25 at 01:23p.m., Resident #12 seen on her electric wheelchair, stated she do not get needed assistance at night. Resident #12 stated it takes time for them to come take me over to my bed, it happens every night and the night shift staff (CNAs) did not round every 2 hours and been going on for couple of months especially Monday's and weekends. She stated the matter was discussed at Resident council meeting before she rolled out of the room on her electric wheelchair. Interview on 5/20/25 at 10:45a.m., RN D stated not rounding every 2 hours would lead to terrible outcomes for residents, especially those in bed all the time. RN D stated she had complaints from the residents, that CNAs did not perform rounds every 2 hours at night, and she monitors staff, if she had to. Interview on 5/20/25 at 11:46a.m., CNA E stated most of the residents needed incontinent care and rounds should be performed every 2 hours to prevent sores, skin tears and infections. CNA E stated that at night, the staff do fall asleep. She said, we had in-services/meetings, but nothing changed. Interviews during Resident Council on, 05/19/2025 at 11:00am, revealed 12 confidential residents, stated the CNAs did not round every 2 hours at night. The Residents stated the lack of rounds being performed every 2 hours made them feel ignored, not a priority, and their needs were not being met. The Residents stated they informed the DON of the issue with rounding on the night shift when she attended Resident Council on 12/23/2024; however, the night CNAs continued to disregard rounding every 2 hours. The Residents stated the DON informed them during the council meeting she would complete an in-service with the night CNAs regarding the importance of rounding every 2 hours. In an interview on 5/20/2025 at 11:40am, the DON stated CNAs should be performing rounds at a minimum of every 2 hours. The DON stated rounds should be completed a minimum of every 2 hours during all shifts. The DON stated rounds were performed every 2 hours to ensure consistency and appropriate care for every Resident. The DON stated the potential negative outcome for rounds not being completed every 2 hours was residents not having their needs met and lack of care. In an interview on 5/20/2025 at 11:00am, the Activities Director stated CNAs not rounding every two hours was discussed in Resident Council every month for the past 6 months. The AD stated the Residents stated the evening/night nurses did not perform rounds every 2 hours; the CNAs were difficult to find at night and were often on their cell phones at the nurses' station or in the hallways speaking loudly and using inappropriate language while talking on their cell phones. The AD stated she had written and submitted grievances in regards to the absence of rounding at night and had included the complaint on her Resident Council notes. The AD stated she had also mentioned the complaint several times in morning staff meetings. In an interview on 5/20/2025 at 1:14pm, the ADM stated CNAs should perform rounds every 2 hours on all shifts. The ADM stated rounds were completed to ensure ADLs and to provide incontinent care. The ADM stated rounds every 2 hours were also completed to prevent skin breakdowns and ensure ADLs were met. The ADM stated the potential negative outcome for rounds not being completed every 2 hours was skin breakdown, emergencies, and falls. Record review of the facility's undated policy for ADL indicated Certified Nurse Aides (CNAs) must attend to the needs of all residents and provide the care that residents need at all times. 48275

Based on observation, interview, and record review, the facility failed to provide a private meeting space for residents' monthly council meetings for 12 of 24 confidential residents who were reviewed for resident council. The facility failed to provide a private space for resident council meetings. This failure could place residents at risk of not being able to voice concerns due to a lack of privacy. Findings include: Observation of dining room on 5/19/25 at 11:00AM revealed multiple staff in and out of the dining room, multiple residents in and out of the dining room who were not attending Resident Council, and several side conversations in the dining room due to Residents visiting family members in the dining room. Interview on 5/20/24 at 10:30AM, the Activities Director stated Resident Council was held in the dining room for the entirety of her employment with the facility, 18months. The AD stated it was not a private space; her sign posted during resident council asked staff not to enter the dining room was not respected. The AD stated there were no doors to close for the dining room. She stated there was no barriers to add doors to the dining room. The AD stated the potential negative outcome for no privacy for Resident Council was Residents may not speak freely in Resident Council due to staff overhearing their conversations. Interview on 5/20/25 at 11:00AM with 12 alert and orientated residents who attended resident council stated resident council met in the dining room. They stated staff came in and out with no privacy, and they filtered what they said due to staff presence. Residents stated the AD placed a large sign at the entrance to the dining room asking staff not to enter the dining room due to resident council being held; however, staff did not respect the sign. Interview on 5/20/25 at 1:40AM the Administrator stated that she was aware the facility did not have a private area for Resident Council to meet. She stated resident council was held in the dining room and they posted signs asking staff not to enter the dining room; however, the staff did not respect the sign. She stated she had not thought of privacy screens or meeting in the courtyard. She stated with weather permitting she would like to have meetings outside but had not thought of it. She stated the potential negative outcome of not having a private setting for Resident Council was the Residents may not feel comfortable sharing their needs, thoughts, feelings, and complaints. Record review of Resident Council Minutes dated 11/17/24 revealed Resident Council was held in the dining room with 5 residents present. Record review of Resident Council Minutes dated 12/23/24 revealed Resident Council was held in the dining room with 6 residents present. Record review of Resident Council Minutes dated 1/23/25 revealed Resident Council was held in the dining room with 6 residents present. Record review of Resident Council Minutes dated 2/18/25 revealed Resident Council was held in the dining room with 6 residents present. Record review of Resident Council Minutes dated 3/27/25 revealed Resident Council was held in the dining room with 6 residents present. Record review of Resident Council Minutes dated 4/24/25 revealed Resident Council was held in the dining room with 6 residents present. Record Review of the facility's Resident Council Policy Revised April 2017, revealed the following: Policy Statement The facility supports residents' rights to organize and participate in the Resident Council. Policy Interpretation and Implementation 1. The purpose of the Resident Council is to provide a forum for: a. Residents, families, and resident representatives to have input in the operation of the facility. b. Discussion of concerns and suggestions for improvement. c. Consensus building and communication between residents and facility staff; and d. Disseminating information and gathering feedback from interested residents. 2. All residents are eligible to participate in the Resident Council. The facility staff encourages residents who are willing to participate. 3. The council is encouraged to elect a President or Chair to act as a liaison and facilitate communication between the council and a designated staff person who has been approved by the Council. Staff, visitors, or other guests may attend Resident Council meetings if invited by the respective resident group. 4. Council meetings are scheduled monthly or more frequently if requested by residents. The date, time and location of the meetings are noted in the Activities calendar. 5. A Resident Council Response Form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible for addressing the item(s) of concern. 6. The Quality Assurance and Performance Improvement (QAPI) Committee will review information and feedback from the Resident Council as part of their quality review. Issues documented on council response forms may be referred to the QAPI Committee, if applicable (i.e., the issue is of serious nature or if there is a pattern, etc.).

Based on interviews and record review, the facility failed to ensure the resident had a right to personal privacy and confidentiality of his or her personal and medical records which included accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups for 12 of 12 confidential residents. The facility failed to ensure staff were not on their personal cell phones while providing care, which included peri-care to residents. This failure could place residents at risk of not having their personal privacy maintained during medical treatment. Findings include: Interview with 12 confidential residents stated the use of cell phones by CNAs while performing care made them feel ignored, not a priority, embarrassed, concerned the CNA could make a mistake due to distraction by the cell phone conversation, and, most of all, their privacy was violated. Interview with 12 confidential residents stated the use of cell phones by CNAs occurred on every shift; however, primarily occurred during the night shift. Interviewed with 12 confidental residents stated when they confronted CNAs about the cell phone usage while care was being performed the CNAs ignored them, the CNAs stated it was their right to utilize their cell phone, and CNAs informed the residents the use of the cell phone during care was none of the Residents' business. Interviewed with 12 confidental residents stated they did not know the names of the CNAs who utilized their cell phones while performing care. The residents stated cell phone usage of the CNAs while performing care happened in the facility so often, they would say every CNA in the facility utilized their cell phone while performing care. During an interview on 5/20/25 at 11:40am with the DON, she stated staff should provide privacy any time they were performing resident care. She stated cell phones should only be used in the break room and outside of the facility. The DON stated cell phones should never be used in resident rooms, in the hallways of the facility, or at the nurses' stations. The DON stated she and her ADON oversaw training staff on cell phone usage in the facility. The DON stated there was continuous education provided to staff concerning cell phone usage via team meetings and in-service trainings. She stated the DON and ADON monitored staff by observing and addressing grievances and complaints regarding cell phone usage while performing care. She stated there was no reason privacy for residents should not be provided. She stated the potential negative outcome was resident dignity, HIPPA violations, and disrespect for residents. She stated not providing privacy could also have a psychological effect like embarrassment for the resident. During an interview on 05/20/25 at 1:14pm, the ADM stated residents should be provided privacy during resident care. She stated all staff were trained on privacy, dignity, and cell phone usage during orientation and through continuous education by the DON and the ADON. She stated staff were monitored by making rounds and correcting any issues found, and by addressing complaints and grievances concerning cell phone usage by staff while performing resident care. She stated cell phones should never be used in resident rooms, hallways, or nurses' stations. She stated the potential negative outcome could be mess ups, not paying attention to residents' needs, and dignity. Record review of the undated facility policy titled Confidentiality of Information and Personal Privacy revealed the following: Policy Statement - Our facility will protect and safeguard resident confidentiality and personal privacy. Policy Interpretation and Implementation 2. The facility will strive to protect the resident's privacy regarding his or her: a. accommodations; b. medical treatment; c. written and telephone communications; d. personal care; e. visits; and f. family and resident group meetings.

Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 12 of 24 confidential residents. The facility failed to ensure 12 of 24 confidential residents were provided, through postings in prominent locations; the Grievance Procedure, were provided access to the Grievance form, were provided information regarding who the facility grievance officer was, their contact information, and how to file an anonymous grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings include: Interviews during Resident Council on, 05/19/2025 at 11:00am, 12 confidential residents, stated they did not know they could file a Grievance anonymously and they had not observed a posting of the Grievance procedure in prominent locations. Residents attending Resident Council stated there was no system for submitting a Grievance anonymously. The 12 residents in attendance had all been Residents of the facility for 6 plus months. Observed prominent postings on 5/19/2025 at 1:45pm; Grievance forms were available on the wall outside of the Social Worker's office, there were no instructions included for completing the Grievance form; there was no system indicated for submitting a Grievance anonymously. Interview with the ADM on 5/20/2025 at 1:14pm; the ADM stated the SW was the Grievance Officer for the facility. The ADM stated the SW was responsible for the review of Grievances and assign them to department heads. The ADM stated there was no system for submitting a Grievance form anonymously. Grievance forms are available for the Residents outside the SW's office, the Grievance forms were submitted to the SW by the Resident or their family member. The ADM stated the facility should resolve grievances as soon as possible once they were submitted. The ADM stated the procedure for submission of a Grievance was the SW assigned the grievance to the appropriate department, that department addressed the grievance, resolved the grievance, and explained the resolution to the complainant. The resolution was documented on the original Grievance form. The ADM stated completed Grievances were kept in a notebook. The ADM stated she monitored the Grievance process for success by following up with the staff member assigned to resolve the Grievance, the ADM stated she would also meet with the complainant to ensure they were satisfied with the resolution. The ADM stated she was responsible for ensuring staff were trained on the Grievance process. The ADM stated the potential negative outcome for Resident's not having a system to file Grievances anonymously was the Resident may not file a Grievance and the issue will not be resolved. Record Review of the Grievance Policy revised January 2017. Policy Statement Residents, family, and resident representatives have the right to voice or file grievances without discrimination or reprisal in any form, and without fear of discrimination or reprisal. You are requested to follow the procedures outlined below when filing grievance or complaint: 1. Obtain a Resident Grievance/Complaint Form from the nurses' station or from the business office. 2. Answer all questions on the form, as applicable. Be sure that all information is accurate. 3. You may sign the form, or file anonymously. 4. Give the completed form to the Administrator or his/her designee. If the Administrator is not available, you may leave the form with the supervisor on duty, or you may submit it anonymously to the appropriate person you wish to handle the grievance or complaint. 5. Within five (5) working days of the date you filed the grievance; you will be notified of the results of the investigation. (Note: Complaints of abuse, harassment, or mistreatment will be immediately investigated, and you may request a report of the findings, recommendations, and/or corrective action taken within five (5) working days of the filing of the report.) 6. Should you disagree with the findings, recommendations, or actions taken, you may meet with the Administrator, or you may file a complaint with any of the advocacy agencies listed on the residents' bulletin board. 7. It is the policy of this facility to assist you in filing a grievance or complaint. Should you feel that our staff has not assisted you in this matter, or you feel that you are being discriminated against for taking such steps, you are encouraged to report such incidents to the Administrator at once.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly for 3 of 4 medication carts (medication cart for hall 200, medication cart for hall 100, and nurse's medication cart for hall 200), reviewed for medication storage. The facility failed on 05/19/25 to maintain proper medication storage after the following was found: 1. The medication cart for 200 hall contained 10.5 loose pills. 2. The medication cart for 100 hall contained 3 loose pills. 3. The nurse's medication cart for hall 200 contained 10 loose pills. This failure could place residents at risk of not receiving prescribed medications as ordered and place the facility at risk of drug diversions. The findings included: 1. On 05/19/25 at 9:03 AM an observation of the medication cart for 200 hall was conducted with MA A. Ten and one-half loose pills were found in the drawers of the medication cart. MA A placed the pills in a dispensing cup and took the cup to the DON for medication identification. The DON identified the medications as followed: -Rosuvastatin 10 mg - used to lower cholesterol (one pill) -Mirtazapine 15 mg - used to treat depression (one pill) -Lasix 20 mg - used to treat swelling (one pill) -Omeprazole 20 mg - used to treat indigestion (one pill) -Pantoprazole 40 mg - used to treat heartburn (one pill) -Sertraline hydrochloride 50 mg - used to treat depression (one pill) -Keppra 500 mg - used to treat seizures (one pill) -Methocarbamol 500 mg - used to treat muscle spasms (one pill) -Eliquis 2.5 mg - used to prevent blood clots (one pill) -Atorvastatin 10 mg - used to lower cholesterol (one pill) -Lasix - strength unknown - used to treat swelling (1/2 pill) 2. On 05/19/25 at 9:46 AM an observation of the medication cart for 100 hall was conducted with MA A. Three loose pills were found in the drawers of the medication cart. MA A placed the pills in a dispensing cup and took the cup to the DON for medication identification. The DON identified the medications as followed: -Metoprolol 25 mg - used to treat high blood pressure (one pill) -Zofran 4 mg - used to prevent nausea and vomiting (one pill) -Amitriptyline - strength unknown - used to treat depression (one pill) During an interview on 05/19/25 at 9:51 AM, MA A stated there should not be loose pills on the medication cart. She stated she was not sure why there were loose pills on the medication carts for halls 100 and 200. She stated it was her responsibility to check the medication carts for loose pills. MA A stated the medication carts were periodically audited for loose medications by nursing administration and the Pharmacy Consultant. She stated a potential negative outcome of loose medications on the cart would be that a resident could miss a dose of medication. 3. On 05/19/25 at 10:15 AM an observation of the nurse's medication cart for 200 hall was conducted with RN C. Ten loose pills were found in the drawers of the medication cart. RN C placed the pills in a dispensing cup and took the cup to the DON for identification. The DON identified the medications as followed: -Famotidine - strength unknown - used to treat stomach ulcers (2 pills) -Ondansetron 4 mg -used to prevent nausea and vomiting (five pills) -Levothyroxine 100 mcg - used to treat low thyroid (one pill) -Clonidine 0.1 mg - used to treat high blood pressure (one pill) -Benzonatate 200 mg - used to treat cough (one pill) During an interview on 05/20/25 at 10:15 AM, RN C stated there should not be loose pills on the medication cart. She stated she did not know why there were loose medications on the cart. She stated the medication cards were very tight in the drawers and the pills sometimes get knocked loose from the blister packs. RN C stated it was the responsibility of the charge nurse to check the cart for loose medications. She stated the carts were audited periodically for proper medication storage by the Pharmacy Consultant and by nursing administration. RN C stated a potential negative outcome for loose pills on the medication cart would be the resident missing a dose of medication or the medication not being able to be reordered from the pharmacy. During an interview on 05/20/25 at 10:27 AM, the ADM stated she was not aware that there were loose medications on the medication carts for halls 100 and 200. She stated it was the responsibility of the charge nurse and medication aid to assure medications were properly stored on the medication carts. The ADM stated proper storage of medications on the carts was monitored through periodic cart audits conducted by nursing administration and the Pharmacy Consultant. She stated her expectation of staff for proper medication storage was to follow policy and routinely check carts for loose medications. The ADM stated a potential negative outcome for loose medications on the cart would be a resident missing a medication. During an interview on 05/20/25 at 10:46 AM, the DON stated there should not be loose medications on the medication carts. She stated the charge nurse or medication aid assigned to the cart was responsible to assure medications were stored properly. She stated staff were trained on proper medication storage and the medication carts were monitored through spot checks conducted by nursing administration. The DON stated the Pharmacy Consultant conducted cart audits approximately monthly to check for proper storage of medications. She stated a potential negative outcome for loose pills on the medication cart would be missed doses of medication for residents. Record review of the facility's policy titled, Storage of Medications, Revised April 2019, revealed: Policy Statement The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation . 2. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: The facility failed on [DATE] to seal and date food stored in refrigerator. The facility failed on [DATE] to ensure kitchen equipment was clean. These failures could place residents at risk for food contamination and foodborne illness. The findings included: The following observations were made on [DATE] at beginning 9:45 AM during initial tour of the kitchen: Observation of the following stored in dry storage room: 4 dessert cake pans with cake on rolling cart not covered. Large container of cornmeal with lid open. Observation of the following stored in the refrigerator: Bag of green beans with no date. Bag of corn with no date. Bag of spaghetti with meat sauce no date. Metal bowl of cooked beans with no date. Metal bowl of tartar sauce cups with no date. Observation of the Ice machine in dining room with cream color buildup in drip pan and on top beside ice spout. Observation of the Steam table with food residue on top and splatters on glass barrier. During a follow up visit and observation on [DATE] at 2:00 PM was a Bowl of cheese slices not covered stored in the refrigerator. During an interview on [DATE] at 9:10 AM the DM, who stated all items in the fridge and in the storage, room are to be labelled with date and sealed. She stated the dietary aides are responsible to monitor the fridge and dry storage rooms and she follows up daily. She stated anyone who puts food in the fridge for storage was responsible for dating and making sure it was sealed. The DM stated all staff have been trained and safe serve certificates are all current for the kitchen staff. DM stated the potential negative outcome could be bacteria in food and be harmful to resident. She stated it was maintenance responsibility to clean the ice machine in the dining room. DM stated the kitchen staff do not clean the ice machine. During an interview on [DATE] at 10:56 AM with ADM, she stated DM and staff were responsible for dating items in fridge and dry storage room and making sure all items are sealed. All staff have been trained on food storage in the refrigerator and dry storage . The facility policy was to have all items sealed and dated. She stated the possible negative outcome could be serving expired food to residents. During an interview on [DATE] at 12:00 PM with maintenance supervisor who stated he was not sure who cleans the outside of the ice machine. He stated he cleans the inside of the machine (filter and compressor) every 3 months. He stated, I guess everything is my responsibility. He stated he had not been trained on cleaning the outside of the machine. He stated it should be cleaned daily. During an interview on [DATE] at 12:10 PM with the ADM, she stated she was not sure who was responsible for cleaning the outside of ice machine. She stated she has reached out to corporate for clarification. During an interview on [DATE] at 12:33 PM with the maintenance supervisor, he stated I spoke with my supervisor at corporate and he stated the kitchen was responsible for daily cleaning of the outside of ice machine. Record review of the facility's policy, titled Food Receiving and Storage revised date 2014, reflected the following: Policy Statement- Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation . 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) . Record review of the facility's policy, titled Sanitization revised date 2014, reflected the following: Policy Statement - The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation . 12. Ice machines and ice storage containers will be drained, cleaned, and sanitized per manufacturer's instructions and facility policy . Record review of the FDA Food Code 2022 reflected the federally established standards.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 24 residents (Resident #73, #97 and #304) reviewed for infection control. 1. The facility failed on 05/18/25 to implement and maintain Enhanced Barrier Precautions physicians ordered on 04/16/25 when LVN B failed to wear proper PPE when providing wound care for Resident #97. 2. The facility failed on 05/19/25 to ensure proper medication administration infection control procedures were used when MA A failed to sanitize her hands before or after medication administration for Resident #73 and #304. These failures could place residents at risk for the spread of infection and cross contamination. Findings included: 1. Record review of Resident #97's face sheet dated 05/18/25 revealed a [AGE] year-old female with an admitted [DATE]. Resident #97 had diagnoses which included: pancreatitis (inflammation of the pancreas), dysphagia (difficulty swallowing), cognitive communication deficit (difficulty with communication), and cerebral infarction (stroke). Record review of Resident #97's admission MDS, dated [DATE], revealed a BIMS score of 14, which indicated the resident was mildly cognitively impaired. Record review of Resident #97's current physician's orders revealed an order with a start date of 04/16/25 for Nursing Intervention: Implement and maintain Enhanced Barrier Precautions when performing high contact care activities every shift. Further review revealed an order with a start date of 04/24/25 for daily wound care to the right lower leg and an order with a start date of 05/07/25 for daily wound care to left lower leg. During an observation of wound care on 05/18/25 at 11:35 AM for Resident #97, LVN B gathered supplies and entered the resident's room. Resident #97 was on Enhanced Barrier Precautions, per signage on the outside of the door. A PPE cart was observed at the entrance to Resident #97's room. LVN B washed her hands, applied gloves, and performed wound care on the right and left lower leg wounds, according to physician's orders. Following the procedure, LVN B removed her gloves, sanitized her hands and exited the room. LVN B failed to put on required PPE (gown) prior to performing wound care for Resident #97. During an interview on 05/18/25 at 11:40 AM, LVN B stated she did not put on a gown prior to performing wound care for Resident #97 because she did not remember the gown until she had already started the wound care procedure and it was too late at that point. She stated a gown should always be worn when performing wound care on a resident who was on EBP. LVN B stated she was trained on EBP through in-services conducted by the DON. She stated a potential negative outcome for failure to wear proper PPE during wound care for a resident on EBP would be wound infections from outside germs. 2. During an observation of medication pass on 05/19/25 at 9:36 AM, MA A prepared medications for Resident #73 and administered her medications. MA A did not sanitize her hands before or after medication administration. During an observation of medication pass on 05/19/25 at 9:46 AM, MA A prepared medications for Resident #304 and administered her medications. MA A did not sanitize her hands before or after medication administration. During an interview on 05/19/25 at 10:08 AM, MA A stated she did not sanitize her hands before or after administering medications to Resident #73 and Resident #304 because she changed to a different medication cart and forgot to set her sanitizer out on top of the cart. She stated hand hygiene should always be performed before and after handling and administering medications. MA A stated she was trained on hand hygiene during medication pass through in-services conducted by the ADON and through monthly medication administration skills checks. She stated a potential negative outcome for failure to sanitize hands before and after medication administration was spreading germs. During interview on 05/20/25 at 10:27 AM, the ADM stated nursing administration was responsible for training staff on proper hand hygiene and Enhanced Barrier Precautions. She stated her expectation of staff regarding hand hygiene and EBP was that they always follow policy for hand sanitizing during medication administration and always wear proper PPE when performing direct care on a resident on EBP. The ADM stated a potential negative outcome of failure to properly sanitize hands during medication administration and observe the rules of EBP would be the spread of infection. During an interview on 05/20/25 at 10:46 AM, the DON stated she and the ADON's were responsible for training staff on proper hand hygiene during medication administration and Enhanced Barrier Precautions. The DON stated proper PPE during wound care should include a gown and gloves. She stated hand hygiene should be performed before and after medication administration for each resident. The DON stated staff are trained on hand hygiene and EBP through competencies and in-services conducted monthly and as needed. She stated the facility planned to incorporate computer-based training for staff in the next month. The DON stated a potential negative outcome of failure to properly sanitize hands and observe the rules of EBP would be the spread of infection. Record review of the facility's polity titled, Implementation of Standard Transmission-Based Precautions, Dated March 2024, revealed: Policy Statement Infection control measures are implemented in attempts to prevent the spread of communicable diseases. . Policy Implementation . 3. Enhanced Barrier Precautions (EBP) - Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO to staff hands and clothing. . I. Examples of Enhanced-Based Precaution residents: -Wounds - includes chronic wounds, but are not limited to pressure ulcers, diabetic ulcers, unhealed surgical wounds and venous stasis ulcers; II. Enhanced-Based Precautions are indicated during: -Wound care; any skin opening requiring dressing. Record review of the facility's policy titled, Administering Oral Medications, Revised October 2010, revealed: Purpose The purpose of this procedure is to provide guidelines for the safe administration of oral medications. . Steps in the Procedure 1. Wash your hands . 21. Remain with the resident until all medications have been taken. . 23. Perform hand antisepsis. Record review of the facility's policy titled, Handwashing/Hand Hygiene, Revised December 2023, revealed: Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation . 2. All personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. . 7. Use an alcohol-based hand rub containing at least 60 - 90% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . b. Before and after direct contact with residents; c. Before preparing or handling medications;

