Cadia Rehabilitation Broadmeadow

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility policy review, the facility failed to ensure residents were informed of psychotropic medication side effects and the associated risks versus benefits for two out of five residents (Resident (R) 58 and R5) reviewed for unnecessary medications of 31 sample residents. This failure had the potential for residents to be uninformed of potential outcomes related to psychotropic medications. Findings include: 1. Review of R58's admission Record located under the Profile tab of the electronic medical record (EMR) revealed R58 was admitted on [DATE] with diagnoses which included bipolar disorder, major depressive disorder (MDD), and anxiety. Review of R58's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/25 and located under the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated intact cognition. Review of the Order Summary Report located under the Orders tab of the EMR, active as of 01/29/26, revealed the following orders: -Buspirone HCL [hydrochloric acid] [antianxiety medication] oral tablet 15 MG [milligram]. Give one tablet by mouth two times a day for anxiety, dated 07/10/25. -Duloxetine HCL [antidepressant medication] oral capsule delayed release particles 60 MG. Give one capsule by mouth one time a day for MDD, dated 07/10/25. -Risperidone [antipsychotic medication] oral tablet three MG. Give one tablet by mouth at bedtime for delusional disorder, dated 07/10/25. Review of the EMR revealed no documentation of consent or risk versus benefit review with the resident or representative. During an interview on 01/29/26 at 1:09 PM, the resident stated she was told what medications she was on but not about potential effects related to the medications provided. During an interview on 01/29/26 at 8:05 AM, the Director of Nursing (DON) stated they did not have any documentation specific to the review of the potential effects of the psychotropic medications with the resident or representative. At 11:56 AM, she acknowledged that the required information was listed in the policy. 2. Review of R5's admission Record located under the Profile tab of the EMR revealed R5 was admitted on [DATE], and readmitted on [DATE], with diagnoses which included MDD and anxiety disorder. Review of R5's quarterly MDS with an ARD of 11/27/25 and located under the MDS tab of the EMR revealed a BIMS score of 15 out of 15, which indicated intact cognition. Review of the Order Summary Report located under the Orders tab of the EMR, active as of 01/29/26, revealed the following orders: -Buspirone HCL [antianxiety medication] oral tablet 10 MG. Give one tablet by mouth three times a day for anxiety, dated 08/25/25. -Duloxetine HCL [antidepressant medication] capsule delayed release particles 20 MG. Give one capsule by mouth one time a day for depression, dated 01/29/26. Review of the EMR revealed no documentation of consent or risk versus benefit review with the resident or representative. During an interview on 01/30/26 at 8:16 AM, the resident stated she did not remember having any discussion with staff about the medication effects. She stated she was unsure of what medication she was taking.During an interview on 01/30/26 at 9:38 AM, the DON stated there was no documentation of any staff conversation with R5 regarding risks versus benefits for the medications. Review of the facility's policy titled, Psychoactive Medications, reviewed 01/13/26, revealed residents are educated on the benefits and the potential risks of the drugs and education is documented in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and policy review, the facility failed to notify the correct emergency contact of a change in condition for one of one resident (Resident (R) 122) reviewed for change in condition out of a total of 31 sampled residents. This failure had the potential to delay timely notification of R122's representative regarding the resident's condition change.Findings include:Review of R122's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R122 was admitted to the facility on [DATE] with diagnoses of unspecified dementia, severe, with other behavioral disturbance and chronic pain.Review of R122's annual Minimum Data Set (MDS) located under the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 09/12/24, indicated R122 had a Brief Interview for Mental Status (BIMS) score of two out of 15 which indicated R122 was severely cognitively impaired. R122 was also coded as not having one or more unhealed pressure ulcers.Review of R122's Nursing Progress Notes located under the Progress Note tab in the EMR indicated on 11/03/24 at 2:20 PM, Charge nurse alerted writer that the resident [R122] was noted with a blister to right heel . Message left for [emergency contact #2]; awaiting return call.During a phone interview