Based on observations, interview and record review, the facility failed to treat each resident with respect and dignity, and care for each resident in a manner and environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident individuality and protected and promoted the rights of the resident personal privacy for each resident's individuality for 1 of 24 residents (Resident #254) reviewed for dignity in that: The facility failed to ensure Resident #254's Condom catheter bag had a privacy cover on it to provide respect and dignity. This failure placed residents in the facility, with Condom catheters, at risk of feeling uncomfortable or embarrassed and decreased privacy. Findings included: Record review of Resident #254's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #254 diagnoses which included: Chronic kidney disease (a progressive condition where the kidneys gradually lose their ability to filter waste and excess fluid from the blood), Constipation (problem with passing stool), Muscle weakness (a decrease in the strength and ability of muscles to perform their normal functions, often resulting in a reduced ability to move the body) and Calculus of kidney (hard deposits that form in the kidneys from minerals and salts in urine). Record review of Resident #254's undated care plan, revealed Resident #254 had a Condom catheter and he needs prompt response to all requests for assistance due to risk for falls. Record review of Resident #254's Physician Orders, dated 05/18/2025, revealed: Catheter: urinary catheter monitor urine consistency,1 = clear, 2 = cloudy, 3 = mucus every shift, .Catheter: urinary catheter provides catheter care with approved cleaning agent every shift, .Catheter: change catheter as needed for occlusion or leakage. Observation on 05/18/2025 at 12:58 p.m., revealed the resident #254 was at the dining hall and had a condom catheter bag hanging on the side of his electric wheelchair and was visible to anyone who was at the dining area. The bag contained a yellow fluid and did not have a cover to provide privacy. During a follow-up observation and interview on 05/19/2025 at 09:22 a.m., revealed Resident #254 was in his electric wheelchair, with the room door open. Resident #254's condom catheter bag was on the left side of the electric wheelchair, facing the door. The condom catheter drainage bag was visible through the open door and not in a privacy bag. Resident #254 stated the staff provided care every day, but without privacy bag in place since he had the condom catheter a month ago. During an interview with RN D on 05/20/2025 at 10:45 a.m., RN D stated she was the charge nurse and condom catheters should be covered with privacy bags. RN D said she was not aware Resident #254 did not have a privacy cover over his condom catheter bag. She stated the nurses and CNAs were responsible for ensuring the privacy covers were on the bags. RN D stated the covers were important to maintain privacy and dignity. During an interview with CNA E on 05/20/2025 at 11:06 a.m., CNA E stated the nurses and CNAs were responsible for placing the privacy covers over the bags and stated she did inform the charge nurse each time about the privacy covers. CNA E stated the privacy bags were important because without such Resident's dignity were lowered and stated she empty the condom catheter bag whenever it was full. During an interview with the DON on 05/20/2025 at 01:24 p.m., the DON stated the charge nurse and CNAs were responsible for making sure catheter bags had privacy covers. The DON stated all residents should have privacy covers on the condom catheter, and it was important for the resident's dignity and their right to privacy. During an interview with the ADM on 05/20/2025 at 02:01 p.m., the ADM stated the condom catheter bags should be covered due to dignity issues, Residents would not be comfortable and could cause embarrassment. The ADM stated CNAs were responsible for placing the privacy covers. Record review of the facility's Policy titled, Resident Rights (Revised October 2022), stated in part, that a resident has right to a dignified existence; to be treated with respect, kindness, and dignity; exercise his or her rights as a resident of the facility and as a resident or citizen of the United States; the right to privacy and confidentiality.

Based on observation, interview, and record review the facility failed to ensure that its medication error rate was not 5 percent or greater. The facility had a medication error rate of 8.0% based on 2 errors out of 25 opportunities, which involved 2 of 3 residents (Resident #8 and Resident #304) reviewed for medication administration. 1. MA A failed to properly verify and dispense Eliquis (blood thinner) according to physician's order with a start date of 12/04/24 for Resident #304, when on 05/19/25 MA A dispensed and was going to administer Resident #304 with one 2.5 MG tablet instead of two 2.5 MG tablets until surveyor intervention. 2. MA A failed to administer Vitamin A (supplement) according to physician's order dated 05/13/25 to Resident #8, when on 05/19/25 MA A was unable to administer the Vitamin A supplement to Resident #8, resulting in a missed dose. These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health. Findings included: 1. Record review of Resident #304's face sheet dated 05/20/25 revealed a [AGE] year-old female with an original admitted [DATE]. Resident #304 had diagnoses which included: cerebral infarction (stroke), peripheral vascular disease (reduced blood flow to limbs), hypertension (high blood pressure), and atherosclerotic heart disease (damage of the major blood vessels). Record review of Resident #304's Quarterly MDS, dated [DATE], revealed a BIMS score of 11, which indicated the resident was moderately cognitively impaired. Record review of Resident #304's current physician's orders revealed an order with a start date of 12/04/24 for Eliquis Oral Tablet 2.5 MG, give 5 MG by mouth two times a day. During a medication administration observation on 05/19/25 at 9:03 AM for Resident #304, MA A dispensed one Eliquis 2.5 MG tablet into a medication cup. Observation of the medication card and order for Resident #304's medication - Eliquis 2.5 MG showed: give two tablets by mouth two times daily. MA A picked up the medication cup and entered the resident's room to administer the medication. After surveyor intervention, MA A returned to the cart, verified the order, and dispensed an additional Eliquis 2.5 MG tablet into the medication cup and administered the medication to Resident #304. During an interview on 05/19/25 at 9:09 AM, MA A stated she failed to verify and dispense the correct dose of Eliquis medication for Resident #304. She stated she failed to read the order correctly and only dispensed one tablet instead of two, which would have resulted in Resident #304 being underdosed. MA A stated she had been trained on accuracy of medication administration through in-services and skills checks conducted by nursing administration. She stated a potential negative outcome for failure to administer medications according to physician's orders would be the resident getting sick. 2. Record review of Resident #8's face sheet dated 05/20/25 revealed an [AGE] year-old female with an original admitted [DATE]. Resident #8 had diagnoses which included: unspecified muscle disorder, gastric ulcer (a break in the lining of the stomach), glaucoma (condition causing gradual loss of sight), kidney failure, and hypertension (high blood pressure). Record review of Resident #8's Admission MDS, dated [DATE], revealed a BIMS score of 12, which indicated the resident was moderately cognitively impaired. Record review of Resident #8's current physician's orders revealed an order with a start date of 05/13/25, for Vitamin A Oral Capsule 3 MG (10000UT), give 1 capsule by mouth one time a day for supplement. During a medication administration observation on 05/19/25 at AM 9:46 AM for Resident #8, MA A verified the physician's order for Vitamin A and determined the medication was not available on the medication cart. MA A stated a note in the MAR indicated the medication was on order. MA A checked the medication room and determined the medication was not available in the facility. MA A was unable to administer the medication to Resident #8, resulting in a missed dose. During an interview on 05/19/25 at 9:53 AM, MA A stated she was not able to administer Resident #8's Vitamin A medication according to physician's orders due to the medication not being available in the facility. She stated the medication had been ordered, according to the notation in the MAR. She stated she did not know why the medication was unavailable and her protocol was to let the DON know so the medication could be obtained. MA A stated a potential negative outcome for failure to administer medications according to physician's orders would be the resident getting sick. During an interview on 05/20/25 at 10:27 AM, the ADM stated medications should be given according to physician's orders. She stated the DON was responsible to assure staff were trained on accuracy of medication administration and the timely acquisition of medications. She stated the system to monitor for proper medication administration was periodic skills checks conducted by nursing administration and medication pass observations conducted by the Pharmacy Consultant. The ADM stated her expectation of staff was to follow the five rights of medication administration. She stated a potential negative outcome for failure to administer medication according to physician's orders would be the resident missing a dose of medication. During an interview on 05/20/25 at 10:46 AM, the DON stated she was made aware that there were medication errors made during medication pass observation. She stated staff were in-serviced on verification of physician's orders and timely ordering of medications. The DON stated staff were monitored for accuracy of medication administration through competency checks and periodic medication pass observations conducted by nursing administration. She stated a potential negative outcome for failure to administer medications according to physician's orders would be complications or harm to a resident's health. Record review of the facility's policy titled, Administering Oral Medications, Revised October 2010, revealed: Purpose The purpose of this procedure is to provide guidelines for the safe administration of oral medications. . Steps in the Procedure . 3. Place the MAR within easy viewing distance. . 6. Check the label on the mediation and confirm the medication name and dose with the MAR. . 8. Check the medication dose. Re-check to confirm the proper dose. 9. Prepare the correct dose of medication.

Based on observation, interview, and record review the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for 1 of 24 residents (Resident #8) reviewed for dental services. The facility did not assist Resident #8, who had missing teeth, with a dental service consult. This failure could place residents at risk of oral complications, dental pain, and diminished quality of life. Findings included: Record review of Resident #8's face sheet showed a [AGE] year-old woman, who was admitted on [DATE]. Diagnoses included: Cerebral infarction (referred to as a stroke, means the death of brain muscle due to a reduced blood supply), Chronic obstructive pulmonary disease (a progressive lung disease that makes it hard to breathe), Constipation (problem with passing stool), Muscle weakness (a decrease in the strength and ability of muscles to perform their normal functions, often resulting in a reduced ability to move the body), Heart Failure (condition in which the heart does not pump blood as well as it should), Diabetes Mellitus (long term condition where body has trouble controlling blood sugar and using it for energy), Cognitive communication deficit (difficulty with any aspect of communication that is affected by disruption of intellectual processes like attention, memory). Record Review of Resident #8's quarterly MDS dated [DATE], revealed a BIMS score of 09 slightly cognitively impaired. Record review of Resident #8's Care plan showed resident has an ADL self-care performance deficit and personal hygiene requires No assistance. The care plan also reflected the resident had behaviors which included non-compliance with Lasix medication that treats fluid retention caused by Heart failure. Record Review of Resident #8's Oral Care showed she had tooth extractions without replacement since 02/13/2023. Interview and Observation on 5/18/25 at 01:23 p.m. with Resident #8 stated I asked them to fix my teeth though no pains, resident placed her hand over her mouth showing portions of tooth extraction with no replacement. Resident #8 raised her seven fingers which implied 7 months, when asked how long she has been waiting for approval for dental follow up. Observation of Resident #8's upper and lower gums had no artificial teeth (denture) on them. Interview on 5/19/25 at 11:31 a.m. with SW stated they were waiting for resident #8 dental approval from Cooperate or the ADM (No document seen/reviewed or provided). SW stated not sure how long the time process was for resident #8 to get the approval for her dentures. Interview on 5/20/25 at 10:45 a.m. with RN D stated she would immediately let the SW, Physician or NP (Nurse Practitioner) know if there were any dental issues. RN D stated delay in Resident #8 dental services would affect her dignity and lower her level of socialization. Interview on 5/20/25 at 11:46 a.m. with CNA E stated if a resident had dental problems, she would let her nurse know and she had not done any dental care on Resident #8. Interview on 5/20/25 at 1:24 p.m. with DON stated the social worker made the dental appointments. Usually, if resident had painful teeth or something with their mouth, they would contact the Physician or NP immediately. Interview on 5/20/25 at 02:01 p.m. with ADM stated only records found was Resident #8's extractions and no other information regarding the referrals to the surgeon and the progress of her dental services till date. ADM stated facility had quarterly visit by the dentist. Then, a letter for dental approval was sent off to Resident #8' for the in-house dental services and she was not sure of the date the letter was sent. Record Review of facility policy Dental Services revised December 2016, under Policy stated, Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Record Review of facility policy Routine Dental Care revised April 2007, under Policy stated, Each resident will receive routine dental care. Record Review of facility policy Quality of Life - Dignity revised October 2022, stated Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality.

Based on interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of property and exploitation for 1 of 3 residents (Resident #1) reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Resident #1's Morphine Medication. This failure could place residents at risk for not receiving prescribed medication. Findings include: Record review of Resident #1's, undated, face sheet revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had diagnoses which included: dementia (loss of remembering), anxiety (feeling of uneasiness), dysphagia (swallowing difficulties), Cognitive communication deficit (difficulty communication) and chronic pain (long lasting pain). Record review of a Resident #1's quarterly MDS, dated [DATE], revealed a BIMS of 11, which indicated cognitively intact. Record review of Resident #1's physician orders, dated 02/25/25, revealed an active order for Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 0.25 ml by mouth every 4 hours as needed for pain. Ordered on 09/28/2024. Record review of Resident #1's Individual Control Drug Record Narcotic Count sheet for the Morphine Sulfate Oral Solution revealed the facility received the medication from the pharmacy on 09/20/24 and quantity received 30ml. The record revealed one dose of medication administered on 01/26/25. During an interview on 02/25/25 at 10:15 AM, the ADM stated she worked with the DON on the investigation of the 29.50 ML missing morphine. She stated the best she could tell was the morphine had to have gone missing on the weekend of 02/08-09/25. She stated RN B completed the medication cart and narcotic count and LVN A did not call out the morphine for Resident #1, and since there was not a bottle of morphine in the medication cart, RN B didn't realize something was missing. During an interview on 02/25/25 at 12:50 PM, LVN A stated she worked a double shift on 02/08/25 and 2/09/25 and the morphine was discovered missing on 02/10/25. She stated she couldn't recall which nurses she worked with the weekend of 02/08-09/25 but was able to recall she counted the medication cart not the papers in the narcotic book when she started her shift. She stated she did not recall morphine being counted for Resident #1 that weekend. She stated when she went on shift, she counted the medications in the cart not the papers in the narcotic book, the off going nurse counted the medications in the book. She stated when she finished her shift on 02/09/25 she counted the paper in the narcotic book and RN B counted the medications in the cart. She stated she did not see a paper for the morphine for Resident #1. She stated she did not know the morphine was missing until Monday 02/10/25 when she received a call and was asked about the morphine. During an interview on 02/25/2025 at 1:10 PM, the DON stated she interviewed staff who worked before, during and after the weekend of 02/08-09/25 and RN B stated when doing the medication cart and narcotic book, LVN A did not call out the morphine from the narcotic book, and RN B did not know the morphine was missing until change of shift on the morning of 02/10/25 when counting with LVN C. She stated she spoke with LVN A and stated, something like that happened at another facility I worked at and it was an agency nurse that took it. She stated LVN A told her she was only calling out the medication from the book she knew were in the cart. The DON stated Resident #1 did not have any increased pain or negative outcome as the morphine was ordered as needed, and Resident #1 did not take the morphine. During an interview on 02/25/25 at 2:06 PM, Resident #1 could not answer questions about her medication and stated, leave me alone and get out. During an interview on 02/25/25 at 2:30 PM, LVN D stated she worked the day shift on 02/08/25 and the morphine for Resident #1 was in the cart and counted on 02/08/25. She stated at the end of her shift on 02/08/25 she counted the medication cart and narcotic book with LVN A and everything was in the medication cart and narcotic book. She stated she did not work on Sunday, 02/09/25. During an interview on 02/25/25 at 3:09 PM, RN B stated she worked 10PM -6AM on 02/09/25. She stated when she started her shift, at 10PM, on 02/09/25, she counted the medication cart and narcotic book with LVN A. She stated LVN A did not call out the morphine from the narcotic book, so she was not aware at that time the morphine was missing. She stated the following morning on 02/10/25, LVN C arrived for work and around 6AM they were counting the cart and narcotic book and LVN C called out the morning for Resident #1 and that was when they started looking for the morphine. She stated they did not locate the morphine, and they notified the DON and ADM the morphine was missing. During an interview on 02/25/25 at 3:20 PM, LVN C stated when she arrived for work on 02/10/25 while counting the medication cart and narcotic book she noticed the morphine was in the narcotic book and there was not any morphine for Resident #1 in the medication cart. She stated she asked RN B where the morphine was, and RN B did not know. She stated she spoke with LVN D, and LVN D remembered she saw the morphine for Resident #1 in the medication cart the weekend of 02/08-09/25. Record review of the facility's in-service: Drug Pass, dated 02/10/24, revealed 9 staff received in-service drug pass, and reviewed the policy titled Reporting Suspicion of a Crime. Record review of the facility's policy Reporting Suspicion of a Crime, dated 2001, with a revised date of July 2017, revealed the following: Policy Statement The Administrator, Director of Nursing, or any other designated individual will report (within the required time frames) any reasonable suspicion of a crime against a resident to the state Survey Agency and local law enforcement agency. Employees will be protected against retaliation for reporting any reasonable suspicion of a crime against a resident. 3. Each covered individual must report to the state Survey Agency and at least one local law enforcement agency any reasonable suspicion of a crime against a resident of the facility. d. Examples of crimes that would be reportable in any jurisdiction include but are not limited to: (6) Theft/robbery (7) Drug diversion for personal gain or use Record review of the facility's policy Controlled Substances, dated 2001, with a revised date of December 2012, revealed the following: Policy Statement The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. Policy Interpretation and Implementation Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services.

Based on observations, interviews, and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 3 of 3 residents (Residents #1, #2 and #3) reviewed for infection control. 1. CNA A failed to utilize hand hygiene during incontinence care for Resident #1. 2. CNA B failed to utilize hand hygiene during incontinence care for Resident #2. 3. CNA C failed to utilize hand hygiene during incontinence care for Resident #3. These failures could place residents at risk for infection and cross contamination. Findings included: Resident #1 Record review of Resident #1's face sheet revealed an [AGE] year-old female originally admitted on [DATE]. Resident #1 had a medical history of cerebral infarction (lack of oxygen to brain due to clot), muscle weakness, and hypertension (high blood pressure). Record review of Resident #1's quarterly MDS assessment dated [DATE], Section C- Cognitive patterns revealed Resident #1 had a BIMS score of 05 which indicated Resident #1 had severe cognitive deficit. Section H- Bladder and bowel revealed Resident #1 was always incontinent of bowel and bladder. Record review of Resident #1's care plan dated 6/25/24 revealed The resident has bowel and bladder incontinence. Check Q 2 hours and as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. During an observation on 8/8/2024 at 11:50 PM, CNA A washed her hands with soap and water and donned clean gloves. CNA A unfastened Resident #1's brief, cleaned with wet wipes, rolled Resident #1 onto her left side, and cleaned Resident #1's buttocks with wet wipes. CNA A removed the dirty brief and doffed dirty gloves. CNA A donned clean gloves and placed a clean brief on Resident #1. CNA A failed to utilize hand hygiene between glove changes. During an interview with CNA A on 8/9/2024 at 12:59AM, she stated she had been trained on hand hygiene between glove changes and hand hygiene and her last training was sometime this year. CNA A stated the infection preventionist was the DON. CNA A stated the potential negative outcomes of not utilizing hand hygiene is spreading germs from residents to caregivers or to other residents. CNA A stated she was nervous and realized afterwards that she had missed some steps. Resident #2 Record review of Resident #2's undated face sheet revealed a [AGE] year-old female originally admitted on [DATE]. Resident #2 had a medical history of cerebral palsy (weakness in or problems with using the muscles), dysphagia (trouble swallowing), neuromuscular dysfunction of bladder (the nerves and muscles don't work together very well) and multiple sclerosis (chronic disease of the central nervous system). Record review of Resident #2's quarterly MDS assessment dated [DATE], Section C- Cognitive patterns revealed Resident #2 had a BIMS score of 15 which indicated Resident #1 was cognitively intact. Section H- Bladder and bowel revealed Resident #2 was always incontinent of bladder. Record review of Resident #2's care plan dated 5/04/24 revealed The resident has bladder incontinence. Check Resident #2 as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. During an observation on 8/9/2024 at 12:04 AM CNA B washed her hands with soap and water and donned clean gloves. CNA B unfastened Resident #2's brief and cleaned the residents front with a wet wipe. CNA B doffed dirty gloves and donned clean gloves. CNA B wiped Resident #2s front again with a wet wipe and doffed dirty gloves. CNA B donned clean gloves and assisted Resident #2 onto her left side. CNA B cleaned Resident #2's buttock with a wet wipe and removed the dirty brief. CNA B grabbed a clean brief with contaminated gloves and placed the brief onto Resident #2. CNA B doffed dirty gloves and removed the dirty trash bag. CNA B washed her hands with soap and water. CNA B failed to utilize hand hygiene between glove changes and failed to change gloves before grabbing the clean brief. During an interview with CNA B on 8/9/2024 at 12:20AM she stated she had no training on hand hygiene or infection control. CNA B stated they had an in-service on hand hygiene but did not know when. CNA B stated she did not know who the Infection Preventionist was. CNA B stated a potential negative outcome of not utilizing proper hand hygiene between glove changes could be passing on germs. CNA B stated she knew she had messed up during the incontinence care. Resident #3 Record review of Resident #3's undated face sheet revealed a [AGE] year-old male originally admitted on [DATE]. Resident #3 had a medical history of neuroleptic induced parkinsonism (Parkinsonism a term used to describe the collection of signs and movement symptoms caused by antipsychotic medication), type 2 diabetes, and psychotic disorder with delusions (false beliefs that are not based on reality). Record review of Resident #3's quarterly MDS assessment dated [DATE], Section C- Cognitive patterns revealed Resident #3 had a BIMS score of 03 which indicated Resident #3 had severe cognitive deficit. Section H- Bladder and bowel revealed Resident #3 was always incontinent of bowel and bladder. Record review of Resident #3's care plan dated 5/10/24 revealed Resident #3 bladder incontinence. Check Resident #3 as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. During an observation on 8/9/2024 at 11:05 AM, CNA C washed her hands with soap and water and donned clean gloves. CNA C unfastened Resident #3's brief and cleaned resident with wet wipes. Resident #3 turned to his left side and CNA C clean his buttocks with wet wipes. CNA C removed Resident #3's brief and placed a clean brief on the resident. CNA C doffed dirty gloves and washed her hands with soap and water. CNA C failed to change gloves throughout the incontinence care. CNA C failed to utilize hand hygiene during the incontinence care. During an interview with CNA C on 8/9/2024 at 11:30AM, she stated the IP is the ADM. CNA C stated she has been trained on hand hygiene and her last training was a couple months ago. CNA C stated hand hygiene should occur before and after care and in between care. She stated hand hygiene should occur between glove changes, or if you take off your gloves. CNA C stated the potential negative outcome of not utilizing hand hygiene between glove changes could be spreading infection and the residents getting sick from that infection. CNA C stated she was nervous to do incontinence care. She stated they had told her to come do care and did not feel like she had time to prepare. She stated she had been trained as a CNA in the hospital and not a nursing facility and she feels it is different. During an interview with DON on 8/9/2024 at 12:25PM, she stated the IP is the ADON. She stated the IP is responsible for hand hygiene and infection prevention training. She stated training is done monthly on a random selection basis. She stated 15 employees are picked a month and they are observed on hand hygiene and how to don and doff PPE. The DON stated night shift staff is also included in these training. She stated the potential negative outcomes of not utilizing hand hygiene is spreading diseases to residents and to staff members. She stated staff should be washing their hands when going into a room, coming out of a room, and between glove changes or if their gloves are soiled. She stated staff can use soap and water or ABHS. The DON stated she was not aware they were not utilizing hand hygiene between glove changes. During an interview with the ADM on 8/9/2024 at 12:41 PM, he stated the IP is the DON and the ADON, but they all have the training. He stated training on hand hygiene is done quarterly and the last training was last month. The ADM stated they have a schedule, and they observe and do the check offs with staff on hand hygiene. He stated the DON or ADON will come in on night shift and do competencies with them as well. He stated the potential negative outcome of not utilizing hand hygiene between glove changes could be infection. The ADM stated hand hygiene should occur before, during and after care and anytime gloves are removed. The ADM stated he was not aware of staff not utilizing hand hygiene between glove changes. During an interview with the ADON on 8/9/2024 at 12:55 PM she stated she was the IP. She stated she had done training on hand hygiene, and it is done monthly. She stated the new hire staff are trained separately before they begin to work with residents. The ADON stated during the checkoff she monitors how staff washes their hands, how they dry their hands and if they are using enough soap and water. She stated she does the same for the night shift staff and comes in and observes their hand hygiene technique. She stated the potential negative outcomes of not utilizing hand hygiene between glove changes could be spreading infection and transferring it to other residents or their own family. She stated hand hygiene should occur before, after and during incontinence care. She stated staff should be changing gloves and using ABHS or washing their hands with soap and water between glove changes. The ADON stated she was not aware of staff not utilizing hand hygiene between glove changes. She stated they would be doing an in-service that will address handwashing and glove changes. Record review of facility policy titled, Infection Prevention and Control Program, last revised August 2016 revealed: 1. The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. 2. The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. Record review of facility policy titled Handwashing/Hand Hygiene, last revised on December 2023 revealed: Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections . 7. Use an alcohol-based hand rub containing at least 60 - 90% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . . j. After contact with blood or bodily fluids. .h. Before moving from a contaminated body site to a clean body site during resident care; .m. After removing gloves.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. 1) The facility failed to protect foods from potential contamination. 2) The facility failed to ensure foods were not expired. These failures could place residents at risk for food contamination and foodborne illness. The findings included: - The following observation was made during a kitchen tour on [DATE] that began at 10:00 AM and concluded at 10:35 AM: -An opened bag of potato chips on the counter, open date [DATE]. -An opened bag od bologna in the fridge, open date [DATE]. -an opened gallon jug of milk in the fridge, best by [DATE]. -an opened bag of shredded cheddar cheese in the fridge; open date [DATE]. -an opened container of boiled eggs, best by [DATE]. -2 stacks of small bowls stored right side up in the dish washing room. Interview on [DATE] at 2:49 PM, the Dietary Manager stated all the dietary staff were responsible for ensuring food items were secure and not expired. The Dietary Manager stated she did not know how the items were missed. The Dietary Manager stated she was responsible for ensuring food items were secure and not expired. The Dietary Manager stated the staff believed the opened food items were closed all the way and they were not. The Dietary Manager stated she trains staff regularly via in-services and she would be able to provide copies. The Dietary Manager stated the potential negative outcomes to the residents were the food may not taste as good or the residents could be given expired food items. Interview on [DATE] at 3:37 PM, the Dietary Manager stated she was unable to access her previous in-services regarding food storage and food palatability due to technological issues. Interview on [DATE] at 11:55 AM, the ADM stated he expects dietary staff to make sure food containers were sealed and not expired. The ADM stated the Dietary Manager was responsible for making sure foods were properly sealed and not expired. The ADM stated he did not know why these items were missed in the kitchen. The ADM stated the potential negative outcomes to the residents were expired food was bad food and unsealed food would not stay fresh. Record review of the facility policy and procedure titled, Food Storage, dated 2021, reflected the following: Policy: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry and free from contaminants. Food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination

Based on observations, interviews and record review, the facility failed to make residents and residents' family members aware of the grievances process and allow them to exercise their right to file a grievance leading to the facility not addressing the grievances of residents. According to the facilities' grievance policy the facility failed to make prompt effortsto resolve grievances for 5 of 26residents. The facility failed to provide residents and family members follow up communication and resolutions to filed grievances. The facility failed to file and resolve a grievance for Resident #80 regarding missing laundry. The facility failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings include: During the survey process for the infection control task, it was determined that the laundry services staff members were not allowing residents enough time to locate lost clothing. Laundry was only holding lost clothing for 7-10 days and then placing the items in the hallway for anyone to reclaim. Observation of laundry services on 04/11/2024 at 8:05 AM., revealed a rack in the laundry facility with lost clothing items. Observation of the rack that was also outside the laundry services with items that were give away clothing. It was said by the laundry staff member and laundry supervisor that the rack outside was strictly for give away clothing. Interview with Resident #80 during resident sample selection for survey process on 04/09/24 at 11:30 AM. Resident #80 stated that she is missing 2 brand new bras, 2 gowns, and a t-shirt with ice cube on it. Resident # 80 stated that she had notified the Administrator and was told that he would look into it and see what he could find and let her know but no one had let her know anything. Resident # 80 stated that had been three or four months ago. Interview with the laundry Staff member on 04/11/2024 at 8:05 AM., the laundry staff member stated that when there were lost clothing it was placed on the back rack and labeled for the date that it became missing. The laundry staff member stated that when the clothing has been held in the laundry room for the 7 to 10 days then it was placed on a rack in the hallway for anyone who wants the clothing. The laundry staff member stated that they do not attempt to take the clothing around to the residents. The laundry staff member stated that for the residents that were not able to get to the laundry, she The laundry staff member stated that the only negative potential outcome that she can name was if the resident was not able to get more clothing and ran out of clothes. Interview with the laundry Supervisor on 04/11/2024 at 8:32 AM., the laundry Supervisor stated that lost or missing clothing was only held in the laundry room on the rack for 7 to 10 days and then was placed in the hallway for anyone to grab what they want out of it. The laundry Supervisor stated that they do not take the clothes around to the residents because they do not have the time to do that. The laundry Supervisor stated that if the resident realizes that they were missing clothing they were welcome to come and check as long as it was within the 7 to 10 days and if it was outside of the timeframe then hopefully the items will still be on the rack outside of the laundry room. The laundry Supervisor stated that she felt that was enough time for a resident to know if they had lost clothing or not. Interview with the Administrator on 04/12/2024 at 11:55 PM., the Administrator stated that he does know that the resident's do need more time to locate their lost laundry or items. The Administrator stated that he did not know that this was how the laundry was being handled but he will get with the Laundry Supervisor to come up with a better plan for the residents to have more time to retrieve their clothing. The Administrator stated that the negative potential outcome of not being able to get lost laundry back to the resident possession was that they may be left with nothing to wear, and it cost the residents money on a fixed income, and they may not be able to afford it. Record review of the Resident Council Meeting on 4/10/24 at 10:00am revealed Residents in the group meeting did not know how to file a grievance, Residents did not know where to acquire a grievance form, who to turn the form into, and what happens once a grievance was filed. 12 Residents attended the meeting, none of the Residents who attended the meeting were new Admits. Interview on 4/11/24 at 2:45 PM, the Activity Director confirmed she had never discussed Grievances in Resident Council as she too does not know the Grievance procedure. The AD stated she was hired for her position in September 2023, the AD stated she was not trained for the AD position, the AD stated she was shown her office and told she needed to develop an Activities Calendar. The AD stated she was a licensed AD, however, she has no experience with the AD position and she was not trained. The AD stated she has not been told the Grievance procedure and she did not know there was a Grievance policy she could request to review. The AD stated she does not know what complaints reported in Resident Council warrant the AD filing a Grievance. The AD stated she has not documented resident complaints on the Resident Council notes as she did not know what to include on Resident Council notes. The AD stated she did not understand, nor had she been trained on the importance of a Grievance or that a Grievance needed to be followed up on by the facility. Interview and record review on 4/11/24 at 4:19PM, Confidential family member stated she has complained to the DON about her concerns regarding her mother's weight loss, diet, and quality of care; she has never been informed of the grievance procedure, told the DON would file a grievance for her, and she has not been offered a grievance form to complete. The Family member stated she has never received follow up communication to any of her concerns. The Family member stated she has never been informed of a resolution or asked if she agrees to the resolution. The Family member stated she feels there was a lack of communication with the DON and the ADM; the family member does feel heard when she shares concerns and when she was told she will receive follow up communication, the follow up communication does not happen. The Family member stated to her knowledge there are no grievance forms available for residents or family members to voice grievances or concerns independently. The Confidential family member stated she has never seen the grievance form and never received a copy of a completed grievance form once the grievance has been resolved. Per the grievance form and the grievance policy the Resident named in the grievance form was required to receive a copy of the resolved grievance form or the Resident's Representative was required to receive a copy of the resolved grievance form. Surveyor reviewed the grievances for April 2024, a grievance was written in regard to the confidential family members complaints on 4/1/2024. The form was completed by the ADON, the grievance stated the confidential family member heard a nurse in the secure unit being rude and hateful to residents, the report also stated the family members' resident was sent with her on Easter Sunday with a soiled brief and no briefs were sent with the resident for the outing. The findings of the investigation stated the nurse was not rude and the resident was sent with the family member with a clean brief when she left the facility. The plan to resolve the complaint on the grievance form was blank, results of action taken was blank on the grievance form, the entire Resolution portion of the grievance form was blank, and there was no documentation of follow up with the family member filing the grievance, no documentation of the family member being given a copy of the grievance, and no signature from the family member filing the grievance. 04/11/2024 at 9:15am Surveyor attempted to complete a telephone interview with a confidential family member named in an incomplete grievance report. Surveyor left vm for family member. 04/12/2024 at 9:45am Surveyor made a second attempt to complete a telephone interview with the confidential family member, left voicemail. The complaint voiced by the family member was documented on a grievance by the SW concerning rude nursing staff and call lights not being answered in a timely manner. The grievance form was not complete: the Documentation of Investigation portion was blank, the Resolution section was blank, there was no documentation of follow up with the family member filing the grievance, no documentation of the family member being given a copy of the grievance, and no signature from the family member filing the grievance. 04/11/2024 at 9:15am Surveyor attempted to complete a telephone interview with a confidential family member named in an incomplete grievance report. Surveyor left vm for family member. 04/12/2024 at 9:45am Surveyor made a second attempt to complete a telephone interview with the confidential family member, left voicemail. Interview and record review on 04/18/2024 at 11:05am Surveyor received a return phone call from the confidential family member, the family member stated the SW completed the grievance form, the family member stated she voiced a complaint regarding her mother's glasses missing. The Confidential family member stated the SW told her the facility would replace the glasses if they were not found. The Family member stated she never received any follow communication regarding the glasses. The family member stated she followed with the ADM and was told if we find the glasses, we will let you know, there was no offer to replace the glasses. The family member stated she never received a phone call regarding any information regarding the investigation completed for the glasses, the solution for the missing glasses, she never received a copy of the grievance, and she never signed or was given the opportunity to review the grievance. The family member informed Surveyor the Resident passed away and she returned to the facility to gather her mother's belongings, her mother's wheelchair was missing, she spoke to the ADM about the wheelchair and was told if we find it, we will let you know. The family member stated the ADM did not offer to complete a grievance or provide her with a grievance to complete. The family member stated she has never had any returned any communication regarding her mother's wheelchair. Surveyor reviewed the grievance: The Documentation of Investigation was blank, the Resolution section of the grievance is blank, there was no indication the family member received a copy of the grievance, no documentation of the results of the grievance being communicated to the family member, and the grievance was not signed by the family member. Interview and record review 04/12/2024 at 1:35pm Interviewed Confidential Resident in regard to a grievance filed on her behalf by the SW on 4/4/2024. Resident stated she was aware of the grievance; she stated nursing staff were rude to her and she reported the incident to the SW. Resident stated the grievance process has never been explained to her; she stated the SW came into her room with the form and documented her complaint. Resident stated she did not know what happened once a grievance was filed. Resident stated the resolution she was offered was she can move to a new room or she will be provided with a referral to a different facility. Resident stated the only resolution she was ever offered was she can have a referral to another facility. Resident stated the staff who were rude to her continued to provide care to her and some of them were still rude. Resident stated following the resolution to the grievance she felt like the facility does not care about providing quality care to her and she felt like the facility was constantly trying to force her out of the facility for every complaint as she was always told she can leave if she does not like the way she was treated by staff. The Resident stated she was provided with a copy of the grievance, and she did not sign the grievance. Surveyor reviewed the grievance, the Findings section of the grievance was blank, the Expected results of actions taken section was blank, and the entire Post-Investigation Follow Up section was blank. The grievance was not signed by the Resident and the grievance did not indicate the Resident was provided a copy of the grievance. Attempted to complete a telephone interview with the SW on 04/11/2024 at 3:47PM, Surveyor left voicemail. 04/12/2024 at 1:15pm Surveyor attempted to complete a telephone interview with SW, left voicemail. Surveyor did not receive a return phone call from the SW. Interview with the Administrator 4/12/2024 at 3:06pm, the ADM stated the SW maintains possession of the grievance form, they were not accessible unless a resident asks the SW for the form. The SW reviews all grievances and decides what respective department the grievance should be assigned to The ADM stated authors of the grievance were informed of the outcome, which include any resolution taken, the resolutions were also documented on the grievance form. The ADM stated the potential negative outcome for the grievance policy not being followed was a negative outcome for resident care. Record review of the Monthly grievance logs revealed the following: January - 1 grievance logged on monthly grievance log. The grievance report was not followed up with residents or resident council. The grievance did not indicate the Resident or Residents Representative received a copy of the grievance and the grievance was not signed by the complainant. February - 3 grievances logged on monthly grievance log. The grievance reports were not completed, the Documentation of Investigation and the Post-Investigation Follow Up was blank and no follow up documentation to residents available. The grievance did not indicate the Resident or Residents Representative received a copy of the grievance and the grievance was not signed by the complainant. March - 1 grievance logged on monthly grievance log. The grievance reports were not completed, the Documentation of Investigation and the Post-Investigation Follow Up was blank and no follow up documentation to residents available. The grievance did not indicate the Resident or Residents Representative received a copy of the grievance and the grievance was not signed by the complainant. April - 2 grievance logged on monthly grievance log. The grievance reports were not completed, the Documentation of Investigation and the Post-Investigation Follow Up was blank and no follow up documentation to residents available. The grievance did not indicate the Resident or Residents Representative received a copy of the grievance and the grievance was not signed by the complainant. Record Review of the Resident Council Minutes from January 2024-March 2024 listed the names of the Residents who attended the meeting, the remainder of the sections for the council minutes were blank. The minutes indicated the ADM was invited and attended the January 2024 meeting; the minutes did not document what was discussed in the meeting. Record Review of Resident Grievances/Complaints- Staff Responsibility Policy Policy: Staff members are encouraged to guide residents about where and how to file a grievance and/or complaints when the resident believes that his/her rights have been violated. Policy Interpretation and Implementation: 1. Should staff member overhear or be the recipient of a complaint voiced by a resident, a resident's representative concerning the resident's medical care, treatment, food, clothing, or behavior of other residents; the staff member is encouraged to guide the resident or resident representative as to how to file a written complaint with the facility. 2. Staff member will inform resident or representative that he or she may file a grievance without fear or threat to any other form of reprisal. 3. Staff members will inform the resident or representative as to where to obtain a grievance form and where to locate the procedures for filing a grievance or complaint. 4. All alleged abuse, mistreatment, neglect, injuries of unknown source, and misappropriation of property will be reported to the Administrator.

Based on interview and record review, the facility failed to ensure preadmission screening for individuals identified with MI, DD, or ID were evaluated for services assessments 6 of 24 residents (Residents #2, #41, #71, #78, #83 and #292) reviewed for PASRR screening, in that: Residents #2, #41, #71, #78, #83 and #292 did not have an accurate PASRR Level 1 assessments when they had a diagnosis of mental illness. These failures could place residents with an inaccurate PASRR Level 1 and no PASRR Level 2 Evaluation at risk for not receiving care and services to meet their needs. The findings included: Resident #2 Record review of Resident #2 electronic face sheet dated 04/10/2024 revealed an [AGE] year-old male admitted to the facility on [DATE]. The face sheet listed under Diagnoses Information, major depressive disorder. Record review of Resident #2's Quarterly MDS dated [DATE], revealed under section I Active Diagnoses, a diagnosis of Dementia. Additionally, under Section C Cognitive Patterns, the MDS revealed a BIMS score of 07 indicating the resident was severely cognitively impaired. Record review of Resident #2's most recent care plan, undated, revealed a focus area and diagnosis of depressive disorder, this problem started 05/31/2021. Record review of Physician progress notes for Resident #2 dated 04/10/2024 revealed under current medications, Resident #2 was prescribed Divalproex Sodium Oral Tablet Delayed Release 500mg one tablet by mouth twice a day, and Fluoxetine HCL Oral Capsule 40mg for depressive disorder. Record review of Resident #2's Preadmission Screening and Resident Review Level One (PL1) form dated 4/21/2021, revealed under section C0100 Mental Illness an answer of No, indicating the resident did not have a mental illness. Resident #41 Record review of Resident #41 electronic face sheet dated 04/10/2024 revealed an [AGE] year-old female admitted to the facility on [DATE]. The face sheet indicates under Diagnoses Information, Major Depressive Disorder, Unspecified. Record review of Resident #41's Annual MDS dated [DATE], revealed under section I Active Diagnoses, a diagnosis of depression. Additionally, under Section C Cognitive Patterns, the MDS revealed a BIMS score of 11 indicating the resident was moderately cognitively impaired. Record review of Resident #41's most recent care plan, undated, revealed a diagnosis of Major Depressive Disorder. Record review of Physician orders for Resident #41 dated 03/31/2024 revealed under Diagnoses, Resident #41 has a diagnosis of Major Depressive Disorder. Record review of Resident #41's Preadmission Screening and Resident Review Level One (PL1) form dated 03/14/2024 revealed under section C0100 Mental Illness an answer of No, indicating the resident did not have a mental illness. Resident #71: Record Review of Resident #71's face sheet dated 04/12/2024 revealed a [AGE] year-old male, originally admitted on [DATE] and readmitted on [DATE] with a primary diagnosis of epilepsy, schizoaffective disorder, difficulty swallowing, major depressive disorder, cognitive communication deficit, and anxiety disorder. Record review of Resident #71's Admission MDS with a date of 02/15/2024, revealed a BIMS score of 06 which indicates Resident #71 had severe impairment. Resident #71 was listed as having delusions with inattention, disorganized thinking and altered level of consciousness. Resident #71 was triggered on the MDS for Cognitive loss/dementia and Psychotropic drug use. Resident #71 had listed on the MDS under medications that he had been taking antipsychotics and antidepressants. Record Review of Resident #71's Care Plan dated 05/1/2021 revealed Resident #71 was listed as having a psychosocial wellbeing problem with anxiety and major depression with the interventions of: assist/encourage/support resident to set realistic goals, consult with pastoral care, social services, psych services, psychologist who sees him weekly, provide opportunities for resident and family to participate in care. Record Review of Resident #71's Care Plan dated 12/27/2021 revealed Resident #71 was listed as having major depressive disorder with psychotic symptoms with interventions of: assist resident, family, caregivers to clarify strengths, positive coping skills and reinforce these, behavioral health consults as needed, referred and visits with doctor weekly, needs encouragement/assistance/support to maintain as much independence and control as possible. Strengths are that he can ask for help, express feelings, and communicates well, Monitor/record/report to doctor prn acute episode feelings or sadness, loss of pleasure and interest in activities, feelings of worthlessness or guilt, change in appetite/eating habits, change in sleep patterns, diminished ability to concentrate, change in psychomotor skills, Monitor/record/report to doctor prn mood patterns and signs and symptoms of depression, anxiety, sad mood as peer facility behavior monitoring protocols. Record Review of Resident #71's care plan dated 04/11/2024 revealed Resident #71 was listed as being PASRR Positive related to severe mental illness with interventions of: coordinate services with RP from LMHA, invite LMHA and RP to care plan meeting, provide service coordination with representative from LIDDA, report any need to evaluate for services and/or durable medical equipment to maintain, report any need to re-evaluate for additional TRR special services. During a Record Review of Resident #71 PASRR information on 4/11/2024 revealed that Resident #71 PASRR Level 2 screening showed a date of 10/05/2023 and PASRR Level 1 screening with a date of 02/07/2024, indicating that a Level 2 screening would have been provided prior to a level 1 screening. Resident #78 Record review of Resident #78's electronic face sheet dated 04/10/2024 revealed an [AGE] year-old male most recently admitted to the facility on [DATE]. The face sheet listed under diagnosis information a diagnosis of major depressive disorder, single episode, unspecified. Record review of Resident #78's Quarterly MDS dated [DATE], revealed under section I Active Diagnoses, a diagnosis of depression. Additionally, under Section C Cognitive Patterns, the MDS revealed a BIMS score of 13 indicating the resident was cognitively intact. Record review of Resident #78's most recent care plan, undated, revealed a focus area and diagnosis of major depressive disorder, this problem started 12/08/2021. Resident #78 was prescribed Mirtazapine, every shift to address this diagnosis. Record review of Physician progress notes for Resident #78 dated 03/31/2024 revealed under current medications, Resident #78 was prescribed Mirtazapine, monitor for codes every shift related to Major depressive disorder. Record review of Resident #78's Preadmission Screening and Resident Review Level One (PL1) form dated 08/26/2022 revealed under section C0100 Mental Illness an answer of No, indicating the resident did not have a mental illness. Resident #83 Record review of Resident #83 electronic face sheet dated 04/10/2024 revealed an [AGE] year-old male admitted to the facility recently on 02/20/2024. The face sheet indicates under Dementia, Mood Disturbance, Anxiety, Unspecified. Record review of Resident #83's Annual MDS dated [DATE], revealed under section I Active Diagnoses, a diagnosis of depression. Additionally, under Section C Cognitive Patterns, the MDS revealed a BIMS score of 09 indicating the resident was moderately cognitively impaired. Record review of Resident #83's most recent care plan, undated, revealed a diagnosis of Major Depressive Disorder. Record review of Physician progress notes for Resident #83 dated 04/10/2024 revealed under current medications, Resident #83 was prescribed Depakote Oral Tablet Delayed Release 125mg, one tablet by mouth twice a day and Celexa Oral Tablet 20mg, one tablet by mouth once a day for depressive disorder. Record review of Resident #83's Preadmission Screening and Resident Review Level One (PL1) form dated 02/16/2024 revealed under section C0100 Mental Illness an answer of No, indicating the resident did not have a mental illness. Resident #292 Record review of Resident #292 electronic face dated 04/10/2024 sheet revealed an [AGE] year-old female admitted to the facility on [DATE]. The face sheet indicates under Diagnoses Information, Dementia, Mood Disturbance, Anxiety, Unspecified. Record review of Resident #292's MDS dated [DATE], revealed section I Active Diagnoses, not available. Record review of Resident #292 most recent baseline plan, undated, revealed no care areas for Anxiety and Dementia, Unspecified. Record review of Physician orders for Resident #292 dated 04/12/2024 revealed under current medications, Resident #292 was prescribed Donepezil HCL Oral Tablet 10mg, one tablet by mouth once a day and Celexa Oral Tablet 20mg, for dementia. Record review of Resident #292's Preadmission Screening and Resident Review Level One (PL1) form dated 03/27/2024 revealed under section C0100 Mental Illness an answer of No, indicating the resident did not have a mental illness. During an interview conducted on 04/11/24 at 9:44am with the MDS Nurse, she verified Residents #2, #41, #71, #78, #83 and #292 had a diagnosis of mental illness. The MDS Nurse verified Residents #2, #41, #71, #78, #83 and #292 did not have PASRR 2 Evaluations as their PASRR 1s were negative. The MDS Nurse stated the purpose of the PASRR 1 was to identify Residents who required additional services which the facility cannot offer. She said if the PASRR 1 was positive then it gets put into an online system and they reach out to the necessary people to ensure a PASRR 2 Evaluation was done. She said she was responsible for entering the PASRR 1 into the system, the MDS nurse was also responsible for ensuring PASRR 1s were accurate by comparing them to medical records. The MDS Nurse stated the potential harm if a resident with a diagnosis of a mental illness had a negative PASRR 1, and no subsequent level PASRR 2 evaluation was the residents could potentially go without services. During an interview with the ADM on 04/11/24 at 9:33am, he verified Residents #2, #41, #71, #78, #83 and #292 had diagnosis of mental illnesses. The ADM confirmed Residents #2, #41, #71, #78, #83 and #292 did not have PASRR 2 Evaluation as their PASRR 1s were negative. The ADM stated it was the MDS nurses' responsibility to ensure every resident admitted to the facility had an accurate PASRR 1. The ADM also stated it was the MDS nurses' responsibility to ensure PASRR 1s were completed accurately by comparing them to the residents' medical records. The ADM stated positive PASRR 1 should be referred to the local mental health authority for completion of a PASRR 2 Evaluation. The ADM stated the potential harm to a resident without an accurate PASRR 1 and a subsequent PASRR 2 Evaluation was the residents will not receive the services they need. Record review of the Preadmission Screening and Resident Review (PASRR) Policy Revised March 15, 2023, read: The facility policy for PASARR states all applicants admitted to a Medicaid-certified nursing facility are evaluated for mental health prior to admissions and offered the most appropriate setting for their needs. If the PASARR level one screening indicated the individual may have an Intellectual Disability or a Mental Illness diagnosis the facility will confer with local mental health providers to complete a PASARR level two screening. Following the completion of the level two screening a care plan will be developed by the facility to meet the needs of a resident with an Intellectual Disability or a Mental Illness diagnosis.