on 01/29/26 at 4:37 PM, Family Member (FM) 1 stated, I got a phone call from a nurse on 11/06/24 that [R122] had developed a wound to her buttocks and her heel. I asked the nurse when they first saw these wounds, and she stated that the right heel blister was noted on 11/03/24, and the nurse called [emergency contact #2]. I asked why I was not contacted since I was the first one to be contacted, and the nurse did not know.During an interview on 01/29/26 at 5:10 PM, Registered Nurse/Unit Manager (RN/UM) 1 stated, The nurse would contact the person listed as the first contact and then if they cannot get that person, the nurse would notify the second person on the list to be contacted. When asked if this would be documented, RN/UM1 stated, Yes, in the progress notes. The nurse would document who she notified of the change. If the nurse could not talk to the first contact on the list, then she would document that a message was left and then contact the second person on the list.During an interview on 01/30/26 at 2:36 PM, the Director of Nursing (DON) stated, For this resident it would be emergency contact number one [FM1], and if you were unable to get ahold of that person then you would contact emergency contact number two. The nurse is to document the phone call to the emergency contact. If the first emergency contact could not be contacted, then the nurse would call the second emergency contact and would document both phone calls. The DON confirmed that emergency contact number two was called for R122. A message was left for that person to call the facility back, but it should have been emergency contact number one contacted.Review of the facility's policy titled, Provider Notification of Resident Change in Medical Condition, dated 01/13/26, indicated . Staff will notify the provider and applicable POA [Power of attorney]/responsible parties of: . Significant change in condition in physical, mental, or psychosocial status .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that one of 31 sampled residents (Resident (R) 28) was free from physical restraints when staff failed to identify a seatbelt worn on a motorized wheelchair as a physical restraint, restricting the resident's freedom of movement and access to their body. This failure created the potential for facility residents to receive inappropriate care and services, or a lack of, due to unidentified care needs and interventions from an unassessed lower extremity restraint. Findings include:Review of R28's Face Sheet, located in the Electronic Medical Record (EMR) under the Profile tab, indicated the resident was admitted to the facility on [DATE]. The document indicated the resident's diagnoses included traumatic subarachnoid hemorrhage with loss of consciousness, lack of coordination, abnormal posture, hemiplegia unspecified affecting right dominant side, personal history of traumatic brain injury, aphasia following cerebral infarction, and contracture of right elbow, wrist, and hand. Review of R28's quarterly Minimum Data Set (MDS) Assessment, with an assessment reference date (ARD) of 11/04/25 and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) assessment score of 13 out of 15, which indicated the resident was cognitively intact. The resident was documented to have functional limitation in range of motion for upper extremity on both sides and used a motorized wheelchair. R28 required substantial/maximum assistance for sitting to lying, lying to sitting on side of bed, sit to stand, and chair/bed-to-chair transfers. R28 did not use restraints.Review of R28's Comprehensive Care Plan, dated 09/14/22 and located in the EMR under the Care Plan tab, revealed R28 had an ADL (activities of daily living) self-care performance deficit related to right [side] hemiparesis. An identified intervention, revised 02/26/24, documented that R28 had a power chair (motorized wheelchair) with back cushion on her wheelchair to maximize safety, comfort, and independence in mobility throughout the facility. The care plan did not identify a seat belt intervention.Review of R28's Comprehensive Care Plan, and located under the Care Plan tab in the EMR failed to identify any problem or associated interventions that indicated the resident used a seat belt while seated in the motorized wheelchair, as observed throughout the survey.During an observation on 01/28/26 at 1:19 PM, R28 was observed in their room seated in their motorized wheelchair, with a seat belt on, with the buckle observed off to the right side of the lap. The resident was observed with a contracted right arm. R28 was asked if they were able to release the seat belt, and they stated yes. They then proceeded to lean to the left and attempted to manipulate the wheelchair controller.During an additional observation on 01/29/26 at 8:08 AM, R28 was observed in their room