Based on the interview and record review, the facility failed to immediately consult the physician and/or inform the Resident/Responsible Party (RP) when there was a change of condition for 1 of 5 residents reviewed for notification of changes. (Residents #1) The facility failed to consult the physician, emergency services, or responsible party that Resident #1 had a significant drop in oxygen saturation levels of 31% throughout three shifts. This failure could place residents at risk of not having notifications made for health-related issues and could hinder resident treatment, even causing death. An IJ was identified on [DATE] at 5:00 PM. The IJ template was provided to the facility on [DATE] at 5:30 PM. While the IJ was removed on [DATE] at 5:30 PM, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. Findings included: Review of Resident #1's face sheet revealed she was an [AGE] year-old female admitted to the facility on [DATE] with a primary diagnoses of stroke, dementia, difficulty swallowing, heart failure, heart valve replacement, hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), Anxiety disorder, Chronic Obstructive Pulmonary Disease (a group of lung diseases that block the air flow and make it difficult to breathe), hypertension (high blood pressure), acid reflux. Review of Resident #1's admission MDS, dated [DATE], revealed her BIMS (Brief Interview for Mental Status) was 04, suggesting that the resident's cognitive was severely impaired. Review of Resident #1's admission care plan, dated [DATE], revealed that Resident #1 has limited mobility with the interventions of: encourage the resident to use the bell to call for assistance, monitor/document/report any PRN changes or declines in function. Review of Resident #1's admission care plan, dated [DATE], revealed that Resident #1 has altered cardiovascular status due to mitral valve disorder with interventions of: administer cardiac meds as ordered, assess for chest pain as indicated, enforce the need to call for assistance if pain starts, monitor vital signs as ordered and indicated, notify MD of significant abnormalities. Review of Resident #1's admission care plan, dated [DATE], revealed that Resident #1 has a communication problem due to hearing deficit with interventions of: allow adequate time to respond, repeat as necessary, do not rush, request clarification from the resident to ensure understanding, Face when speaking, make eye contact, use simple/brief consistent words/clues, use alternative communication tools as needed, monitor/document for physical nonverbal indicators of discomfort or distress and follow up as needed. Review of Resident #1's physician's orders dated [DATE] revealed the following order was written on [DATE]: Admit to facility under hospice services - Hospice to evaluate and treat. No diagnosis indicated. Review of Resident #1's physician's orders dated [DATE] revealed the following: Portable chest x ray AP and Lateral due to in house patient: Diagnosis: coughing and wheezing. Record Review indicated that no Physician orders were indicated in Resident #1's Physician Orders. Record Review of facility standing orders provided on [DATE], labeled, Standing Orders for attending Physician of the facility, date not provided, stated: O2 Sats: Below 90%, start O2 at 3 Liters nasal cannula and call Nurse Practitioner. No standing orders listed for Albuterol with nebulizer. Not listed in Physician order. An Interview was conducted on [DATE] at 9:00 AM with the family member of Resident #1. Family member stated that she visited the facility on [DATE] at 2:30 pm. Family member stated Resident #1 was showing signs of distress by moaning and was not responsive to her or her questions. Family member stated that while she was at the facility that LVN C stated to family member that Resident #1 oxygen saturation levels had fall to 30% the day before and was up and down in the 80%. Family member stated that she went to talk to the DON to let her know to call EMS to have Resident #1 sent to the hospital and to find out what was going on with Resident #1. Family member stated that the DON did not seem to know anything, and DON stated, Resident #1's health has just deteriorated considerably. Family member stated that she did not know why the DON was so unaware of the status of Resident #1 because DON office is right next to Resident #1's room. Family member stated that DON had told her that she did not call EMS before because Resident #1 was on antibiotics for 5 days and needed to be on them for 7 days. Family member stated that Resident #1's oxygen saturation levels were falling in the 30% the day before and no one thought to call the doctor, family member, or medical services. Family member stated that she had to insist that the DON call 911 for EMS to take Resident #1 to the hospital. Family member stated that Resident #1 had pneumonia and did not feel that Resident #1's quality of life was considered the last couple of days by her moaning in pain, showing distress, and her oxygen saturation levels falling the day before. Family member stated that she feels that at the point of Resident #1's oxygen saturation levels being unstable and inconsistent that the facility should have sought out medical attention for Resident #1. An Interview was conducted on [DATE] at 11:48 AM with LVN A stated she was the nurse that cared for Resident #1 on [DATE]. LVN A (Shift 6am-2 pm) stated she was the nurse taking over shift (10pm-6am) to care for Resident #1 and received report from LVN B. LVN A stated in report LVN B stated that Resident #1 had issues on LVN B's shift with Resident #1's oxygen saturation levels declining and that at one point Resident #1's oxygen saturation levels had dropped to 31% and again to 78%, People should contact a health care provider if their oxygen saturation readings drop below 92%, as it may be a sign of hypoxia (a condition in which not enough oxygen reaches the body's tissues), If blood oxygen saturations levels fall to 88% or lower, seek immediate medical attention (Foley Finbar & [NAME], Mridu, 2023, Pulse Oximetry-Fact-Sheets-[NAME] Medicine). LVN A stated that LVN B did report to LVN A that Resident #1's nasal canula kept coming off during the night, but no other interventions were placed. LVN A stated that LVN B during report that Albuterol was administered by nebulizer and oxygen at ,d+[DATE] Liters was administered. LVN A stated that during her shift Resident #1's oxygen saturation levels had dropped to 80% when Resident #1's nasal canula had come off of her but the oxygen saturation levels would come up to 90% when nasal canula was placed back on. LVN A stated that she does not know how much oxygen that Resident #1 was receiving exactly but thinks it might have been ,d+[DATE] Liters. The facility only had standing orders for all residents in the facility. Resident #1 did not have any individual orders labeled in Physician Orders. There were standing orders for all the residents in the facility indicating that for O2 sats below 90%, start at 3 Liters of oxygen and call Nurse Practitioner. LVN A stated that a couple of days prior, Resident #1 was wheezing badly, and she had called the physician and Resident #1 was put on antibiotic for Pneumonia after an x-ray was completed to confirm pneumonia. LVN A failed to notify physician or contact emergency services when Resident #1 had a significant decrease in oxygen saturation for the prior and current shift. LVN A stated that now that she is thinking about the situation, Resident #1 should have been sent out by emergency services and she should have notified the physician. LVN A stated that she had a lack of judgement and did not send Resident #1 out, contact the DON,< Physician, or emergency services. LVN A stated that she made rounds to check on Resident #1 every 2 hours and Resident #1 slept most of her shift, but no other interventions were placed. LVN A stated that she did not assess Resident #1's oxygen saturation levels or respirations during her shift because she felt that Resident #1 was not in distress and did not show any discomfort. LVN A did not specify if she took any vitals during rounds. LVN A stated that she did not document the situation in the nurse notes because she was busy that day and forgot to document. LVN A stated that the procedure for notification for change of condition is to report to the Physician, DON, and Emergency Services when the resident shows signs of a change of condition. LVN A stated that she failed to follow the procedure because she thought by administering oxygen that Resident #1 was taken care of and now that she is thinking about it, LVN A stated she should have contacted the Physician and emergency services because of the low oxygen saturation levels when Resident #1 has pneumonia. LVN A stated that she did assume care for Resident #1, responsibility for her residents and the situation. LVN A stated she did not contact physician or emergency services and Resident #1 was not sent out to hospital (where she expired) until the next shift (2pm-10pm) on [DATE]. LVN A stated that she did not realize that Resident #1 was in such bad condition, or she would have called the emergency services or the physician. LVN A stated that the negative potential outcome for not reporting change of condition is obviously the resident could decline in health or die. LVN A stated that she is aware of the process to report change of condition and who to report to. LVN A stated that she failed to report because lack of judgement. Record Review of website, labeled, Pulse Oximetry-Fact Sheets-[NAME] Medicine dated 2023, stated: People should contact a health care provider if their oxygen saturation readings drop below 92%, as it may be a sign of hypoxia (a condition in which not enough oxygen reaches the body's tissues), If blood oxygen saturations levels fall to 88% or lower, seek immediate medical attention (Foley Finbar & [NAME], Mridu, 2023, Pulse Oximetry-Fact-Sheets-[NAME] Medicine). An interview was conducted on [DATE] at 12:15 pm with CNA E who stated she was the CNA that was on the shift of 10pm-6am on [DATE]-[DATE] and she stated that the nurse that was working with her is was LVN B. CNA E stated that when she got to work that LVN B told her (CNA E) to keep a close eye on Resident #1 because she was not doing well and may need to be sent out if Resident #1's oxygen levels do not get better. CNA E stated that LVN B told her about Resident #1's status of oxygen saturation levels declining. CNA E stated at that point she went immediately to check on Resident #1. CNA E stated that when she saw Resident #1, she was on her bed laying backwards towards the wall and her legs were off the bed. CNA E stated that Resident #1 was not coherent, and she was a blue color. CNA E stated that she called out Resident #1's name and asked if she was okay. CNA E stated that it looked like Resident #1 wanted to respond because she tried to move her mouth, but she couldn't. CNA E stated that Resident #1 was in bad shape. CNA E stated that she told Resident #1, I am going to get help. CNA E stated that she ran out of the room to try and get help but could not find LVN B, but she noticed that LVN D was working 400 hall so she grabbed LVN D and told her that Resident #1 needed help now. CNA E stated at that point her and LVN D ran into Resident #1's room and LVN D turned Resident #1 in the bed to lay her down correctly and then LVN D used the pulse oximeter (is a noninvasive method for monitoring a person's oxygen saturation), and tested Resident #1, the oxygen saturation levels were at 31%. LVN D administered a breathing treatment of Albuterol by nebulizer and then LVN D placed oxygen at 4 liters by nasal canula on Resident #1. CNA E stated that Resident #1 was very weak and still could not respond. CNA E stated that it really freaked her out, so she kept checking on Resident #1 to make sure she was okay. CNA E stated that it was around 5:30 am when Resident #1's color started to come back to her. CNA E stated that she does feel that this was a medical emergency and does feel that Resident #1 should have been sent to the hospital. CNA E stated that she just assumed that LVN B or LVN D had called the physician because that is what you would normally do in a situation like that. CNA E stated that she never heard anything else about it. CNA E stated that it is the responsibility of the nurses to report incidents like that to the Physician or call emergency services. An interview was conducted on [DATE] at 12:45 pm with LVN B who stated that she worked the shift of 10pm-6am on [DATE]-[DATE] and had worked with Resident #1. LVN B stated that she did not know anything had happened with Resident #1 until CNA E and LVN D had finished assessing and caring for Resident #1 because she was taking care of another resident down the hall. LVN B stated that LVN D had told her about the incident and that she got a reading from the oximeter of 31 or 37%. LVN B stated that she didn't exactly remember which one it was. LVN B stated that LVN D told her that she administered Albuterol by nebulizer and oxygen of 4 liters by nasal canula. LVN B stated that she kept Resident #1 on the oxygen at 4 liters by nasal canula for the remainder of the shift because with the nasal canula Resident #1's oxygen saturation levels were at 91%. LVN B stated that she continued to monitor Resident #1 by checking on her every hour to make sure she was not in distress. LVN B did not check for orders for oxygen for Resident #1. LVN B stated that she did not contact the Physician, DON, or emergency services after this incident because she felt that Resident #1 was stable and there was no need to send her out. LVN B stated that there was one more time during the early morning hours probably around 3am-4am she took Resident #1's oxygen saturation levels when she realized Resident #1's nasal canula was off and her oxygen saturation level was at 78%. LVN B stated that she placed the nasal canula back on Resident #1. LVN B stated that Resident #1's nasal canula kept coming off and she wasn't sure if it was just because of normal movement from sleeping or if Resident #1 was removing it. LVN B stated that no other interventions were put into place at this time. LVN B stated that she did not contact the Physician, DON, or emergency services with this incident either. LVN B stated that she is not familiar with Resident #1 health condition and did not know if this was something that was because of the pneumonia. LVN B stated that Resident #1 wasn't coughing or anything and she felt that Resident #1 was stable and there was no need to contact physician. LVN B stated that the only concern was Resident #1's oxygen. LVN B stated that she did not document the incident. LVN B stated that it is her responsibility to document and is not sure why she did not document but normally she would have documented. LVN B stated that normally if someone's oxygen levels would fall below 90%, they would send the resident out to the hospital. LVN B stated that Resident #1 had no other distress and rested the remainder of the shift. LVN B stated that the process for reporting a change of condition is that the Nurse would fix the change of condition and then report to the DON, Physician, and/or Emergency Services. LVN B stated that she failed to report when she should have reported to the DON, Physician, and Emergency Services. LVN B stated that in her mind she had fixed the situation with putting oxygen on the resident, and she did not see any further concern to contact the physician, DON, or Emergency Services. LVN B stated that she had just come back onto shift from having days off and it was not in her mind to contact the Physician, DON, and Emergency Services. LVN B stated that Resident #1 was not sent out on this (10pm-6am) shift. LVN B stated that she gave report to LVN A for the next on-coming shift (6am-2pm), of Resident #1 oxygen decline during her shift. LVN B stated that the negative potential outcome for residents for not reporting a change in condition is that the resident's health could decline. Review of Resident #1's physician's orders revealed no physician orders or standing orders for Albuterol and nebulizer that was given to resident before transfer to the hospital. Record Review of facility standing orders provided on [DATE], labeled, Standing Orders for attending Physician of the facility, date not provided, stated: O2 Sats: Below 90%, start O2 at 3 Liters nasal cannula and call Nurse Practitioner. No standing orders listed for Albuterol with nebulizer. Not listed in Physician order. Record Review of Resident #1's emergency room Records dated [DATE], documented by emergency room Physician, revealed: Under Basic Information: The date and time that Resident #1 arrived at the emergency room by ambulance was listed as [DATE] at 3:51 pm. Under Arrival Mode is listed as ambulance, Under History of Present Illness stated: Resident #1 presents with decreased responsiveness. The course/duration of symptoms is constant. Associated Symptoms is abdominal pain. Under emergency room Physician Documentation stated: Resident #1 presents from facility by EMS with concerns for decreased responsiveness. Resident #1 was found to be hypoxic today in the morning with sp02 of 30% and was sent to hospital in the afternoon for decreased responsiveness. Per family members, Resident #1 has not been herself for a few days. Resident #1 has been treated recently with antibiotics and steroids for concern of possible respiratory infection. Under Events Information stated: Arrival on [DATE] at 3:50 pm. Record Review of Resident #1's Progress Note dated on [DATE] at 3:09 pm documented by DON, revealed: Family member wanted resident sent out due to low O2 sats, non-responsiveness and continued coughing spells with no appetite. Will send resident to UMC. Record Review of Resident #1's Progress Note dated on [DATE] at 4:54 pm documented by LVN C, revealed: 1520 EMS arrived, assisted with transfer to stretcher with EMS personnel. 1527 EMS left building in route to UMC with family member following. An interview was conducted on [DATE] at 2:16 pm with LVN C stated that she worked the shift on 2pm-10pm on [DATE]. LVN C stated that Resident #1 was sent out on her shift. LVN C stated that she received report by LVN B that was working 6am-2pm shift. LVN C stated that she was told in report by LVN A that she had trouble keeping Resident #1's oxygen level up and had to put her on oxygen with the nasal canula. LVN C stated she received no special instructions from LVN A other than Resident #1 being on oxygen at 4 liters by nasal canula and that Resident #1's oxygen level stayed at 90% for the majority of the shift and continue antibiotics for pneumonia. LVN C stated that usually after narcotic count, she then gets temps and O2 saturation levels. LVN C stated that Resident #1 seemed very sleepy and was not running a temperature or anything like that and that Resident #1's oxygen saturation level was at 93% with nasal canula on. LVN C stated that LVN A stated that Resident #1 had been having trouble with her nasal canula coming off. LVN C stated that she did make sure to keep an eye on Resident #1 due to the things that she had received in report. LVN C stated that she did not call EMS because family member of Resident #1 had just gotten to the facility to visit the Resident #1 and then the family member requested to the DON for Resident #1 to be sent to the hospital due to Resident #1's decline in oxygen levels and this was at the beginning of the shift. LVN C stated that Resident #1 was sent out to the hospital due to DON telling another LVN to call EMS because family member was requesting Resident #1 be sent to the hospital. LVN C stated that she did not take Resident #1's oxygen saturation without the nasal canula because she knew that Resident #1's oxygen level would drop drastically. LVN C stated that the process for reporting a change of condition is when you see a change of condition with a resident, and it depends on the severity of the change of condition if it is something extreme LVN C stated she would call and send the resident out to the hospital. LVN C stated that once the resident is sent out, she would then contact the physician, DON, and family. LVN C stated that the incident that occurred with Resident #1 does constitute as severe and life threatening. LVN C stated that Resident #1 should have been sent out to the hospital before now and without any hesitation LVN C stated that it should not have taken the family member to demand that Resident #1 be sent to the hospital. LVN C stated that Resident #1 should have already been sent out to the hospital. An interview conducted on [DATE] at 11:06 am, the Administrator stated she is the Administrator at the facility overseeing staff when an incident of Neglect and failure to notify of change of condition occurred with Resident #1. The Administrator stated that she was notified of the situation during a clinical meeting during the week of [DATE]th 2023 prior to the [DATE]th 2023, about Resident #1's pneumonia condition and was aware that Resident #1 was placed on antibiotic. Administrator stated that she was not aware that Resident #1 had a decline until the morning that Resident #1 was sent out to the hospital. The Administrator stated that the process for reporting change of condition starts with reporting to the physician, then the family should be notified only if there is a chronic issue, and she does not feel that what happened to Resident #1 was a chronic issue. The Administrator stated that she does feel that just administering oxygen as the nursing staff had done and not contacting the physician was correct because Resident #1 did not have a chronic situation. The Administrator stated that the family was not notified because family member of Resident #1 came in the facility during shift change on the day that Resident #1 was sent out to the hospital. The Administrator stated that from her understanding it was the family member of Resident #1 that requested that she be sent to the hospital due to a decline in oxygen levels. The Administrator stated that the Physician and family member was not notified because she was notified that the oxygen levels had come back up and was stable with the nasal canula. The Administrator stated that she is not certain that by calling emergency services or the physician if it would have changed the outcome. Facility policy states our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. An interview conducted on [DATE] at 11:32 am, the Director of Nurses stated she was over LVN A and LVN B in which had failed to report a change of condition for Resident #1 to the Physician and Emergency Services causing Resident #1 to delay medical attention when her oxygen saturation levels would decline for the following 2 shifts of [DATE]-[DATE] of shift 10pm-6am and [DATE] of shift 6am-2pm. Resident #1 was not sent out to hospital through emergency services until family informed the Director of Nurses to call Emergency Services on [DATE] for the shift 2pm-10pm. The Director of Nurses stated that she was informed of the incident of Resident #1 oxygen saturation levels decline when she arrived to work on the morning of [DATE]. The Director of Nurses stated that she did not contact the Physician or Emergency Services for Resident #1 because the facility has standing orders for oxygen for all of the residents in the facility and she felt that Resident #1 was stable with the nasal canula. The Director of Nurses stated that Resident #1 oxygen saturation levels would stay at 90% if the nasal canula was on. There were standing orders for all the residents in the facility indicating that for O2 sats below 90%, start at 3 Liters of oxygen and call Nurse Practitioner. The Director of Nurses stated that she had not assessed Resident #1 the after incident, DON stated she was told by her LVN C nursing staff (third shift 6am-2pm), about the incident. The Director of Nurses stated that she was not aware of the oxygen saturation decline of 31% for Resident #1. The DON stated that the oxygen saturation should be documented, and documentation should be provided in the nurse notes section. The Director of Nurses stated that the process of reporting a change of condition is if an acute change should occur to call the Director of Nurses immediately. The Director of Nurses stated that she does not feel that this is a change of condition that should have to be reported. The Director of Nurses stated that Resident #1 had not had problems with her oxygen saturation levels declining before. The Director of Nurses stated that a change of condition would be if the resident was completely unresponsive, and DON stated that Resident #1 was not completely unresponsive. The Director of Nurses stated that no other interventions were put into place because there was no need for further interventions. The Director of Nurses stated that the only other intervention that she can think of to put into place would have been to tape the nasal canula on Resident #1 to keep nasal canula on the resident. The Director of Nurses stated that she stands by her word in that she does not feel that the nursing staff did anything wrong, and she will not say that they did. The Director of Nurses stated that the facility has standing orders to administer oxygen. The Director of Nurses stated that the only reason the resident was sent out was because the family member requested that Resident #1 be sent to the hospital by emergency services. Resident #1 later expired at the hospital on [DATE] due to pneumonia and septic shock. The Director of Nurses stated that the family should have been contacted with the morning shift and she is not sure why they were not, but it may have been because the family had come up to the facility the day that Resident #1 was sent out because the family is who requested that Resident #1 be sent to the hospital due to the decline in oxygen saturation levels. The Director of Nurses stated that she thinks that the family is just having a hard time coping with Resident #1 death and could be why they are so upset at the facility. Interview conducted on [DATE] at 1:41 pm, the Physician stated that he is the attending Physician that oversees Resident #1's health conditions in the facility. The Physician stated that Resident #1 had a diagnosis of pneumonia on [DATE] and was taking antibiotics. The Physician stated that he was not notified of the decline in Resident #1's oxygen saturation levels and stated that he would consider this to have been a change of condition for Resident #1. The Physician stated that with Resident #1's declining oxygen levels that he should have been contacted immediately. The Physician stated that Resident #1 had pneumonia and was on antibiotics but when a resident has pneumonia and has a decrease in oxygen levels, this is a change of condition. The Physician stated that he should have been notified of Resident #1's decline and was not. The Physician stated that he did also talk with his other attending physician about the situation, and she also stated that she was not notified of Resident #1's decline either. The Physician stated that the other attending Physician had covid and would be unable to interview but that he could confirm that she was not notified by the facility. The Physician confirmed that both physicians were not notified of the decline with Resident #1 by the facility. Physician stated that he cannot say if it would have changed the outcome. Interview conducted on [DATE] at 9:48 am, LVN D stated that she was working 400 hall and the even number of 100 hall for the third shift of 10pm-6am (on [DATE]th, 2023), the shift that Resident #1 showed decline in oxygen saturation levels). LVN D stated that the incident with Resident #1 approximately happened somewhere around midnight. LVN D stated that CNA E was doing her rounds and had come out of Resident #1's room and kind of yelled, Someone come and look at this lady, she is not doing well. LVN D stated that she grabbed her pulse oximeter and went to help Resident #1. LVN D stated that she does not remember if Resident #1 was in the wheelchair or in the bed because it all happened so fast, and it has been a while for her to remember small details. LVN D stated that she thinks Resident #1 was in the bed, so she moved her around to where she was laying correctly in the bed and propped up her legs. LVN D stated that Resident #1 was not responding to her calling her name or anything. LVN D stated that she placed the pulse oximeter on Resident #1's finger and it read 31%. LVN D stated that she told CNA E to grab the oxygen because the facility has standing orders for all residents in the facility indicating that for O2 sats below 90%, start at 3 Liters of oxygen and call Nurse Practitioner. LVN D stated that she placed the nasal canula on Resident #1's face. LVN D stated that she did know that Resident #1 had been struggling to breathe. LVN D stated that it took a while for Resident #1's oxygen to come up but it got to 91% with the nasal canula. LVN D stated she then reported the incident to the nurse (LVN B) that was assigned to take care of Resident #1. LVN D stated that she is not sure how much oxygen she placed Resident #1 on, but she thinks it was ,d+[DATE] liters of oxygen. LVN D stated that she also raised the head of the bed for Resident #1 so that she could breathe better. LVN D stated that when she saw Resident #1, she was in distress, very weak, couldn't respond. LVN D did not document any of the occurrence with Resident #1 because she was not the nurse assigned to Resident #1. LVN D stated that she does not remember if the call light was in place because her focus was on the resident, and it all happened so fast. LVN D stated that she reported to LVN B. LVN D stated that she did not contact the physician because, She didn't want to step on anyone's toes. LVN D stated that she was not assigned to Resident #1 and was just trying to help in an emergency situation. LVN D stated that if any of her assigned resident's would have been in this same situation, she would have contacted the physician or emergency services. LVN D stated that she did ask LVN B if she needed anything else when she reported to LVN B and LVN B stated she did not need her to do anything else. LVN D stated that she was with Resident #1 for approximately 10 to 15 minutes. Record Review of Resident #1's x-ray findings provided by the facility, dated [DATE], signed by MD, revealed: Study Description XR chest 2 views, cough, wheezing, Medical Director at facility, STAT. Technique: PA and lateral views of the chest Findings: Heart size is normal, Lungs are clear, The moderate right pleural effusion present. No pneumothorax identified. No acute osseous abnormally identified. Indistinct density of the right diaphragm present. Distended colon or less likely free air not excluded. Irregular appearance of the right diaphragm diaphragmatic hernia, or loculated effusion. Recommend clinical and CT of the chest abdomen pelvis correlation. Record Review of Resident #1's Hospital Records provided by hospital records provided on [DATE], dated [DATE], revealed: Date of Service: [DATE] 5:16 pm Chief Complaint: Altered mental status History of Present Illness: [AGE] years old female, nursing home resident, with history of hypertension, hyperlipidemia, chronic GERD, COPD, coronary artery disease, history of lung mass was transferred to ER with altered mental status. Family members are present in the room and reports that patient was awake and alert yesterday but later today she was found to be drowsy and hypoxemic, requiring supplemental O2. Daughters requested transfer to ER for further evaluation. On arrival in ER, pat [TRUNCATED]