in their motorized wheelchair, with a seat belt on. During an additional observation on 01/30/26 at 7:55 AM, R28 was observed in their motorized wheelchair with a seat belt on, and with a visible right arm contracture. R28 was asked if the seat belt was comfortable. The resident leaned forward in their wheelchair and stated, No. The resident used their left hand to reach back and touch her lower left back. At 7:58 AM, Certified Nursing Assistant (CNA) 1 entered the resident room and observed R28 leaning forward. CNA1 said that residents with electric wheelchairs had seat belts. CNA1 said R28 did lean forward, so that the seat belt helped with safety. CNA1 stated that all electric wheelchairs had seat belts and then said that they placed the seat belt on R28 when they were put into the wheelchair in the morning and that it was on all day until bedtime, or if R28 had to go to the bathroom.During an interview on 01/30/26 at 8:13 AM, CNA2 said residents with electric wheelchairs had seat belts for their wheelchairs. CNA2 said the CNAs were trained during orientation, and the rehab staff would educate them if a resident was using a seat belt. CNA2 confirmed that they would put the seat belt on the resident when they put them into the wheelchair and only take it off when they were removed from the wheelchair, like toileting or going back to bed. CNA2 said they thought some of the residents could remove the belts themselves.During an interview on 01/30/26 at 8:25 AM, Registered Nurse/Unit Manager (RN/UM) 1 said that they were not sure what the seat belt process was at the facility but believed the rehabilitation department assessed for them and would then educate the CNAs on how to use them. RNUM1 then reviewed the EMR for R28 and confirmed that there was no order for R28 to use a wheelchair seat belt. RNUM1 again, upon review of the EMR, confirmed there was no care plan for a seat belt. RNUM1 said that the nurses could add interventions, but that care plans were reviewed with the interdisciplinary team.During an interview on 01/30/26 at 8:35 AM, MDS Coordinator (MDS) 1 said that they did not capture the seat belts in MDS because it was their understanding that the rehabilitation department would assess the residents, and that they would be capable of removing them. MDS1 confirmed they did not review these assessments. MDS1 said they would expect staff to check for positioning, that they were secure, and the residents could remove them. MDS1 confirmed these interventions should be identified in a care plan. During an interview on 01/30/26 at 8:58 AM, the Director of Rehab (DOR) stated that the facility tried not to use restraints. They said that during orientation they discussed gait belts, but they did not use seat belts. DOR said they were aware that most electric wheelchairs came with them, but the rehab department did not assess them to be used. DOR said that they assess residents quarterly to make sure the residents were positioned well and can get around safely, but since they did not use seat belts, they did not check them. DOR confirmed they were not aware that the CNAs were putting them on, and that it was probably a miscommunication. The DOR said she had been informed that R28 did not like the seat belt, and that she would have a tough time getting it off. They stated they would review the last time they reviewed R28's seat belt.During an additional interview on 01/30/26 at 10:04 AM, the DOR said that the last full assessment for R28's wheelchair was upon admission and provided the documentation. The DOR said that the assessment stated the resident could unlock the seat belt, and it would not be a restraint.Review of the facility provided document titled Physical Therapy and Plan of Treatment, dated 10/20/22, revealed that R28, .was able to unbuckle her seatbelt upon command but needs assistance w/buckling seatbelt.due to documented physical impairments and associated functional deficits, the patient is at risk for falls, injury to RLE (right lower extremity) during power chair mobility, further decline in function, increased dependency upon caregivers and compromised general health. This documentation revealed the facility was aware that the resident had a seat belt, and that it had been in use, but there was no indication in the EMR of any ongoing follow-up to its use or safety. During a follow-up interview on 01/30/26 at 10:15 AM, DOR provided the last wheelchair assessment from physical and occupation therapy.Review of the provided Occupational Therapy Discharge summary, dated [DATE], documented R28, .demonstrates MI (modified independent) and safety with wheelchair (sic) mobility with good demonstration of safety to reduce speed through doors and include.demonstrated an increase ROM (range of motion) for right shoulder flexion to 110* from 100*. Documentation