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 5 residents (Resident #1) by failing to contact physician or emergency services, to provide medical attention for Resident #1's declining oxygen saturation levels. 1.) The facility failed to contact the physician or emergency services after Resident #1 was found to have a decrease in oxygen saturation levels and possibly causing death. Resident #1 was only sent to the hospital after family member intervened and requested Resident #1 to seek medical attention because of Resident #1's decrease and unstable oxygen saturation levels. Resident #1 later passed away in the hospital. This failure could affect residents that resident in the facility placing them at risk of not receiving the required medical services or attention that could affect the outcome of their health, and even death. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:30 pm. While the IJ was removed on [DATE] at 5:30 pm, the facility remained out of compliance at a scope of pattern and a severity level of actual harm to resident health or safety due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents in the facility at risk for severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being. Findings included: Review of Resident #1's face sheet revealed she was an [AGE] year-old female admitted to the facility on [DATE] with a primary diagnosis of stroke, dementia, difficulty swallowing, heart failure, heart valve replacement, hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), Anxiety disorder, Chronic Obstructive Pulmonary Disease (a group of lung diseases that block the air flow and make it difficult to breathe), hypertension (high blood pressure), acid reflux, muscle wasting, muscle weakness. Review of Resident #1's quarterly MDS, dated [DATE], revealed her BIMS (Brief Interview for Mental Status) was 04, suggesting that the resident's cognitive was severely impaired. Review of Resident #1's quarterly MDS, dated [DATE], revealed her mobility status under Section G for Functional Status being listed as extensive assistance requiring one to two people assist in the areas of: Bed mobility, Transfer, Locomotion on unit, Locomotion off unit, Toilet use, Personal hygiene. Resident #1 is listed as total dependence in the areas of bathing. Review of Resident #1's quarterly MDS, dated [DATE], revealed her mobility status under Section GG for Functional Abilities and Goals being listed as supervision or touching assistance requiring helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently in the areas of: roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, and toilet transfer. Review of Resident #1's quarterly care plan, dated [DATE], revealed that Resident #1 has an ADL self-care performance deficit due to impaired balance. Limited mobility with the interventions of: Bathing/Showing: Resident #1 totally dependent on one staff to provide bath three times a week as necessary. Bed mobility: Resident #1 requires limited assistance by one staff to turn and reposition in bed. Dressing: Resident #1 requires limited assistance by two staff to dress. Eating: Resident #1 requires supervision to eat. Personal hygiene: Personal hygiene: Resident #1 requires limited assistance by one staff with personal hygiene and oral care. Toilet use: Resident #1 requires limited assist by one staff for toileting. Transfer: Resident #1 requires limited assistance with staff to move between surfaces. Encourage Resident #1 to participate to the fullest extent possible with each interaction. Resident #1 has limited mobility with the interventions of: encourage the resident to use the bell to call for assistance, monitor/document/report any PRN changes or declines in function. Review of Resident #1's quarterly care plan, dated [DATE], revealed Resident #1 has impaired cognition, memory loss, and impaired decision making related to BIMS score due to dementia with the interventions of: Ask yes/no questions in order to determine the resident's needs. Communication: Use the resident preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distraction, turn off tv, radio, close door etc. Provide the resident with necessary cues, stop and return if agitated. Cue, reorient and supervise as needed. Keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Monitor/document, report PRN any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing consciousness, mental status. Review of Resident #1's quarterly care plan, dated [DATE], revealed Resident #1 has a communication problem due to hearing deficit with the interventions of: Anticipate and meet needs. Be conscious of resident's position when in groups, activities, dining room, to promote proper communication with others. Allow adequate time to respond, repeat as necessary. Do not rush, request clarification from the resident to ensure understanding. Face when speaking, make eye contact. Turn off tv, radio to reduce environmental noise. Ask yes/no questions if appropriate. Use simple, brief, consistent words/cues. Use alternative communication tools as needed. Monitor/document for physical nonverbal indicators of discomfort or distress and follow up as needed. Monitor/document residents' ability to express and comprehend language, memory, reasoning, problem solving ability, and ability to attend. Review of Resident #1's quarterly care plan, dated [DATE], revealed that Resident #1 has a psychosocial well-being problem with anxiety with the interventions of: Encourage participation from resident who depends on others to make decisions. Resident #1 needs (assistance, encouragement, and support) to identify problems that cannot be controlled. Review of Resident #1's quarterly care plan revealed that it was not care planned for Hospice. Review of Resident #1's quarterly care plan revealed that it was not care planned for Oxygen. An Interview was conducted on [DATE] at 9:00 AM with the family member of Resident #1. Family member stated that she visited the facility on [DATE] at 2:30 pm. Family member stated Resident #1 was showing signs of distress by moaning and was not responsive to her or her questions. Family member stated that while she was at the facility that LVN C stated to family member that Resident #1 oxygen saturation levels had fall to 30% the day before and was up and down in the 80%. Family member stated that she went to talk to the DON to let her know to call EMS to have Resident #1 sent to the hospital and to find out what was going on with Resident #1. Family member stated that the DON did not seem to know anything, and DON stated, Resident #1's health has just deteriorated considerably. Family member stated that she did not know why the DON was so unaware of the status of Resident #1 because DON office is right next to Resident #1's room. Family member stated that DON had told her that she did not call EMS before because Resident #1 was on antibiotics for 5 days and needed to be on them for 7 days. Family member stated that Resident #1's oxygen saturation levels were falling in the 30% the day before and no one thought to call the doctor, family member, or medical services. Family member stated that she had to insist that the DON call 911 for EMS to take Resident #1 to the hospital. Family member stated that Resident #1 had pneumonia and did not feel that Resident #1's quality of life was considered the last couple of days by her moaning in pain, showing distress, and her oxygen saturation levels falling the day before. Family member stated that she feels that at the point of Resident #1's oxygen saturation levels being unstable and inconsistent that the facility should have sought out medical attention for Resident #1. An Interview was conducted on [DATE] at 11:48 AM with LVN A stated she was the nurse that cared for Resident #1 on [DATE]. LVN A (Shift 6am-2 pm) stated she was the nurse taking over shift (10pm-6am) to care for Resident #1 and received report from LVN B. LVN A stated in report LVN B stated that Resident #1 had issues on LVN B's shift with Resident #1's oxygen saturation levels declining and that at one point Resident #1's oxygen saturation levels had dropped to 31% and again to 78%, People should contact a health care provider if their oxygen saturation readings drop below 92%, as it may be a sign of hypoxia (a condition in which not enough oxygen reaches the body's tissues), If blood oxygen saturations levels fall to 88% or lower, seek immediate medical attention (Foley Finbar & [NAME], Mridu, 2023, Pulse Oximetry-Fact-Sheets-[NAME] Medicine). LVN A stated that LVN B did report to LVN A that Resident #1's nasal canula kept coming off during the night, but no other interventions were placed. LVN A stated that LVN B during report that Albuterol was administered by nebulizer and oxygen at ,d+[DATE] Liters was administered. LVN A stated that during her shift Resident #1's oxygen saturation levels had dropped to 80% when Resident #1's nasal canula had come off of her but the oxygen saturation levels would come up to 90% when nasal canula was placed back on. LVN A stated that she does not know how much oxygen that Resident #1 was receiving exactly but thinks it might have been ,d+[DATE] Liters. The facility only had standing orders for all residents in the facility. Resident #1 did not have any individual orders labeled in Physician Orders. There were standing orders for all the residents in the facility indicating that for O2 sats below 90%, start at 3 Liters of oxygen and call Nurse Practitioner. LVN A stated that a couple of days prior, Resident #1 was wheezing badly, and she had called the physician and Resident #1 was put on antibiotic for Pneumonia after an x-ray was completed to confirm pneumonia. LVN A failed to notify physician or contact emergency services when Resident #1 had a significant decrease in oxygen saturation for the prior and current shift. LVN A stated that now that she is thinking about the situation, Resident #1 should have been sent out by emergency services and she should have notified the physician. LVN A stated that she had a lack of judgement and did not send Resident #1 out, contact the DON,< Physician, or emergency services. LVN A stated that she made rounds to check on Resident #1 every 2 hours and Resident #1 slept most of her shift, but no other interventions were placed. LVN A stated that she did not assess Resident #1's oxygen saturation levels or respirations during her shift because she felt that Resident #1 was not in distress and did not show any discomfort. LVN A did not specify if she took any vitals during rounds. LVN A stated that she did not document the situation in the nurse notes because she was busy that day and forgot to document. LVN A stated that the procedure for notification for change of condition is to report to the Physician, DON, and Emergency Services when the resident shows signs of a change of condition. LVN A stated that she failed to follow the procedure because she thought by administering oxygen that Resident #1 was taken care of and now that she is thinking about it, LVN A stated she should have contacted the Physician and emergency services because of the low oxygen saturation levels when Resident #1 has pneumonia. LVN A stated that she did assume care for Resident #1, responsibility for her residents and the situation. LVN A stated she did not contact physician or emergency services and Resident #1 was not sent out to hospital (where she expired) until the next shift (2pm-10pm) on [DATE]. LVN A stated that she did not realize that Resident #1 was in such bad condition, or she would have called the emergency services or the physician. LVN A stated that the negative potential outcome for not reporting change of condition is obviously the resident could decline in health or die. LVN A stated that she is aware of the process to report change of condition and who to report to. LVN A stated that she failed to report because lack of judgement. LVN A stated that she has been trained in abuse and neglect. LVN A stated that the training consists of computer-based training and in-services. LVN A stated the training is held approximately monthly. Record Review of website, labeled, Pulse Oximetry-Fact Sheets-[NAME] Medicine dated 2023, stated: People should contact a health care provider if their oxygen saturation readings drop below 92%, as it may be a sign of hypoxia (a condition in which not enough oxygen reaches the body's tissues), If blood oxygen saturations levels fall to 88% or lower, seek immediate medical attention (Foley Finbar & [NAME], Mridu, 2023, Pulse Oximetry-Fact-Sheets-[NAME] Medicine). An interview was conducted on [DATE] at 12:15 pm with CNA E stated she was the CNA that was on the shift of 10pm-6am on [DATE]-[DATE] and she stated that the nurse that was working with her is LVN B. CNA E stated that when she got to work that LVN B told her (CNA E) to keep a close eye on Resident #1because she was not doing well and may need to be sent out if Resident #1's oxygen levels do not get better. CNA E stated that LVN B told her about Resident #1's status of oxygen saturation levels declining. CNA E stated at that point she went immediately to check on Resident #1. CNA E stated that when she saw Resident #1, she was on her bed laying backwards towards the wall and her legs were off the bed. CNA E stated that Resident #1 was not coherent, and she was a blue color. CNA E stated that she called out Resident #1's name and asked if she was okay. CNA E stated that it looked like Resident #1 wanted to respond because she tried to move her mouth, but she couldn't. CNA E stated that Resident #1 was in bad shape. CNA E stated that she told Resident #1, I am going to get help. CNA E stated that she ran out of the room to try and get help but could not find LVN B, but she noticed that LVN D was working 400 hall so she grabbed LVN D and told her that Resident #1 needed help now. CAN E stated at that point her and LVN D ran into Resident #1's room and LVN D turned Resident #1 in the bed to lay her down correctly and then LVN D used the pulse oximeter (a noninvasive method for monitoring a person's oxygen saturation levels), and tested Resident #1, the oxygen saturation levels were at 31%. LVN D administered a breathing treatment of Albuterol by nebulizer and then LVN D placed oxygen at 4 liters by nasal canula on Resident #1. CNA E stated that it really freaked her out, so she kept checking on Resident #1 to make sure she was okay. CNA E stated that it was around 5:30 am when Resident #1's color started to come back to her. CNA E stated that she does feel that this was a medical emergency and does feel that Resident #1 should have been sent to the hospital. CNA E stated that she just assumed that LVN B Or LVN D had called the physician because that is what you would normally do in a situation like that. CNA E stated that she never heard anything else about it. CNA E stated that it is the responsibility of the nurses to report incidents like that to the Physician or call emergency services. An interview was conducted on [DATE] at 12:45 pm with LVN B revealed LVN B revealed that LVN B neglected Resident #1's medical need by not contacting the Physician or emergency services to adequately report a change in condition in an emergency situation as stated in facility policy. LVN B stated that she worked the shift of 10pm-6am on [DATE]-[DATE] and had worked with Resident #1. LVN B stated that she did not know anything had happened with Resident #1 until CNA E and LVN D had finished assessing and caring for Resident #1 because she was taking care of another resident down the hall. LVN B stated that LVN D had told her about the incident and that she got a reading from the oximeter of 31 or 37%. LVN B stated that she didn't exactly remember which one it was. LVN B stated that LVN D told her that she administered Albuterol by nebulizer and oxygen of 4 liters by nasal canula. LVN B stated that she kept Resident #1 on the oxygen at 4 liters by nasal canula for the remainder of the shift because with the nasal canula Resident #1's oxygen saturation levels were at 91%. LVN B stated that she continued to monitor Resident #1 by checking on her every hour to make sure she was not in distress. LVN B stated that she did not contact the Physician, DON, or emergency services after this incident because she felt that Resident #1 was stable and there was no need to send her out. LVN B stated that there was one more time during the early morning hours probably around 3am-4am she took Resident #1's oxygen saturation levels when she realized Resident #1's nasal canula was off and her oxygen saturation level was at 78%. LVN B stated that she placed the nasal canula back on Resident #1. LVN B stated that Resident #1's nasal canula kept coming off and she wasn't sure if it was just because of normal movement from sleeping or if Resident #1 was removing it. LVN B stated that no other interventions were put into place at this time. LVN B stated that she did not contact the Physician, DON, or emergency services with this incident either. LVN B stated that she is not familiar with Resident #1 health condition and did not know if this was because of the pneumonia. LVN B stated that Resident #1 wasn't coughing or anything and she felt that Resident #1 was stable and there was no need to contact physician. LVN B stated that the only concern was Resident #1's oxygen. LVN B stated that she did not document the incident. LVN B stated that it is her responsibility to document and is not sure why she did not document but normally she would have documented. LVN B stated that normally if someone's oxygen levels would fall below 90%, they would send the resident out to the hospital. LVN B stated that Resident #1 had no other distress and rested the remainder of the shift. LVN B stated that the process for reporting a change of condition is that the Nurse would fix the change of condition and then report to the DON, Physician, and/or Emergency Services. LVN B stated that she failed to report when she should have reported to the DON, Physician, and Emergency Services. LVN B stated that in her mind she had fixed the situation with putting oxygen on the resident, and she did not see any further concern to contact the physician, DON, or Emergency Services. LVN B stated that she had just come back onto shift from having days off and it was not in her mind to contact the Physician, DON, and Emergency Services. LVN B stated that Resident #1 was not sent out on this (10pm-6am) shift. LVN B stated that she gave report to LVN A for the next on-coming shift (6am-2pm), of Resident #1 oxygen decline during her shift. LVN B stated that she has been trained in abuse and neglect and the training is held monthly by computer and sometimes more often by in-services. LVN B stated that the negative potential outcome for residents for not reporting a change in condition is that the resident's health could decline. Review of Resident #1's physician's orders revealed no physician orders or standing orders for Albuterol and nebulizer that was given to resident before transfer to the hospital. Record Review of Resident #1's emergency room Records dated [DATE], documented by emergency room Physician, revealed: Under Basic Information: The date and time that Resident #1 arrived at the emergency room by ambulance was listed as [DATE] at 3:51 pm. Under Arrival Mode is listed as ambulance, Under History of Present Illness stated: Resident #1 presents with decreased responsiveness. The course/duration of symptoms is constant. Associated Symptoms is abdominal pain. Under emergency room Physician Documentation stated: Resident #1 presents from facility by EMS with concerns for decreased responsiveness. Resident #1 was found to be hypoxic today in the morning with sp02 of 30% and was sent to hospital in the afternoon for decreased responsiveness. Per family members, Resident #1 has not been herself for a few days. Resident #1 has been treated recently with antibiotics and steroids for concern of possible respiratory infection. Under Events Information stated: Arrival on [DATE] at 3:50 pm. Record Review of Resident #1's Progress Note dated on [DATE] at 3:09 pm documented by DON, revealed: Family member wanted resident sent out due to low O2 sats, non-responsiveness and continued coughing spells with no appetite. Will send resident to UMC. Record Review of Resident #1's Progress Note dated on [DATE] at 4:54 pm documented by LVN C, revealed: 1520 EMS arrived, assisted with transfer to stretcher with EMS personnel. 1527 EMS left building in route to UMC with family member following. An interview was conducted on [DATE] at 2:16 pm with LVN C revealed LVN C revealed that LVN C neglected Resident #1's medical need by not contacting the Physician or emergency services to adequately report a change in condition in an emergency situation as stated in facility policy. LVN C stated that she worked the shift on 2pm-10pm on [DATE]. LVN C stated that Resident #1 was sent out on her shift. LVN C stated that she received report by LVN B that was working 6am-2pm shift. LVN C stated that she was told in report by LVN A that she had trouble keeping Resident #1's oxygen level up and had to put her on oxygen with the nasal canula. LVN C stated she received no special instructions from LVN A other than Resident #1 being on oxygen at 4 liters by nasal canula and that Resident #1's oxygen level stayed at 90% for most of the shift and continue antibiotics for pneumonia. LVN C stated that usually after narcotic count, she then gets temps and O2 saturation levels. LVN C stated that Resident #1 seemed very sleepy and was not running a temperature or anything like that and that Resident #1's oxygen saturation level was at 93% with nasal canula on. Observed no documentation on the oxygen saturation levels that were said to have been taken by nursing staff. LVN C stated that LVN A stated that Resident #1 had been having trouble with her nasal canula coming off. LVN C stated that she did make sure to keep an eye on Resident #1 due to the things that she had received in report. LVN C stated that she did not call EMS because family member had just gotten to the facility to visit Resident #1 and family member then requested to the DON for Resident #1 to be sent to the hospital due to Resident #1's decline in oxygen levels and this was at the beginning of the shift. LVN C stated that Resident #1 was sent out to the hospital due to DON telling another LVN to call EMS because family member was requesting Resident #1 be sent to the hospital. LVN C stated that she did not take Resident #1's oxygen saturation without the nasal canula because she knew that Resident #1's oxygen level would drop drastically even tough Resident #1 had problems keeping her nasal canula on. LVN C stated that the process for reporting a change of condition is when you see a change of condition with a resident, and it depends on the severity of the change of condition if it is something extreme LVN C stated she would call and send the resident out to the hospital. LVN C stated that once the resident is sent out, she would then contact the physician, DON, and family. LVN C stated that the incident that occurred with Resident #1 does constitute as severe and life threatening. LVN C stated that Resident #1 should have been sent out to the hospital before now and without any hesitation C stated that it should not have taken the family member to demand that Resident #1 be sent to the hospital. LVN C stated that Resident #1 should have already been sent out to the hospital. An interview conducted on [DATE] at 11:06 am, the Administrator revealed that Administrator neglected Resident #1's medical need by not contacting the Physician or emergency services to adequately report a change in condition in an emergency situation as stated in facility policy. Administrator stated she is the Administrator at the facility when an incident of Neglect and failure to notify of change of condition occurred with the Nursing staff for Resident #1. The Administrator stated that she was notified of the decline of Resident #1's oxygen saturations levels during a clinical meeting during the week of the [DATE]th 2023, prior to [DATE]th 2023, about Resident #1's pneumonia condition and was aware that Resident #1 was placed on antibiotic. The Administrator stated that she was not aware that Resident #1 had a decline until the morning that Resident #1 was sent out to the hospital. The Administrator stated that the process for reporting change of condition starts with reporting to the physician, then the family should be notified only if there is a chronic issue, and she does not feel that what happened to Resident #1 was a chronic issue. The Administrator stated that she does feel that just administering oxygen as the nursing staff had done and not contacting the physician was correct because Resident #1 did not have a chronic condition (a chronic condition is conditions that last one year or more and require ongoing medical attention or limit activities of daily living or both). The Administrator stated that the family was not notified because the family member of Resident #1, came in the facility during shift change on the day that Resident #1 was sent out to the hospital. The Administrator stated that from her understanding it was the family member of Resident #1 that requested that she be sent to the hospital due to a decline in oxygen levels. The Administrator stated that the Physician and family member was not notified because she was notified in the meeting by the DON that the oxygen levels had come back up and was stable with the nasal canula. The Administrator stated that she is not certain that by calling emergency services or the physician if it would have even changed the outcome. Administrator stated it is the responsibility of the DON to train staff on abuse and neglect. An interview conducted on [DATE] at 11:32 am, the Director of Nurses revealed that DON neglected Resident #1's medical need by not contacting the Physician or emergency services to adequately report a change in condition in an emergency situation as stated in facility policy. The DON stated she was over LVN A and LVN B in which had failed to report a change of condition for Resident #1 to the Physician and Emergency Services causing Resident #1 to delay medical attention when her oxygen saturation levels would decline for the following 2 shifts of [DATE]-[DATE] of shift 10pm-6am and [DATE] of shift 6am-2pm. Resident #1 was not sent out to hospital through emergency services until family informed Director of Nurses to call Emergency Services on [DATE] for shift 2pm-10pm. The Director of Nurses stated that she was informed of the incident of Resident #1 oxygen saturation levels decline when she arrived to work on the morning of [DATE]. The Director of Nurses stated that she did not contact Physician or Emergency Services for Resident #1 because the facility has standing orders for oxygen for all the residents in the facility and she felt that Resident #1 was stable with the nasal canula. There were standing orders for all the residents in the facility indicating that for O2 sats below 90%, start at 3 Liters of oxygen and call Nurse Practitioner the Director of Nurses stated that Resident #1 oxygen saturation levels would stay at 90% as long as the nasal canula was on. The Director of Nurses stated that she had not assessed Resident #1 after incident, DON stated she was told by her nursing staff about the incident of Resident #1 decline in oxygen saturation levels. DON stated she was told by her LVN C nursing staff (third shift 6am-2pm), about the incident. The Director of Nurses stated that she was not aware of the oxygen saturation decline of 31% for Resident #1. The Director of Nurses stated that the process of reporting a change of condition is if an acute change (acute condition is defined as severe and sudden in onset), should occur to call the Director of Nurses immediately. The Director of Nurses stated that she does not feel that this is a change of condition that should have to be reported. The Director of Nurses stated that Resident #1 had not had problems with her oxygen saturation levels declining before. The Director of Nurses stated that a change of condition would be if the resident was completely unresponsive, and DON stated that Resident #1 was not completely unresponsive. The Director of Nurses stated that no other interventions were put into place because there was no need for further interventions. The Director of Nurses stated that the only other intervention that she can think of to put into place would have been to tape the nasal canula on Resident #1 to keep nasal canula on the resident. The Director of Nurses stated that she stands by her word in that she does not feel that the nursing staff did anything wrong, and she will not say that they did. The Director of Nurses stated that the facility has standing orders to administer oxygen. The Director of Nurses stated that the only reason the resident was sent out was because the family member requested that Resident #1 be sent to the hospital by emergency services. Resident #1 later expired at the hospital on [DATE] due to pneumonia and septic shock. The Director of Nurses stated that the family should have been contacted with the morning shift and she is not sure why they were not, but it may have been because the family had come up to the facility the day that Resident #1 was sent out because the family is who requested that Resident #1 be sent to the hospital due to the decline in oxygen saturation levels. The Director of Nurses stated that she thinks that the family is just having a hard time coping with Resident #1 death and could be why they are so upset at the facility. Interview conducted on [DATE] at 1:41 pm, Physician stated that he is aware of the situation with Resident #1. The Physician stated that he became aware of Resident #1's decline in oxygen saturation levels the day that Resident #1 was sent to the hospital on [DATE], after Resident #1 had been sent out to the hospital. The Physician stated that Resident #1 had a diagnosis of pneumonia on [DATE] and was taking antibiotics. The Physician stated that he was not notified of the decline in Resident #1's oxygen saturation levels. The Physician stated that he would consider this to have been a change of condition for Resident #1. The Physician stated that Resident #1 had pneumonia and was on antibiotics but when a resident has pneumonia and has a decrease in oxygen levels, this is a change of condition. Physician stated that he should have been notified of Resident #1's decline and was not. The Physician stated that he did also talk with his other attending physician about the situation, and she also stated that she was not notified of Resident #1's decline either. The Physician stated that the other attending Physician had covid and would be unable to interview but that he could confirm that she was not notified by the facility. The Physician confirmed that both physicians were not notified of the decline with Resident #1 by the facility. The Physician stated that he cannot say if it would have changed the outcome. Interview conducted on [DATE] at 9:48 am, LVN D revealed that LVN D neglected Resident #1's medical need by not c [TRUNCATED]

Based on interview, and record review, the facility failed to consult with the physician for a significant change in condition for 1 of 2 residents reviewed for physician notification. (Resident #1) The facility did not immediately report to the physician when Resident #1 had a bruise and swelling to the right knee with pain on [DATE]. The resident was diagnosed with [REDACTED]. This failure could cause residents to have a delay in necessary medical intervention. Findings included: Physician orders [REDACTED].#1, admitted [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. A nursing note dated [DATE] indicated Resident #1 expired in the facility. The MDS dated [DATE] indicated Resident #1's cognition was severely impaired. The resident was totally dependent with two plus physical assistance from staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS indicated the resident was totally dependent on 1-person physical assistance with bathing. The MDS indicated the resident received hospice services and received scheduled and as needed pain medications. A care plan initiated [DATE] indicated Resident #1 had acute and chronic pain due to arthritis, contractures, history of old fractures, and lump in the left breast. The plan indicated the physician was to be notified if current complaint was a significant change from the resident's past experience of pain. The care plan was canceled on [DATE] due to discharge. A care plan initiated [DATE] indicated Resident #1 had a goal of to be free from injury. The focus was the resident was at risk for falls due to lack of safety needs, history of falls, confusion, incontinence, and deconditioning. The care plan initiated on [DATE] indicated Resident #1 had terminal [DIAGNOSES REDACTED]. A revised care plan dated [DATE] indicated Resident #1 had a pressures ulcer and was at risk for further breakdown. According to the care plan staff were to report to the nurse immediately any new areas including bruising, redness, and discoloration noted during bath or daily care. A weekly skin sheet dated [DATE] by LVN D at 9:09 a.m. indicated Resident #1 had a bruise to the top of the right knee, swelling to right foot and knee. The interventions checked were pressure reducing device for the bed and tuning and repositioning. The 24-hour report/change of condition dated [DATE] indicated no issues with Resident #1 on the ,[DATE] shift, LVN D administered Resident #1 [MEDICATION NAME] at 6:15 a.m., no other comments, ,[DATE] with no issues. There were no nursing note entries for Resident #1 for [DATE] or [DATE]. An x-ray report dated [DATE] at 10:34 p.m., indicated Resident #1 had a comminuted [MEDICAL CONDITION] femur involving distal shaft, supracondylar and condylar (thigh bone break at the knee) regions with extensive spread of fracture fragments. During an interview on [DATE] at 11:03, LVN D said she did not remember who reported to her about Resident #1 having a bruise and swelling to her right knee and foot on [DATE]. She said she did not do an accident/incident report for the bruise and swelling to her right knee and she did not report the bruise and swelling to hospice, physician, DON or the administrator, where it could be followed up on. LVN D said she did not remember giving Resident #1 pain medication on [DATE]. During an interview on [DATE] at 10:00 a.m., the nurse practitioner said facility staff indicated Resident #1 possibly sustained a fracture during a Hoyer lift transfer. The nurse practitioner said it was potentially the Hoyer lift, a fall, or the resident would have to been bumped or hit hard. The nurse practitioner said, I think the Hoyer life may have been more likely, but I do not know. During an interview on [DATE] at 12:34 p.m., hospice aide F said she reported to LVN D on [DATE] Resident #1 had a bruise and swelling to the top of her right knee and exhibited signs and symptoms of pain which was not normal for her. The aide said the resident was gritting her teeth which meant she was in pain and she reported it to LVN D who gave her some pain medication. Hospice aide F said when she saw Resident #1 on [DATE] she had a skin tear, a bruise to her back, her right knee was swollen with purplish discoloration behind the knee and discoloration to the top of the knee. She said she reported her findings to LVN D who took pictures of her skin issues around 6:00 a.m. on [DATE]. During an interview on [DATE] at 3:04 p.m., the DON said she did not know LVN D was aware of a bruise and swelling to Resident #1's right knee on [DATE]. The DON said LVN D should had completed an incident report, notified the physician, hospice, and performed an assessment and initiated an investigation into the cause of the bruise and followed up on for 72 hours. She said there was a delay on [DATE] of the right leg/knee being assessed because everyone was focused on the skin breakdown. She said once she was made aware of the right leg/knee, orders were received to obtain an x-ray and investigation initiated. The conclusion of their investigation was the probable cause of the fracture occurred during a Hoyer lift transfer. The DON said an incident report should be completed for bruises, falls, skin sheers, and skin tears. During a telephone interview on [DATE] at 12:20 p.m., the radiologist said the type of fracture Resident #1 sustained did not happen on its own. The radiologist said the fracture was the result of some type of trauma. During a telephone interview on [DATE] at 2:03 p.m., the nurse practitioner said the cause of Resident #1's fracture was undetermined, could not happen by itself. During an interview on [DATE] at 2:42 p.m., the administrator said he was not aware Resident #1 had a bruise and swelling to her right knee of unknown origin on [DATE] until he started investigation on [DATE] and he read the hospice aide witness statement. He said an incident reported should had been completed on [DATE], investigation started and followed up on for 72 hours. He said he concluded the probable cause of the fracture was related to Hoyer lift transfer. An Acute Condition Changes- Clinical Protocol policy and procedure dated (MONTH) (YEAR) indicated the physician would help identify individuals with a significant risk for having acute changes of condition . The policy indicated the nursing staff would collect pertinent detail to report to the physician about someone with an acute change of condition. the policy indicated the staff and physician would discuss possible causes of the condition change and if necessary the physician would order diagnostic tests and evaluate the resident directly. The Accident and Incidents-Investigating and Reporting policy revised ,[DATE] indicated all accidents or incidents involving residents, employees, visitors, vendors et occurring on premises shall be investigated and reported to the administrator, the investigation shall be documented and include date and time, nature of injury/illness, circumstances surrounding injury, where it took place, witness statements,physician/family notification, condition of resident including vital signs, any corrective action taken and signature of person completing the form.

Based on interview and record review, the facility failed to ensure the right to be free from abuse and was provided for 1 of 2 residents reviewed for abuse and neglect. The facility did not provide assessment, notification to the physician, and interventions to prevent further injury to Resident #1 when she was noted to have bruising and swelling of unknown origin to her right knee on [DATE]. On [DATE] the resident was noted to have additional injuries that included a skin tear, a bruise to her back, her right knee was swollen with purplish discoloration behind the knee and discoloration to the top of the knee. Resident #1 who was totally dependent on staff for care was diagnosed with [REDACTED]. This failure could place residents at risk for a delay in needed treatment. Findings included: Physician orders [REDACTED].#1, admitted [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. A nursing note dated [DATE] indicated Resident #1 expired in the facility. The MDS dated [DATE] indicated Resident #1 cognition was severely impaired. The resident was totally dependent with two plus physical assistance from staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS indicated the resident was totally dependent on 1-person physical assistance with bathing. The MDS indicated the resident received hospice services and received scheduled and as needed pain medications. A care plan initiated [DATE] indicated Resident #1 had acute and chronic pain due to arthritis, contractures, history of old fractures, and lump in the left breast. The plan indicated the physician was to be notified if current complaint was a significant change from the resident's past experience of pain. A care plan initiated [DATE] indicated Resident #1 had a goal of to be free from injury. The focus was the resident was at risk for falls due to lack of safety needs, history of falls, confusion, incontinence, and deconditioning. The care plan initiated on [DATE] indicated Resident #1 had terminal [DIAGNOSES REDACTED]. A care plan initiated on [DATE] indicated she was a 2 person transfer with a mechanical lift. A revised care plan dated [DATE] indicated she had a pressures ulcer and was at risk for further breakdown. According to the care plan staff were to report to the nurse immediately of any new areas including bruising, redness, and discoloration noted during bath or daily care. A weekly skin sheet dated [DATE] by LVN D at 9:09 a.m. indicated Resident #1 had a bruise to the top of the right knee, swelling to right foot and knee. The interventions checked were pressure reducing device for the bed and turning and repositioning. A weekly skin sheet dated [DATE] by LVN D at 10:39 a.m. indicated Resident #1 had .redness to her mid back, opened area to right possibly caused by brief sheer, left gluteal fold opened area and rash, treatment nurse notified first thing this morning. The 24-hour report/change of condition indicated the following for Resident # 1: *[DATE] indicated no issues on the ,[DATE] shift, LVN D administered Resident #1 [MEDICATION NAME] at 6:15 a.m., no other comments, ,[DATE] with no issues, *[DATE] no issues on the ,[DATE], ,[DATE] or ,[DATE] shifts. [DATE] with no issues on the ,[DATE] shift, ,[DATE] shift with redness/rash to mid back, stage 2 left gluteal fold, wound care nurse aware, ,[DATE] shift knee with redness, [MEDICAL CONDITION], 2 plus [MEDICAL CONDITION], bruise, hot to touch. An x-ray report dated [DATE] at 10:34 p.m., indicated Resident #1 had a comminuted [MEDICAL CONDITION] femur involving distal shaft, supracondylar and condylar (thigh bone break at the knee) regions with extensive spread of fracture fragments. There were no nursing note entries for Resident #1 for [DATE] or [DATE]. A nursing note dated [DATE] indicated the following: *9:08 a.m. LVN D documented hospice CNA F reported Resident #1 had an open area to the right gluteal fold, redness/rash like area to middle back, and a bruise to her right knee. *10:46 a.m. Resident #1 had redness to the mid back, opened area to right possibly caused by a brief sheer, treatment nurse notified first thing this morning. *12:42 p.m. indicated LVN D notified hospice of the skin breakdown. *2:11 p.m., treatment nurse [NAME] assessed Resident #1 and noted a stage 2 pressure injury to her left ischium measuring 2.5x2.5x0.1cm and a deep tissue injury to her mid spine 5.0x2.0 cm. While repositioning resident, treatment nurse [NAME] noted discoloration to Resident #1's right leg posterior with warmth and [MEDICAL CONDITION]. an order for [REDACTED].>During an interview on [DATE] at 9:24 a.m., LVN/treatment nurse [NAME] said during shift change around 2 :00 p.m. on [DATE] she assessed Resident #1's skin issues that were reported to her from LVN D. She said when she crossed the resident's feet to roll her over she saw Resident #1's back of her right leg was discolored from mid-thigh past her knee, a red spot/bruise to the top of the knee with swelling and the foot was swollen. She said no one else was aware of it, she said she got the DON and contacted hospice. She said LVN D said she were not aware of the issue with the right leg. During an interview on [DATE] at 11:03 a.m., LVN D said she did not remember who reported to her about Resident #1 having a bruise and swelling to her right knee on [DATE]. She said she did not do an accident/incident report for the bruise and swelling to her right knee and she did not report the bruise and swelling to hospice, physician or anyone else where so it could be followed up on. LVN D said she did not remember giving Resident #1 pain medication on [DATE]. She said she was focused on Resident #1's skin issues on [DATE] and forgot to tell hospice about the bruising and swelling to the knee that was reported to her by the hospice aide. LVN D said when she looked at Resident #1's buttocks and back on [DATE], she did not see any bruising to her leg. LVN D said she did not complete an incident/accident report regarding the sheer that she thought was probably caused by the brief. During an interview on [DATE] at 10:00 a.m., the nurse practitioner said facility staff indicated Resident #1 possibly sustained a fracture during a Hoyer lift transfer. The nurse practitioner said it was potentially the Hoyer lift, a fall, or the resident would have to been bumped or hit hard. The nurse practitioner said, I think the Hoyer life may have been more likely, but I do not know. During an interview on [DATE] at 10:49 a.m., hospice RN G said she was not aware of the bruise and swelling to Resident #1's right knee on [DATE]. She said she received a text from LVN D on [DATE] at 12:14 p.m. about Resident #1's skin breakdown on her left gluteal fold and redness and rash to mid back. Hospice RN G said she did not say anything about Resident #1's right knee being bruised and swollen. Hospice RN G said when she arrived at the facility on [DATE], Resident #1 was sitting up in her wheelchair, she had the CNAs transfer her to bed, so she could assess her skin issues that had been reported. She said she stayed out of the room while the aides transferred her because she was a Hoyer lift transfer. Once Resident #1 was in the bed she and the aides rolled her to her right side, so she could assess her bottom and back. She said she did not notice anything out of the ordinary with her legs. During an interview on [DATE] at 12:34 p.m., hospice aide F said she reported to LVN D on [DATE] Resident #1 had a bruise and swelling to the top of her right knee and exhibited signs and symptoms of pain which was not normal for her. The aide said the resident was gritting her teeth which meant she was in pain and she reported it to LVN D who gave her some pain medication. Hospice aide F said when she saw Resident #1 on [DATE] she had a skin tear, a bruise to her back, her right knee was swollen with purplish discoloration behind the knee and discoloration to the top of the knee. She said she reported her findings to LVN D who took pictures of her skin issues around 6:00 a.m. on [DATE]. During an interview on [DATE] at 3:04 p.m., the DON said she did not know LVN D was aware of a bruise and swelling to Resident #1's right knee on [DATE]. The DON said LVN D should had completed an incident report, notified the physician, hospice, and performed an assessment and initiated an investigation into the cause of the bruise and followed up on for 72 hours. She said there was a delay on [DATE] of the right leg/knee being assessed because everyone was focused on the skin breakdown. She said once she was made aware of the right leg/knee, orders were received to obtain an x-ray and investigation initiated. The conclusion of their investigation was the probable cause of the fracture occurred during a Hoyer lift transfer. The DON said an incident report should be completed for bruises, falls, skin sheers, and skin tears. During a telephone interview on [DATE] at 12:20 p.m., the radiologist said the type of fracture Resident #1 sustained did not happen on its own. The radiologist said the fracture was the result of some type of trauma. During a telephone interview on [DATE] at 2:03 p.m., the nurse practitioner said the cause of Resident #1's fracture was undetermined, could not happen by itself. During an interview on [DATE] at 2:42 p.m., the administrator said he was not aware Resident #1 had a bruise and swelling to her right knee of unknown origin on [DATE] until he started investigation on [DATE] and he read the hospice aide witness statement. He said an incident reported should had been completed on [DATE], investigation started and followed up on for 72 hours. He said he concluded the probable cause of the fracture was related to Hoyer lift transfer. The Accident and Incidents-Investigating and Reporting policy revised ,[DATE] indicated .all accidents or incidents involving residents, employees, visitors, vendors ect occurring on premises shall be investigated and reported to the administrator, th investigation shall be documented and include date and time, nature of injury/illness, circumstances surrounding injury, where it took place, witness statements, physician/family notification, condition of resident including vital signs, any corrective action taken and signature of person completing the form . The Hospice Policy revised ,[DATE] indicated .communicating with the hospice provider (and documenting such communication) including reporting any alleged violations including injuries of unknown source .