review of the last wheelchair assessment for R28 revealed no documentation or assessment related to the identification of a seat belt on the wheelchair. This was the last documentation for wheelchair or seat belt assessment. During an interview on 01/30/26 at 1:08 PM, the Director of Nursing (DON) stated that they had been informed that wheelchairs should be assessed on admission and quarterly, going forward. They said that the seat belt should be a part of the care plan. She stated that if the seat belt is not being documented as a restraint in assessments, then it should not be on the electric wheelchair. The DON said there needed to be more training for staff regarding seat belt use.Review of the facility's policy titled, Restraint and Seclusion Policy, last reviewed 01/13/26 read, in pertinent part, .residents have the right to be free from any physical or chemical restraint/or seclusion imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms.Physical Restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.In an extreme safety situation that compromises the safety of the resident or others, a provider's order may be obtained to restrain or seclude the resident until the situation has ceased or the resident has been transferred to an acute setting and the safety of the resident and others can be ensured.Documentation in the Electronic Medical Record must support the assessment for, evaluation of, and timeframe of use of a restraint or seclusion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review, the facility failed to report an injury of unknown origin to the State Agency for one resident (Resident (R) 21) reviewed for injuries of unknown origin out of 31 sampled residents. The facility's failure to promptly report injuries of unknown origin limited regulatory oversight and had the potential to delay protective interventions. Findings include:Review of R21's admission Record, located under the admission tab of the electronic medical record (EMR) revealed R21 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, dementia, and transient cerebral ischemic attack. Review of R21's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/14/25, revealed that R21 had a Brief Interview for Mental Status (BIMS) score of 7 of 15, indicating that R21's cognitive function was severely impaired. Review of R21's Care Plan, initiated on 12/04/25, located under the Care Plan tab revealed that R21 had fallen and was at an increased risk for experiencing additional falls related to deconditioning, hearing problems, poor safety awareness, impulsive, muscle weakness, unsafe transfer behavior, medications, and history of falls. Interventions included following facility post fall protocol, assess for injuries, monitoring vital signs, and notifying the physician. Review of R21's Care Plan, initiated on 12/12/25, located under the Care Plan tab revealed that R21 had impaired cognitive function related to dementia with an intervention in place that included, .to cue, reorient and supervise as needed.Review of the Nurse Practitioner's (NP), note dated 01/15/26, located under the Progress Notes tab in the EMR stated, [AGE] year-old female seen today for Right arm swelling, multiple falls, dementia. She is seen sitting up in a chair in the common area. Per staff they noticed swelling on her right forearm. Patient was unaware of it, denying pain. She has had multiple falls[.] No injuries noted at the time[.] Patient is a poor historian with advanced dementia. She was able to move her right arm, no grimacing, and no pain to area. Wrist, elbow and shoulder [have] full range of motion, positive pulses, [and] cap refill less than 3 seconds.Review of the facility provided form titled, Witness Written Summary, dated 01/14/26 at 8:30 AM, written and signed by physical therapy assistant (PTA)indicated, .during therapy session, resident was noted with increased edema on right forearm and resident was unable to explain what happened and quantify pain level due to cognition. Nursing was notified.Review of the facility provided form titled, Witness Written Summary, dated 01/14/26 at 11:29 AM, written and signed by Licensed Practical Nurse (LPN) 3 stated, .resident was noted with hematoma to right forearm and unable to recall what happened. Noted with signs of pain and resident was given pain medication per physician's order and the nurse practitioner was made aware.During an interview on 01/30/26 at 11:55 AM with the Administrator, she stated .for our state, an insignificant or non-serious injury of unknown source, that we do not have to report that to them. I report and the Director of Nursing (DON) does the investigation. She and I review the reports together.During an interview on 01/30/26 at 12:07 PM with the DON, she stated, .we determine if it needs to be reported. We interview the staff, the residents and then we determine if it meets the criteria for reporting. When asked if this incident was reported to the state, she stated, No, I don't have a copy of this being reported to the state.Review of the facility's policy titled, Abuse, Neglect, Mistreatment, Misappropriation, Exploitation, and Reasonable Suspicions of Crime, last review date of 01/09/26, on page four of five, stated, under the item, Investigation,. All alleged incidents involving abuse, neglect, mistreatment, misappropriation of resident property, exploitation, or reasonable suspicions of crime, including injuries of unknown source, shall be reported to the Administrator or designee immediately. The Administrator or designee shall investigate allegations and report to appropriate regulatory agencies and/or law enforcement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review, the facility failed to investigate an injury of unknown origin for one resident (Resident (R) 21) out of a total sample of 31 residents. The facility's failure to promptly investigate injuries of unknown origin had the potential to delay protective interventions for residents.Findings include:Review of R21's admission Record, located under the admission tab of the electronic medical record (EMR) revealed R21 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy, dementia, and transient cerebral ischemic attack. Review of R21's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/14/25, located under the MDS tab of the EMR revealed that R21 was assessed with a Brief Interview for Mental Status (BIMS) score of 7 of 15 indicating that R21's cognitive function was severely impaired. Review of R21's Care Plan, initiated on 12/04/25, located under the Care Plan tab revealed that R21 had fallen and was at an increased risk for experiencing additional falls related to deconditioning, hearing problems, poor safety awareness, impulsive, muscle weakness, unsafe transfer behavior, medications, and history of falls. Interventions included following facility post fall protocol, assessing injuries, monitoring vital signs, and notifying the physician. Review of R21's Care Plan, initiated on 12/12/25, located under the Care Plan tab revealed that R21 had impaired cognitive function related to dementia with an intervention in place that included, .to cue, reorient and supervise as needed.Review of the Nurse Practitioner's (NP) note, dated 01/15/26, located under the Progress Notes tab in the EMR stated, [AGE] year-old female seen today for Right arm swelling, multiple falls, [and]dementia. She is seen sitting up in a chair in the common area[.] Per staff they noticed swelling on her right forearm. Patient was unaware of it, denying pain. She has had multiple falls[.] No injuries noted at the time[.] Patient is a poor historian with advanced dementia. She was able to move her right arm, no grimacing, and no pain to area. Wrist, elbow and shoulder [have] full range of motion, positive pulses, [and] cap refill less than 3 seconds.Review of the paper form provided by the facility titled, Witness Written Summary, dated 01/14/26 at 8:30 AM, written and signed by physical therapy assistant (PTA ) stated, .during therapy session, resident was noted with increased edema on right forearm and resident was unable to explain what happened and quantify pain level due to cognition. Nursing was notified.Review of the paper form provided by the facility titled, Witness Written Summary, dated 01/14/26 at 11:29 AM, written and signed by Licensed Practical Nurse (LPN) 3 stated, .resident was noted with hematoma to right forearm and unable to recall what happened. Noted with signs of pain and resident was given pain medication per physician's order and the nurse practitioner was made aware.During an interview on 01/30/26 at 11:55 AM, the Administrator stated For our state, an insignificant or non-serious injury of unknown source, that we do not have to report that to them. I report and the Director of Nursing (DON) does the investigation. She and I review the reports together.During an interview on 01/30/26 at 12:07 PM, the DON stated, We determine if it needs to be reported. We interview the staff, the residents and then we determine if it meets the criteria for reporting. When asked if this incident was reported to the state, she stated, No, I don't have a copy of this being reported to the state. No, this incident was not investigated.Review of the facility's policy titled, Abuse, Neglect, Mistreatment, Misappropriation, Exploitation, and Reasonable Suspicions of Crime, last review date of 01/09/26, on page four of five, stated, under the item, Investigation. All alleged incidents involving abuse, neglect, mistreatment, misappropriation of resident property, exploitation, or reasonable suspicions of crime, including injuries of unknown source, shall