Based on interview and record review, the facility failed to ensure their written policies and procedures were implemented to prevent abuse and neglect for 1 of 2 residents reviewed for abuse. (Resident # 1) The facility did not immediately report to the administrator, thoroughly investigate, and provide interventions to prevent further injury to Resident #1 when she was noted to have bruising and swelling of unknown origin to her right knee on [DATE]. On [DATE] the resident was noted to have additional injuries that included a skin tear, a bruise to her back, her right knee was swollen with purplish discoloration behind the knee and discoloration to the top of the knee. Resident #1 who was totally dependent on staff for care was diagnosed with [REDACTED]. This failure could place residents at risk for abuse. Findings included: An Abuse Investigation and Reporting policy and procedure revised (MONTH) (YEAR) indicated all reports of abuse, neglect, and injuries of unknown source would be promptly reported and thoroughly investigated. The policy indicated the administrator would assign the investigation to an appropriate individual. The Accident and Incidents-Investigating and Reporting policy revised ,[DATE] indicated all accidents or incidents involving residents, employees, visitors, vendors etc occurring on premises shall be investigated and reported to the administrator, the investigation shall be documented and include date and time, nature of injury/illness, circumstances surrounding injury, where it took place, witness statements, physician/family notification, condition of resident including vital signs, any corrective action taken and signature of person completing the form. The Abuse Investigation and Reporting Policy revised ,[DATE] indicated .if an incident or suspected incident of resident abuse, neglect or injury of unknown source is reported , the administratorwill assign the investigation the to the appropriate invidual . Physician orders [REDACTED].#1, admitted [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. A nursing note dated [DATE] indicated Resident #1 expired in the facility. The MDS dated [DATE] indicated Resident #1's cognition was severely impaired. The resident was totally dependent with two plus physical assistance from staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS indicated the resident was totally dependent on 1-person physical assistance with bathing. The MDS indicated the resident received hospice services and received scheduled and as needed pain medications. A care plan initiated [DATE] indicated Resident #1 had acute and chronic pain due to arthritis, contractures, history of old fractures, and lump in the left breast. The plan indicated the physician was to be notified if current complaint was a significant change from the resident's past experience of pain. A care plan initiated [DATE] indicated Resident #1 had a goal of to be free from injury. The focus was the resident was at risk for falls due to lack of safety needs, history of falls, confusion, incontinence, and deconditioning. The care plan initiated on [DATE] indicated Resident #1 had terminal [DIAGNOSES REDACTED]. A revised care plan dated [DATE] indicated Resident #1 had a pressures ulcer and was at risk for further breakdown. According to the care plan staff were to report to the nurse immediately any new areas including bruising, redness, and discoloration noted during bath or daily care. A weekly skin sheet dated [DATE] by LVN D at 9:09 a.m. indicated Resident #1 had a bruise to the top of the right knee, swelling to right foot and knee. The interventions checked were pressure reducing device for the bed and tuning and repositioning. The 24-hour report/change of condition dated [DATE] indicated no issues with Resident #1 on the ,[DATE] shift, LVN D administered Resident #1 [MEDICATION NAME] at 6:15 a.m., no other comments, ,[DATE] with no issues. There were no nursing note entries for Resident #1 for [DATE] or [DATE]. An x-ray report dated [DATE] at 10:34 p.m., indicated Resident #1 had a comminuted [MEDICAL CONDITION] femur involving distal shaft, supracondylar and condylar (thigh bone break at the knee) regions with extensive spread of fracture fragments. During an interview on [DATE] at 11:03, LVN D said she did not remember who reported to her about Resident #1 having a bruise and swelling to her right knee and foot on [DATE]. She said she did not do an accident/incident report for the bruise and swelling to her right knee and she did not report the bruise and swelling to hospice, physician, DON or the administrator, where it could be followed up on. LVN D said she did not remember giving Resident #1 pain medication on [DATE]. During an interview on [DATE] at 10:00 a.m., the nurse practitioner said facility staff indicated Resident #1 possibly sustained a fracture during a Hoyer lift transfer. The nurse practitioner said it was potentially the Hoyer lift, a fall, or the resident would have to been bumped or hit hard. The nurse practitioner said, I think the Hoyer life may have been more likely, but I do not know. During an interview on [DATE] at 12:34 p.m., hospice aide F said she reported to LVN D on [DATE] Resident #1 had a bruise and swelling to the top of her right knee and exhibited signs and symptoms of pain which was not normal for her. The aide said the resident was gritting her teeth which meant she was in pain and she reported it to LVN D who gave her some pain medication. Hospice aide F said when she saw Resident #1 on [DATE] she had a skin tear, a bruise to her back, her right knee was swollen with purplish discoloration behind the knee and discoloration to the top of the knee. She said she reported her findings to LVN D who took pictures of her skin issues around 6:00 a.m. on [DATE]. During an interview on [DATE] at 3:04 p.m., the DON said she did not know LVN D was aware of a bruise and swelling to Resident #1's right knee on [DATE]. The DON said LVN D should had completed an incident report, notified the physician, hospice, and performed an assessment and initiated an investigation into the cause of the bruise and followed up on for 72 hours. She said there was a delay on [DATE] of the right leg/knee being assessed because everyone was focused on the skin breakdown. She said once she was made aware of the right leg/knee, orders were received to obtain an x-ray and investigation initiated. The conclusion of their investigation was the probable cause of the fracture occurred during a Hoyer lift transfer. The DON said an incident report should be completed for bruises, falls, skin sheers, and skin tears. During a telephone interview on [DATE] at 12:20 p.m., the radiologist said the type of fracture Resident #1 sustained did not happen on its own. The radiologist said the fracture was the result of some type of trauma. During a telephone interview on [DATE] at 2:03 p.m., the nurse practitioner said the cause of Resident #1's fracture was undetermined, could not happen by itself. During an interview on [DATE] at 2:42 p.m., the administrator said he was not aware Resident #1 had a bruise and swelling to her right knee of unknown origin on [DATE] until he started investigation on [DATE] and he read the hospice aide witness statement. He said an incident reported should had been completed on [DATE], investigation started and followed up on for 72 hours. He said he concluded the probable cause of the fracture was related to Hoyer lift transfer.

Based on interview and record review, the facility failed to ensure a bruise of unknown origin was thoroughly investigated and interventions were in place to prevent further potential abuse and neglect for 1 of 2 residents reviewed for abuse/neglect. (Resident # 1) The facility did not investigate and provide interventions to prevent further injury to Resident #1 when she was noted to have bruising and swelling of unknown origin to her right knee on [DATE]. On [DATE] the resident was noted to have additional injuries that included a skin tear, a bruise to her back, her right knee was swollen with purplish discoloration behind the knee and discoloration to the top of the knee. Resident #1 who was totally dependent on staff for care was diagnosed with [REDACTED]. This failure could place residents at risk for abuse/neglect. Findings included: Physician orders [REDACTED].#1, admitted [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. A nursing note dated [DATE] indicated Resident #1 expired in the facility. The MDS dated [DATE] indicated Resident #1's cognition was severely impaired. The resident was totally dependent with two plus physical assistance from staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS indicated the resident was totally dependent on 1-person physical assistance with bathing. The MDS indicated the resident received hospice services and received scheduled and as needed pain medications. A care plan initiated [DATE] indicated Resident #1 had acute and chronic pain due to arthritis, contractures, history of old fractures, and lump in the left breast. The plan indicated the physician was to be notified if current complaint was a significant change from the resident's past experience of pain. A care plan initiated [DATE] indicated Resident #1 had a goal of to be free from injury. The focus was the resident was at risk for falls due to lack of safety needs, history of falls, confusion, incontinence, and deconditioning. The care plan initiated on [DATE] indicated Resident #1 had terminal [DIAGNOSES REDACTED]. A revised care plan dated [DATE] indicated Resident #1 had a pressures ulcer and was at risk for further breakdown. According to the care plan staff were to report to the nurse immediately any new areas including bruising, redness, and discoloration noted during bath or daily care. A weekly skin sheet dated [DATE] by LVN D at 9:09 a.m. indicated Resident #1 had a bruise to the top of the right knee, swelling to right foot and knee. The interventions checked were pressure reducing device for the bed and tuning and repositioning. The 24-hour report/change of condition dated [DATE] indicated no issues with Resident #1 on the ,[DATE] shift, LVN D administered Resident #1 [MEDICATION NAME] at 6:15 a.m., no other comments, ,[DATE] with no issues. There were no nursing note entries for Resident #1 for [DATE] or [DATE]. An x-ray report dated [DATE] at 10:34 p.m., indicated Resident #1 had a comminuted [MEDICAL CONDITION] femur involving distal shaft, supracondylar and condylar (thigh bone break at the knee) regions with extensive spread of fracture fragments. During an interview on [DATE] at 11:03, LVN D said she did not remember who reported to her about Resident #1 having a bruise and swelling to her right knee and foot on [DATE]. She said she did not do an accident/incident report for the bruise and swelling to her right knee and she did not report the bruise and swelling to hospice, physician, DON or the administrator, where it could be followed up on. LVN D said she did not remember giving Resident #1 pain medication on [DATE]. During an interview on [DATE] at 10:00 a.m., the nurse practitioner said facility staff indicated Resident #1 possibly sustained a fracture during a Hoyer lift transfer. The nurse practitioner said it was potentially the Hoyer lift, a fall, or the resident would have to been bumped or hit hard. The nurse practitioner said, I think the Hoyer life may have been more likely, but I do not know. During an interview on [DATE] at 12:34 p.m., hospice aide F said she reported to LVN D on [DATE] Resident #1 had a bruise and swelling to the top of her right knee and exhibited signs and symptoms of pain which was not normal for her. The aide said the resident was gritting her teeth which meant she was in pain and she reported it to LVN D who gave her some pain medication. Hospice aide F said when she saw Resident #1 on [DATE] she had a skin tear, a bruise to her back, her right knee was swollen with purplish discoloration behind the knee and discoloration to the top of the knee. She said she reported her findings to LVN D who took pictures of her skin issues around 6:00 a.m. on [DATE]. During an interview on [DATE] at 3:04 p.m., the DON said she did not know LVN D was aware of a bruise and swelling to Resident #1's right knee on [DATE]. The DON said LVN D should had completed an incident report, notified the physician, hospice, and performed an assessment and initiated an investigation into the cause of the bruise and followed up on for 72 hours. She said there was a delay on [DATE] of the right leg/knee being assessed because everyone was focused on the skin breakdown. She said once she was made aware of the right leg/knee, orders were received to obtain an x-ray and investigation initiated. The conclusion of their investigation was the probable cause of the fracture occurred during a Hoyer lift transfer. The DON said an incident report should be completed for bruises, falls, skin sheers, and skin tears. During a telephone interview on [DATE] at 12:20 p.m., the radiologist said the type of fracture Resident #1 sustained did not happen on its own. The radiologist said the fracture was the result of some type of trauma. During a telephone interview on [DATE] at 2:03 p.m., the nurse practitioner said the cause of Resident #1's fracture was undetermined, could not happen by itself. During an interview on [DATE] at 2:42 p.m., the administrator said he was not aware Resident #1 had a bruise and swelling to her right knee of unknown origin on [DATE] until he started investigation on [DATE] and he read the hospice aide witness statement. He said an incident reported should had been completed on [DATE], investigation started and followed up on for 72 hours. He said he concluded the probable cause of the fracture was related to Hoyer lift transfer. The administrator said he did not investigate the bruise and swelling to Resident #1's right knee on [DATE]. An Abuse Investigation and Reporting policy and procedure revised (MONTH) (YEAR) indicated all reports of abuse, neglect, and injuries of unknown source would be promptly reported and thoroughly investigated. The policy indicated the administrator would assign the investigation to an appropriate individual. The Accident and Incidents-Investigating and Reporting policy revised ,[DATE] indicated all accidents or incidents involving residents, employees, visitors, vendors etc occurring on premises shall be investigated and reported to the administrator, the investigation shall be documented and include date and time, nature of injury/illness, circumstances surrounding injury, where it took place, witness statements, physician/family notification, condition of resident including vital signs, any corrective action taken and signature of person completing the form.

Based on interview, and record review the facility failed to ensure treatment and care was provided in accordance with standards of practice and based on the comprehensive assessment for 1 of 2 residents reviewed for quality of care. (Resident #1) The facility did not assess, report to the physician or hospice agency, and provide interventions to prevent further injury to Resident #1 when she was noted to have bruising and swelling of unknown origin to her right knee on [DATE]. On [DATE] the resident was noted to have additional injuries that included a skin tear, a bruise to her back, her right knee was swollen with purplish discoloration behind the knee and discoloration to the top of the knee. Resident #1 who was totally dependent on staff for care was diagnosed with [REDACTED]. This failure could place residents at risk for a delay in needed treatment. Findings included: Physician orders [REDACTED].#1, admitted [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. A nursing note dated [DATE] indicated Resident #1 expired in the facility. The MDS dated [DATE] indicated Resident #1 cognition was severely impaired. The resident was totally dependent with two plus physical assistance from staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS indicated the resident was totally dependent on 1-person physical assistance with bathing. The MDS indicated the resident received hospice services and received scheduled and as needed pain medications. A care plan initiated [DATE] indicated Resident #1 had acute and chronic pain due to arthritis, contractures, history of old fractures, and lump in the left breast. The plan indicated the physician was to be notified if current complaint was a significant change from the resident's past experience of pain. A care plan initiated [DATE] indicated Resident #1 had a goal of to be free from injury. The focus was the resident was at risk for falls due to lack of safety needs, history of falls, confusion, incontinence, and deconditioning. The care plan initiated on [DATE] indicated Resident #1 had terminal [DIAGNOSES REDACTED]. A care plan initiated on [DATE] indicated she was a 2 person transfer with a mechanical lift. A revised care plan dated [DATE] indicated she had a pressures ulcer and was at risk for further breakdown. According to the care plan staff were to report to the nurse immediately of any new areas including bruising, redness, and discoloration noted during bath or daily care. A weekly skin sheet dated [DATE] by LVN D at 9:09 a.m. indicated Resident #1 had a bruise to the top of the right knee, swelling to right foot and knee. The interventions checked were pressure reducing device for the bed and turning and repositioning. A weekly skin sheet dated [DATE] by LVN D at 10:39 a.m. indicated Resident #1 had .redness to her mid back, opened area to right possibly caused by brief sheer, left gluteal fold opened area and rash, treatment nurse notified first thing this morning. The 24-hour report/change of condition indicated the following for Resident # 1: *[DATE] indicated no issues on the ,[DATE] shift, LVN D administered Resident #1 [MEDICATION NAME] at 6:15 a.m., no other comments, ,[DATE] with no issues, *[DATE] no issues on the ,[DATE], ,[DATE] or ,[DATE] shifts. [DATE] with no issues on the ,[DATE] shift, ,[DATE] shift with redness/rash to mid back, stage 2 left gluteal fold, wound care nurse aware, ,[DATE] shift knee with redness, [MEDICAL CONDITION], 2 plus [MEDICAL CONDITION], bruise, hot to touch. An x-ray report dated [DATE] at 10:34 p.m., indicated Resident #1 had a comminuted [MEDICAL CONDITION] femur involving distal shaft, supracondylar and condylar (thigh bone break at the knee) regions with extensive spread of fracture fragments. There were no nursing note entries for Resident #1 for [DATE] or [DATE]. A nursing note dated [DATE] indicated the following: *9:08 a.m. LVN D documented hospice CNA F reported Resident #1 had an open area to the right gluteal fold, redness/rash like area to middle back, and a bruise to her right knee. *10:46 a.m. Resident #1 had redness to the mid back, opened area to right possibly caused by a brief sheer, treatment nurse notified first thing this morning. *12:42 p.m. indicated LVN D notified hospice of the skin breakdown. *2:11 p.m., treatment nurse [NAME] assessed Resident #1 and noted a stage 2 pressure injury to her left ischium measuring 2.5x2.5x0.1cm and a deep tissue injury to her mid spine 5.0x2.0 cm. While repositioning resident, treatment nurse [NAME] noted discoloration to Resident #1's right leg posterior with warmth and [MEDICAL CONDITION]. an order for [REDACTED].>During an interview on [DATE] at 9:24 a.m., LVN/treatment nurse [NAME] said during shift change around 2 :00 p.m. on [DATE] she assessed Resident #1's skin issues that were reported to her from LVN D. She said when she crossed the resident's feet to roll her over she saw Resident #1's back of her right leg was discolored from mid-thigh past her knee, a red spot/bruise to the top of the knee with swelling and the foot was swollen. She said no one else was aware of it, she said she got the DON and contacted hospice. She said LVN D said she were not aware of the issue with the right leg. During an interview on [DATE] at 11:03 a.m., LVN D said she did not remember who reported to her about Resident #1 having a bruise and swelling to her right knee on [DATE]. She said she did not do an accident/incident report for the bruise and swelling to her right knee and she did not report the bruise and swelling to hospice, physician or anyone else where so it could be followed up on. LVN D said she did not remember giving Resident #1 pain medication on [DATE]. She said she was focused on Resident #1's skin issues on [DATE] and forgot to tell hospice about the bruising and swelling to the knee that was reported to her by the hospice aide. LVN D said when she looked at Resident #1's buttocks and back on [DATE], she did not see any bruising to her leg. LVN D said she did not complete an incident/accident report regarding the sheer that she thought was probably caused by the brief. During an interview on [DATE] at 10:00 a.m., the nurse practitioner said facility staff indicated Resident #1 possibly sustained a fracture during a Hoyer lift transfer. The nurse practitioner said it was potentially the Hoyer lift, a fall, or the resident would have to been bumped or hit hard. The nurse practitioner said, I think the Hoyer life may have been more likely, but I do not know. During an interview on [DATE] at 10:49 a.m., hospice RN G said she was not aware of the bruise and swelling to Resident #1's right knee on [DATE]. She said she received a text from LVN D on [DATE] at 12:14 p.m. about Resident #1's skin breakdown on her left gluteal fold and redness and rash to mid back. Hospice RN G said she did not say anything about Resident #1's right knee being bruised and swollen. Hospice RN G said when she arrived at the facility on [DATE], Resident #1 was sitting up in her wheelchair, she had the CNAs transfer her to bed, so she could assess her skin issues that had been reported. She said she stayed out of the room while the aides transferred her because she was a Hoyer lift transfer. Once Resident #1 was in the bed she and the aides rolled her to her right side, so she could assess her bottom and back. She said she did not notice anything out of the ordinary with her legs. During an interview on [DATE] at 12:34 p.m., hospice aide F said she reported to LVN D on [DATE] Resident #1 had a bruise and swelling to the top of her right knee and exhibited signs and symptoms of pain which was not normal for her. The aide said the resident was gritting her teeth which meant she was in pain and she reported it to LVN D who gave her some pain medication. Hospice aide F said when she saw Resident #1 on [DATE] she had a skin tear, a bruise to her back, her right knee was swollen with purplish discoloration behind the knee and discoloration to the top of the knee. She said she reported her findings to LVN D who took pictures of her skin issues around 6:00 a.m. on [DATE]. During an interview on [DATE] at 3:04 p.m., the DON said she did not know LVN D was aware of a bruise and swelling to Resident #1's right knee on [DATE]. The DON said LVN D should had completed an incident report, notified the physician, hospice, and performed an assessment and initiated an investigation into the cause of the bruise and followed up on for 72 hours. She said there was a delay on [DATE] of the right leg/knee being assessed because everyone was focused on the skin breakdown. She said once she was made aware of the right leg/knee, orders were received to obtain an x-ray and investigation initiated. The conclusion of their investigation was the probable cause of the fracture occurred during a Hoyer lift transfer. The DON said an incident report should be completed for bruises, falls, skin sheers, and skin tears. During a telephone interview on [DATE] at 12:20 p.m., the radiologist said the type of fracture Resident #1 sustained did not happen on its own. The radiologist said the fracture was the result of some type of trauma. During a telephone interview on [DATE] at 2:03 p.m., the nurse practitioner said the cause of Resident #1's fracture was undetermined, could not happen by itself. During an interview on [DATE] at 2:42 p.m., the administrator said he was not aware Resident #1 had a bruise and swelling to her right knee of unknown origin on [DATE] until he started investigation on [DATE] and he read the hospice aide witness statement. He said an incident reported should had been completed on [DATE], investigation started and followed up on for 72 hours. He said he concluded the probable cause of the fracture was related to Hoyer lift transfer. The Accident and Incidents-Investigating and Reporting policy revised ,[DATE] indicated .all accidents or incidents involving residents, employees, visitors, vendors ect occurring on premises shall be investigated and reported to the administrator, th investigation shall be documented and include date and time, nature of injury/illness, circumstances surrounding injury, where it took place, witness statements, physician/family notification, condition of resident including vital signs, any corrective action taken and signature of person completing the form . The Hospice Policy revised ,[DATE] indicated .communicating with the hospice provider (and documenting such communication) including reporting any alleged violations including injuries of unknown source .

Based on interview and record review, the facility failed to ensure adequate supervision and assistance to prevent accidents was provided for 1 of 2 residents reviewed for accidents. (Resident #1) The facility did not prevent Resident #1 who was totally dependent with two plus physical assistance from staff for bed mobility, transfers, dressing, toilet use, and personal hygiene from sustaining a comminuted fracture (type of fracture in which the bones has been broken into pieces) of the distal femur (thigh bone) involving distal shaft, supracondylar and condylar (thigh bone break at the knee) regions with extensive spread of fracture fragments This failure could place residents who are dependent on staff for activities of daily living at risk for injury. Findings included: Physician orders [REDACTED].#1, admitted [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated Resident #1 cognition was severely impaired. The resident was totally dependent with two plus physical assistance from staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS indicated the resident was totally dependent on 1-person physical assistance with bathing. The MDS indicated the resident received hospice services and received scheduled and as needed pain medications. A nursing note dated [DATE] indicated Resident #1 expired in the facility. A care plan initiated [DATE] indicated Resident #1 had acute and chronic pain due to arthritis, contractures, history of old fractures, and lump in the left breast. The plan indicated the physician was to be notified if current complaint was a significant change from the resident's past experience of pain. A care plan initiated [DATE] indicated Resident #1 had a goal of to be free from injury. The focus was the resident was at risk for falls due to lack of safety needs, history of falls, confusion, incontinence, and deconditioning. The care plan initiated on [DATE] indicated Resident #1 had terminal [DIAGNOSES REDACTED]. A care plan initiated on [DATE] indicated she was a 2 person transfer with a mechanical lift. A weekly skin sheet dated [DATE] by LVN D at 9:09 a.m. indicated Resident #1 had a bruise to the top of the right knee, swelling to right foot and knee. The interventions checked were pressure reducing device for the bed and tuning and repositioning. A weekly skin sheet dated [DATE] by LVN D at 10:39 a.m. indicated Resident #1 had redness to her mid back, opened area to right possibly caused by brief sheer, left gluteal fold opened area and rash, treatment nurse notified first thing this morning. The 24-hour report/change of condition indicated the following for Resident # 1: *[DATE] indicated no issues on the ,[DATE] shift, LVN D administered Resident #1 [MEDICATION NAME] at 6:15 a.m., no other comments, ,[DATE] with no issues, *[DATE] no issues on the ,[DATE], ,[DATE] or ,[DATE] shifts. [DATE] with no issues on the ,[DATE] shift, ,[DATE] shift with redness/rash to mid back, stage 2 left gluteal fold, wound care nurse aware, ,[DATE] shift knee with redness, [MEDICAL CONDITION], 2 plus [MEDICAL CONDITION], bruise, hot to touch. An x-ray report dated [DATE] at 10:34 p.m.,indicated Resident #1 had a comminuted [MEDICAL CONDITION] femur involving distal shaft, supracondylar and condylar (thigh bone break at the knee) regions with extensive spread of fracture fragments. There were no nursing note entries for Resident #1 for [DATE] or [DATE]. A nursing note dated [DATE] indicated the following: *9:08 a.m. LVN D documented hospice CNA F reported Resident #1 had an open area to the right gluteal fold, redness/rash like area to middle back, and a bruise to her right knee. *10:46 a.m. Resident #1 had redness to the mid back, opened area to right possibly caused by a brief sheer, treatment nurse notified first thing this morning. *12:42 p.m. indicated LVN D notified hospice of the skin breakdown. *2:11 p.m., treatment nurse [NAME] assessed Resident #1 and noted a stage 2 pressure injury to her left ischium measuring 2.5x2.5x0.1cm and a deep tissue injury to her mid spine 5.0x2.0 cm. While repositioning resident, treatment nurse [NAME] noted discoloration to Resident #1's right leg posterior with warmth and [MEDICAL CONDITION]. an order for [REDACTED].>During an interview on [DATE] at 9:24 a.m., LVN/treatment nurse [NAME] said during shift change around 2 :00 p.m. on [DATE] she assessed Resident #1's skin issues that were reported to her from LVN D. She said when she crossed the resident's feet to roll her over she saw Resident #1's back of her right leg was discolored from mid-thigh past her knee, a red spot/bruise to the top of the knee with swelling and the foot was swollen. She said no one else was aware of it, she said she got the DON and contacted hospice. She said LVN D said she were not aware of the issue with the right leg. During an interview on [DATE] at 11:03, LVN D said she did not remember who reported to her about Resident #1 having a bruise and swelling to her right knee on [DATE]. She did not do an accident/incident report for the bruise and swelling to her right knee and she did not report the bruise and swelling to hospice, physician or anyone else where it could be followed up on. LVN D said she did not remember giving Resident #1 pain medication on [DATE]. She said she was focused on Resident #1's skin issues on [DATE] and forgot to tell hospice about the bruising and swelling to the knee that was reported to her by the hospice aide. LVN D said when she looked at Resident #1's buttocks and back on [DATE], she did not see any bruising to her leg. LVN D said she did not complete an incident/accident report regarding the sheer that she thought was probably caused by the brief. During an interview on [DATE] at 10:00 a.m., the nurse practitioner said facility staff indicated Resident #1 possibly sustained a fracture during a Hoyer lift transfer. The nurse practitioner said it was potentially the Hoyer lift, a fall, or the resident would have to been bumped or hit hard. The nurse practitioner said, I think the Hoyer life may have been more likely, but I do not know. During an interview on [DATE] at 10:49 a.m., hospice RN G said she was not aware of the bruise and swelling to Resident #1's right knee on [DATE]. She said she received a text from LVN D on [DATE] at 12:14 p.m. about resident #1 had skin breakdown on her left gluteal fold and redness and rash to mid back. Hospice RN G said she did not say anything about Resident #1's right knee being bruised and swollen. Hospice RN G said when she arrived at the facility on [DATE], Resident #1 was sitting up in her wheelchair, she had the CNA's transfer her to bed, so she could assess her skin issues that had been reported. She said she stayed out of the room while the aides transferred her because she was a Hoyer lift transfer. Once Resident #1 was in the bed she and the aides rolled her to her right side, so she could assess her bottom and back. She said she did not notice anything out of the ordinary with her legs. During an interview on [DATE] at 12:34 p.m., hospice aide F said she reported to LVN D on [DATE] Resident #1 had a bruise and swelling to the top of her right knee and exhibited signs and symptoms of pain which was not normal for her. The aide said the resident was gritting her teeth which meant she was in pain and she reported it to LVN D who gave her some pain medication. Hospice aide F said when she saw Resident #1 on [DATE] she had a skin tear, a bruise to her back, her right knee was swollen with purplish discoloration behind the knee and discoloration to the top of the knee. She said she reported her findings to LVN D who took pictures of her skin issues around 6:00 a.m. on [DATE]. During an interview on [DATE] at 3:04 p.m., the DON said she did not know LVN D was aware of a bruise and swelling to Resident #1's right knee on [DATE]. The DON said LVN D should had completed an incident report, notified the physician, hospice, and performed an assessment and initiated an investigation into the cause of the bruise and followed up on for 72 hours. She said there was a delay on [DATE] of the right leg/knee being assessed because everyone was focused on the skin breakdown. She said once she was made aware of the right leg/knee, orders were received to obtain an x-ray and investigation initiated. The conclusion of their investigation was the probable cause of the fracture occurred during a Hoyer lift transfer. The DON said an incident report should be completed for bruises, falls, skin sheers, and skin tears. During an interview on [DATE] at 2:42 p.m., the administrator said he was not aware Resident #1 had a bruise and swelling to her right knee of unknown origin on [DATE] until he started investigation on [DATE] and he read the hospice aide witness statement. He said an incident reported should had been completed on [DATE], investigation started and followed up on for 72 hours. He said he concluded the probable cause of the fracture was related to Hoyer lift transfer. During a telephone interview on [DATE] at 12:20 p.m., the radiologist said the type of fracture Resident #1 sustained did not happen on its own. The radiologist said the fracture was the result of some type of trauma. During a telephone interview on [DATE] at 2:03 p.m., the nurse practitioner said the cause of Resident #1's fracture was undetermined, and could not happen by itself. The Accident and Incidents-Investigating and Reporting policy revised ,[DATE] indicated .all accidents or incidents involving residents, employees, visitors, vendors etc. occurring on premises shall be investigated and reported to the administrator, the investigation shall be documented and include date and time, nature of injury/illness, circumstances surrounding injury, where it took place, witness statements,physician/family notification, condition of resident including vital signs, any corrective action taken and signature of person completing the form .

Based on interviews and record review, it was determined the facility failed to promptly resolve grievances voiced by 1 of 6 (Resident #2) sampled residents' families and the facility SW, as the resident was unable to express his needs, when: - the facility failed to address a grievance from Resident #2's family member who complained Resident #2's bed was left soiled and soaked through to bedding with yellow liquid seeping out of his brief, which smelled terrible, on two separate occasions. - the facility failed to address a grievance promptly when the facility SW reported an incident involving 2 staff members who were laughing while changing Resident #2's brief with no regard to his crying nor sensitive to his nonverbal body language. This failure placed Resident #2 at risk of not receiving appropriate care and therefore not maintaining his highest practicable level of functioning. In addition, this facility failure placed all 67 residents at risk of a decreased self-worth and a loss of dignity. The evidence is as follows: Review of the facility's policy and procedure for Filing Grievances/Complaints, revised August 2008, documented the following: Policy Statement: Our facility will help residents, their representatives (sponsors), other interested family members, or resident advocates file grievances or complaints when such requests are made. Policy Interpretation and Implementation: - The Administrator has delegated the responsibility of grievance and/or complaint investigation to _______. (blank) - Upon receipt of a grievance and/or complaint, ___________ (blank) will investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint. -The Administrator will review the findings with the person investigating the complaint to determine what corrective actions, if any, need to be taken. - The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. Review of a Grievance Log, dated May 2013, documented the following complaints filed involving Resident #2: 1. 5/6/13 - complaint by Resident #2's family member - bed left soiled and soaked through to bedding; smells terrible; yellow liquid seeping out of brief; son found 2 separate times. Resolution pending. 2. 5/15/13 - complaint by Medication Aide - last night (5/14/13) around 9:30 p.m., the medication aide came into my office (SW), very upset about what she observed. She indicated that Resident #2 was crying and that the aid and nurse were laughing while changing Resident #2 with no regard to his crying nor sensitive to his non verbals. According to the med aide they never acknowledged his emotions. The med aide was so upset with the lack of professionalism that occurred. Resolution - will be discussed in mandatory meeting last week of May, informally on 5/15/13 with 6 - 2 and 2 - 10 shift change. Review of a Complaint/Grievance report, dated 5/6/13, documented Resident #2's family member had concerns about the bed left soiled and soaked through to bedding, smelled terrible, yellow liquid seeping out of brief, the family member had found Resident #2 this way on 2 separate occasions. The resolution of grievance/complaint section was blank. During a telephone interview on 6/10/13 at 2:41 p.m., Resident #2's family member stated Resident #2 had a stroke and could not speak but understood all that was going on. He said he told the facility about all of his concerns but they did not provide a response to any of his concerns as the poor care was an ongoing problem. He stated he felt his concerns were ignored because Resident #2 was still being found soiled and wet when he or another family member would visit. He stated, "I think my father got better care when he was in prison." Review of Resident #2's clinical record documented the following: -The face sheet documented an admitted [DATE], was [AGE] years of age with the following Diagnoses: [REDACTED]. - An admission MDS resident assessment, dated 5/8/13, documented the following: the resident was unable to speak usually understood and usually understands other people, short and long term memory loss, severely impaired cognitive skills for daily decision making, extensive assistance required by two staff for bed mobility, transfers, toileting, personal hygiene and totally dependent on one staff for eating and bathing, range of motion impairment on one side (right), uses a wheelchair, frequently incontinent of bowel and bladder, 72 inches tall (6 feet tall) and 126 pounds, has a [MEDICATION NAME] tube in the abdomen and received 26 to 50 % of his total calories and 500cc/day or less of fluid intake per day During an interview on 6/10/13 at 3:40 p.m., Resident #2, who could answer yes and no questions by shaking his head, reponded when asked the following questions: - Has any staff member been mean to you - shook his head yes, - Has any staff member ever hit you - shook his head no, - Has any staff member ever been rude to you - shook his head yes, was shaking and tearful, face turning red - Has any staff member ever intimidated you - shook his head yes, was shaking and tearful, face turning red, - Have you had to sit or lay in a poopy and wet bed or brief for long periods of time - shook his head yes, was shaking, face was very red and he was crying out loud. - Have you had this happen to you recently - shook his head yes, was shaking, face still very red and he was crying out loud and rocking back and forth, **gave the resident time to compose himself. - Have you been left dirty more than 5 times - shook his head yes, was shaking, face still very red and he was crying out loud and rocking back and forth, - Do staff talk to you while they are providing your care - shook his head no, tearful and looked down at the floor. During an interview on 6/10/13 at 4:30 p.m., the Administrator, when asked about the resolution to the 5/6/13 Complaint/Grievance Report, he stated he only had a copy and thought the Corporate nurse picked up the original as it could not be located. During a follow-up interview on 6/11/13 at 10:05 a.m., the Administrator stated the Grievance on 5/6/13 was fixed on the day it was reported. When asked what was put into place to ensure Resident #2 received the care and services he required, the Administrator stated he had not heard back from his Corporate Nurse yet but he always monitored. He stated he had planned on an in-service for completing Grievances. During an interview on 6/11/13 at 11:42 a.m., the DON stated she held a mandatory meeting on 5/31/13 to address the Grievance filed on 5/15/13 with regards to Resident #2. She stated she talked to the person who observed the incident concerning Resident #2 and with the two staff members involved but did not talk to any other staff about the incident until 5/31/13, 16 days later. She confirmed she should have implemented an in-service sooner. Review of the Resident Roster, provided by the facility on 6/10/13, documented a census of 67 residents.

Based on observation, interview and record review, it was determined the facility failed to ensure staff implemented the facility's policies and procedures to prohibit neglect for 1 of 6 residents (Resident #2) reviewed for neglect. - Observations of Resident #2 found him wearing a dirty shirt and sweat pants, with dark brown food particles stuck in his beard. In addition, the fingernails on his right hand were long and needed to be trimmed. - The facility failed to address a grievance from Resident #2's family member who complained Resident #2's bed was left soiled and soaked through to bedding with yellow liquid seeping out of his brief, which smelled terrible, on two separate occasions. - The facility failed to address a grievance promptly when the facility SW reported an incident involving 2 staff members who were laughing while changing Resident #2's brief with no regard to his crying nor sensitive to his nonverbal body language. These failures affected Resident #2 and placed all 67 residents at risk of neglect of care and services, and mental or physical anguish and of abuse or neglect going undetected and uninvestigated which could result in additional injury amd lack of treatment. The evidence is as follows: Review of a Grievance Log, dated May 2013, documented the following complaints filed involving Resident #2: 1. 5/6/13 - complaint by Resident #2's family member - bed left soiled and soaked through to bedding; smells terrible; yellow liquid seeping out of brief; son found 2 separate times. Resolution pending. 2. 5/15/13 - complaint by Medication Aide - last night (5/14/13) around 9:30 p.m., the medication aide came into my office (SW), very upset about what she observed. She indicated that Resident #2 was crying and that the aid and nurse were laughing while changing Resident #2 with no regard to his crying nor sensitive to his non verbals. According to the med aide they never acknowledged his emotions. The med aide was so upset with the lack of professionalism that occurred. Resolution - will be discussed in mandatory meeting last week of May, informally on 5/15/13 with 6 - 2 and 2 - 10 shift change. Review of a Complaint/Grievance report, dated 5/6/13, documented Resident #2's family member had concerns about the bed left soiled and soaked through to bedding, smelled terrible, yellow liquid seeping out of brief, the family member had found Resident #2 this way on 2 separate occasions. The resolution of grievance/complaint section was blank. During an interview on 6/10/13 at 4:30 p.m., the Administrator, when asked about the resolution to the 5/6/13 Complaint/Grievance Report, he stated he only had a copy and thought the Corporate nurse picked up the original as it could not be located. During a follow-up interview on 6/11/13 at 10:05 a.m., the Administrator stated the Grievance on 5/6/13 was fixed on the day it was reported. When asked what was put into place to ensure Resident #2 received the care and services he required, the Administrator stated he had not heard back from his Corporate Nurse yet but he always monitored. He stated he had planned on an in-service for completing Grievances. During an interview on 6/11/13 at 11:42 a.m., the DON stated she held a mandatory meeting on 5/31/13 to address the Grievance filed on 5/15/13 with regards to Resident #2. She stated she talked to the person who observed the incident concerning Resident #2 and with the two staff members involved but did not talk to any other staff about the incident until 5/31/13, 16 days later. She confirmed she should have implemented an in-service sooner. During a telephone interview on 6/10/13 at 2:41 p.m., Resident #2's family member stated Resident #2 had a stroke and could not speak but understood all that was going on. He said he told the facility about all of his concerns but they did not provide a response to any of his concerns as the poor care was an ongoing problem. He stated he felt his concerns were ignored because Resident #2 was still being found soiled and wet when he or another family member would visit. He stated, "I think my father got better care when he was in prison." Review of Resident #2's clinical record documented the following: -The face sheet documented an admitted [DATE], was [AGE] years of age with the following Diagnoses: [REDACTED]. - An admission MDS resident assessment, dated 5/8/13, documented the following: the resident was unable to speak usually understood and usually understands other people, short and long term memory loss, severely impaired cognitive skills for daily decision making, extensive assistance required by two staff for bed mobility, transfers, toileting, personal hygiene and totally dependent on one staff for eating and bathing, range of motion impairment on one side (right), uses a wheelchair, frequently incontinent of bowel and bladder, 72 inches tall (6 feet tall) and 126 pounds, has a [MEDICATION NAME] tube in the abdomen and received 26 to 50 % of his total calories and 500cc/day or less of fluid intake per day During an interview on 6/10/13 at 3:40 p.m., Resident #2, who could answer yes and no questions by shaking his head, reponded when asked the following questions: - Has any staff member been mean to you - shook his head yes, - Has any staff member ever hit you - shook his head no, - Has any staff member ever been rude to you - shook his head yes, was shaking and tearful, face turning red - Has any staff member ever intimidated you - shook his head yes, was shaking and tearful, face turning red, - Have you had to sit or lay in a poopy and wet bed or brief for long periods of time - shook his head yes, was shaking, face was very red and he was crying out loud. - Have you had this happen to you recently - shook his head yes, was shaking, face still very red and he was crying out loud and rocking back and forth, **gave the resident time to compose himself. - Have you been left dirty more than 5 times - shook his head yes, was shaking, face still very red and he was crying out loud and rocking back and forth, - Do staff talk to you while they are providing your care - shook his head no, tearful and looked down at the floor. An observation on 6/10/13 at 10:55 a.m. and again at 3:40 p.m., found Resident #2 wearing a dirty shirt and sweat pants with stains on both, with dark brown food particles stuck in his beard. In addition, the fingernails on his right hand were long and needed to be trimmed. Record review of the facility's policy and procedure for Abuse and Neglect - Recognizing Signs and Symptoms of Abuse/Neglect, revised April 2011, documented the following: Policy Statement: Our facility will not condone any form of resident abuse or neglect. Policy Interpretation and Implementation: Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. The following are some examples of acutal abuse/neglect and signs and symptoms of Abuse/Neglect that should be promptly reported. However, this listing is not all-inclusive. Other signs and symptoms or actual abuse/neglect may be apparent. Signs of Actual Physical Nelgect: 1. [MEDICAL CONDITION] 2. Poor hygiene 3. Inappropriate clothing (soiled, tattered) 6. Inadequate provision of care 7. Caregiver indifference to resident's personal care and needs Review of the Resident Roster, provided by the facility on 6/10/13, documented a census of 67 residents.

Based on observation, interview and record review, it was determined the facility failed to follow its written policies and procedures to prohibit neglect for 1 of 6 residents (Resident #2) reviewed for neglect. - Observations of Resident #2 found him wearing a dirty shirt and sweat pants, with dark brown food particles stuck in his beard. In addition, the fingernails on his right hand were long and needed to be trimmed. - The facility failed to address a grievance from Resident #2's family member who complained Resident #2's bed was left soiled and soaked through to bedding with yellow liquid seeping out of his brief, which smelled terrible, on two separate occasions. - The facility failed to address a grievance promptly when the facility SW reported an incident involving 2 staff members who were laughing while changing Resident #2's brief with no regard to his crying nor sensitive to his nonverbal body language. These failures affected Resident #2 and placed all 67 residents at risk of neglect of care and services, and mental or physical anguish and of abuse or neglect going undetected and uninvestigated which could result in additional injury amd lack of treatment. The evidence is as follows: Record review of the facility's policy and procedure for Abuse and Neglect - Recognizing Signs and Symptoms of Abuse/Neglect, revised April 2011, documented the following: Policy Statement: Our facility will not condone any form of resident abuse or neglect. Policy Interpretation and Implementation: Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. The following are some examples of acutal abuse/neglect and signs and symptoms of Abuse/Neglect that should be promptly reported. However, this listing is not all-inclusive. Other signs and symptoms or actual abuse/neglect may be apparent. Signs of Actual Physical Nelgect: 1. [MEDICAL CONDITION] 2. Poor hygiene 3. Inappropriate clothing (soiled, tattered) 6. Inadequate provision of care 7. Caregiver indifference to resident's personal care and needs Review of a Grievance Log, dated May 2013, documented the following complaints filed involving Resident #2: 1. 5/6/13 - complaint by Resident #2's family member - bed left soiled and soaked through to bedding; smells terrible; yellow liquid seeping out of brief; son found 2 separate times. Resolution pending. 2. 5/15/13 - complaint by Medication Aide - last night (5/14/13) around 9:30 p.m., the medication aide came into my office (SW), very upset about what she observed. She indicated that Resident #2 was crying and that the aid and nurse were laughing while changing Resident #2 with no regard to his crying nor sensitive to his non verbals. According to the med aide they never acknowledged his emotions. The med aide was so upset with the lack of professionalism that occurred. Resolution - will be discussed in mandatory meeting last week of May, informally on 5/15/13 with 6 - 2 and 2 - 10 shift change. Review of a Complaint/Grievance report, dated 5/6/13, documented Resident #2's family member had concerns about the bed left soiled and soaked through to bedding, smelled terrible, yellow liquid seeping out of brief, the family member had found Resident #2 this way on 2 separate occasions. The resolution of grievance/complaint section was blank. During an interview on 6/10/13 at 4:30 p.m., the Administrator, when asked about the resolution to the 5/6/13 Complaint/Grievance Report, he stated he only had a copy and thought the Corporate nurse picked up the original as it could not be located. During a follow-up interview on 6/11/13 at 10:05 a.m., the Administrator stated the Grievance on 5/6/13 was fixed on the day it was reported. When asked what was put into place to ensure Resident #2 received the care and services he required, the Administrator stated he had not heard back from his Corporate Nurse yet but he always monitored. He stated he had planned on an in-service for completing Grievances. During an interview on 6/11/13 at 11:42 a.m., the DON stated she held a mandatory meeting on 5/31/13 to address the Grievance filed on 5/15/13 with regards to Resident #2. She stated she talked to the person who observed the incident concerning Resident #2 and with the two staff members involved but did not talk to any other staff about the incident until 5/31/13, 16 days later. She confirmed she should have implemented an in-service sooner. During a telephone interview on 6/10/13 at 2:41 p.m., Resident #2's family member stated Resident #2 had a stroke and could not speak but understood all that was going on. He said he told the facility about all of his concerns but they did not provide a response to any of his concerns as the poor care was an ongoing problem. He stated he felt his concerns were ignored because Resident #2 was still being found soiled and wet when he or another family member would visit. He stated, "I think my father got better care when he was in prison." Review of Resident #2's clinical record documented the following: -The face sheet documented an admitted [DATE], was [AGE] years of age with the following Diagnoses: [REDACTED]. - An admission MDS resident assessment, dated 5/8/13, documented the following: the resident was unable to speak usually understood and usually understands other people, short and long term memory loss, severely impaired cognitive skills for daily decision making, extensive assistance required by two staff for bed mobility, transfers, toileting, personal hygiene and totally dependent on one staff for eating and bathing, range of motion impairment on one side (right), uses a wheelchair, frequently incontinent of bowel and bladder, 72 inches tall (6 feet tall) and 126 pounds, has a [MEDICATION NAME] tube in the abdomen and received 26 to 50 % of his total calories and 500cc/day or less of fluid intake per day During an interview on 6/10/13 at 3:40 p.m., Resident #2, who could answer yes and no questions by shaking his head, reponded when asked the following questions: - Has any staff member been mean to you - shook his head yes, - Has any staff member ever hit you - shook his head no, - Has any staff member ever been rude to you - shook his head yes, was shaking and tearful, face turning red - Has any staff member ever intimidated you - shook his head yes, was shaking and tearful, face turning red, - Have you had to sit or lay in a poopy and wet bed or brief for long periods of time - shook his head yes, was shaking, face was very red and he was crying out loud. - Have you had this happen to you recently - shook his head yes, was shaking, face still very red and he was crying out loud and rocking back and forth, **gave the resident time to compose himself. - Have you been left dirty more than 5 times - shook his head yes, was shaking, face still very red and he was crying out loud and rocking back and forth, - Do staff talk to you while they are providing your care - shook his head no, tearful and looked down at the floor. An observation on 6/10/13 at 10:55 a.m. and again at 3:40 p.m., found Resident #2 wearing a dirty shirt and sweat pants with stains on both, with dark brown food particles stuck in his beard. In addition, the fingernails on his right hand were long and needed to be trimmed. Review of the Resident Roster, provided by the facility on 6/10/13, documented a census of 67 residents

Based on observation, record review, and interview, it was determined the facility failed to ensure 1 of 6 sampled residents (Resident #2), was provided the necessary care and services to maintain good personal hygiene when - - Observations of Resident #2 found him wearing a dirty shirt and sweat pants, with dark brown food particles stuck in his beard. In addition, the fingernails on his right hand were long and needed to be trimmed. This failure had the potential to result in Resident #2 having a lowered self-esteem and depression and developing skin tears from the untrimmed nails. The facilities failure to ensure residents received good personal hygiene placed all 34 residents who required assistance with positioning/had contractures or had limited range of motion. The evidence is as follows: During a telephone interview on 6/10/13 at 2:41 p.m., Resident #2's family member stated Resident #2 had a stroke and could not speak but understood all that was going on. He said he told the facility about all of his concerns but they did not provide a response to any of his concerns as the poor care was an ongoing problem. He stated he felt his concerns were ignored because Resident #2 was still being found soiled and wet when he or another family member would visit. He stated, "I think my father got better care when he was in prison." During an interview on 6/10/13 at 3:40 p.m., Resident #2, who could answer yes and no questions by shaking his head, responded when asked the following questions: - Have you had to sit or lay in a poopy and wet bed or brief for long periods of time - shook his head yes, was shaking, face was very red and he was crying out loud. - Have you had this happen to you recently - shook his head yes, was shaking, face still very red and he was crying out loud and rocking back and forth, **gave the resident time to compose himself. - Have you been left dirty more than 5 times - shook his head yes, was shaking, face still very red and he was crying out loud and rocking back and forth, - Do staff talk to you while they are providing your care - shook his head no, tearful and looked down at the floor. An observation on 6/10/13 at 10:55 a.m. and again at 3:40 p.m., found Resident #2 wearing a dirty shirt and sweat pants with stains on both, with dark brown food particles stuck in his beard. In addition, the fingernails on his right hand were long and needed to be trimmed. Review of Resident #2's clinical record documented the following: -The face sheet documented an admitted [DATE], was [AGE] years of age with the following Diagnoses: [REDACTED]. - An admission MDS resident assessment, dated 5/8/13, documented the following: the resident was unable to speak usually understood and usually understands other people, short and long term memory loss, severely impaired cognitive skills for daily decision making, extensive assistance required by two staff for bed mobility, transfers, toileting, personal hygiene and totally dependent on one staff for eating and bathing, range of motion impairment on one side (right), uses a wheelchair, frequently incontinent of bowel and bladder, 72 inches tall (6 feet tall) and 126 pounds, has a feeding tube in the abdomen and received 26 to 50 % of his total calories and 500cc/day or less of fluid intake per day Review of the Facility Roster/Sample Matrix, received on 6/10/11, documented 34 residents who required assistance with positioning/had contractures or had limited range of motion.