be reported to the Administrator or designee immediately. The Administrator or designee shall investigate allegations and report to appropriate regulatory agencies and/or law enforcement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility policy review, the facility failed to ensure one of 31 sampled residents (Resident (R) 28) care plans were reviewed and revised to identify the regular use of a wheelchair seatbelt. This failure created the potential for facility residents to receive inappropriate care and services, or a lack of, due to unidentified care needs and interventions. Cross-reference to F604, Physical Restraints.Findings include:1. Review of R28's Face Sheet, located in the Electronic Medical Record (EMR) under the Profile tab, indicated the resident was admitted to the facility on [DATE]. The document indicated the resident's diagnoses included traumatic subarachnoid hemorrhage with loss of consciousness, lack of coordination, abnormal posture, hemiplegia unspecified affecting right dominant side, personal history of traumatic brain injury, aphasia following cerebral infarction, and contracture of right elbow, wrist, and hand.Review of R28's quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 11/04/25 and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) assessment score of 13 out of 15, which indicated the resident was cognitively intact. The MDS indicated R28 had functional limitations in range of motion for bilateral upper extremities and used a motorized wheelchair. R28 required substantial/maximum assistance for sitting to lying, lying to sitting on side of bed, sitting to stand, and chair/bed-to-chair transfers.Review of R28's Comprehensive Care Plan, dated 09/14/22 and located in the EMR under the Care Plan tab, revealed R28 had an ADL (activities of daily living) self-care performance deficit related to right [side] hemiparesis. An identified intervention, revised 02/26/24, documented that R28 had a power chair (motorized wheelchair) with back cushion on her wheelchair to maximize safety, comfort, and independence in mobility throughout the facility. The care plan did not identify a seat belt intervention.Further review of R28's Comprehensive Care Plan failed to identify any problem or associated interventions that indicated the resident used a seat belt while seated in the motorized wheelchair, as observed throughout the survey.During an observation on 01/28/26 at 1:19 PM, R28 was observed in their room seated in their motorized wheelchair, with a seat belt on.During an observation on 01/29/26 at 8:08 AM, R28 was observed in their room in their motorized wheelchair, with a seat belt on. During an observation on 01/30/26 at 7:55 AM, R28 was observed in their motorized wheelchair with a seat belt on.During an interview on 01/30/26 at 8:25 AM, Registered Nurse/Unit Manager (RN/UM) 1 reviewed the EMR for R28 and confirmed that there was no order for R28 to use a wheelchair seat belt. RNUM1 again, upon review of the EMR, confirmed there was no care plan for a seat belt. RNUM1 said that the nurses could add interventions, but that care plans were reviewed with the interdisciplinary team.During an interview on 01/30/26 at 8:35 AM, MDS Coordinator (MDS) 1 said that they did not capture the seat belts in MDS because it was their understanding that the rehabilitation department would assess the residents, and that they would be capable of removing them. MDS1 confirmed they did not review these assessments. MDS1 said they would expect staff to check for positioning, that they were secure, and the residents could remove them. MDS1 confirmed these interventions should be identified in a care plan. During an interview on 01/30/26 at 1:08 PM, the Director of Nursing (DON) stated that they had been informed that wheelchairs should be assessed on admission and quarterly, going forward. They said that the seat belt should be a part of the care plan. She stated that if the seat belt is not being documented as a restraint in assessments, then it should not be on the electric wheelchair. The DON said there needed to be more training for staff regarding seat belt use. During an additional interview on 01/30/26 at 5:09 PM, the DON stated that the facility did not have a policy specific to care plan revisions, just a comprehensive care plan policy.Review of the facility's policy titled, Care Planning, last reviewed 01/13/26 read, in pertinent part, .a comprehensive care plan is developed that incorporates resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practical, physical, mental, and psychosocial wellbeing.A comprehensive care plan must be prepared by an interdisciplinary team.Care plans should include: Services furnished to maintain highest practical well-being.The resident's goals for admission and desired outcomes.The resident's preferences.The comprehensive care plans should be reviewed and revised by the interdisciplinary team after each assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure residents who are unable to conduct activities of daily living (ADLs) receive the necessary services for one resident (Resident (R) 73) out of a total sample of 31 residents. R73 reported that she has not received help with oral care, and she was observed to have a buildup of debris on her teeth and gums. This failure had the potential to affect nutritional status, cause dental cavities, and gum diseaseFindings include:Review of R73's admission Record, located under the admission tab of the electronic medical record (EMR) revealed R73 was admitted to the facility on [DATE] with diagnoses that included dysphagia, cognitive communication deficit, bipolar disorder, and osteoarthritis. Review of R73's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) date of 08/21/25, revealed R73 was assessed with a Brief Interview for Mental Status (BIMS) score of 12 of 15 indicating that R73 had moderately impaired cognition. The self-care functional abilities portion of the MDS for oral care revealed a score of 03 which indicated R73 required Partial/Moderate assistance, which is defined as the Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.During an interview on 01/28/26 at 11:08 AM, R73 stated she was not offered to brush her teeth in the mornings or in the evenings. During this interview, R73 was asked to open her mouth and R73's teeth and gums were observed with a buildup of white and brown debris. During an interview on 01/29/2026 at 10:26 AM, R73 did not have a toothbrush at the bedside and stated that she still had not received assistance to brush her teeth this morning or last night. During an interview on 01/29/26 at 2:17 PM, R125, assessed with a BIMS score of 15 of 15 on the quarterly MDS with an ARD of 12/16/25, stated, I brush my teeth on my own, but I have to ask for my toothbrush and toothpaste to be brought to me. It is inside my nightstand. If I don't remind them, they won't bring it to me.During an interview on 01/29/26 at 2:19 PM, R17, assessed with BIMS score of 15 of15 on the quarterly MDS with an ARD of 11/09/25, stated, I wheel myself to the bathroom to brush my teeth.During an interview on 01/29/26 at 2:20 PM, R33, assessed with a BIMS score of 15 of 15 on the quarterly MDS with an ARD of 11/11/25, stated, I wheel myself to the bathroom to brush my teeth.During an interview on 01/29/26 at 2:23 PM R66, assessed with a BIMS score of 15 of 15 on the annual MDS with an ARD of 01/17/26, stated, They have to be reminded to give me my toothpaste and toothbrush. If I don't ask for it, they won't bring it to me.During an interview on 01/30/2026 at 2:15 PM, R73 stated supplies to brush her teeth were not [NAME] to her last night or this morning and staff had not offered to assist her to brush her teeth. She stated, I still haven't brushed my teeth. I didn't ask for the supplies to be brought to me. R73 went on to say, You have to ask, if you don't, it will not be brought to you.During an interview on 01/30/26 at 11:00 AM, the Staff Development (SD) stated, The expectation is that staff should offer mouth care to residents and not have to be reminded by the residents that they need their mouth care supplies. This is all part of my orientation education upon hire for Certified Nursing Assistants (CNAs). During an interview on 01/30/26 at 12:20 PM, the Director of Nursing (DON) stated, The expectation is that the staff provide morning (AM) and evening (PM) care - personal hygiene, showers are scheduled on preferred day/time, including oral care. The CNA will take the outfit out of the closet, prepare the brief, water, washcloths, comb the resident's hair, shaving if necessary, grooming, brushing teeth or dentures, the CNA will set up toothpaste, toothbrush, and mouthwash, if any and perform the procedure if the resident is unable to perform the oral care themselves.During an interview on 01/30/26 at 3:00 PM, CNA4 stated, Oral care is part of morning (AM) care. When I come in for morning care, I let the residents know that I will help them get cleaned up from head to toe, basically.During an interview on 01/30/26 at 3:05 PM, CNA5 stated, Oral care is part of the morning care for residents. There are some residents that can't do the oral care on their own, and I make sure that I assist them.During an interview on 01/30/26 at 6:24 PM, CNA6 stated, Yes I usually work this unit. I usually work with R73 in the evenings. R73 is very chill, she is a heavy wetter so whenever I change her, I must change her sheets too. Sometimes she refuses to have her shirt changed or even her bed sheets changed. Sometimes I offer to have her brush her teeth in the evenings.Review of the educational presentation for CNAs, upon hire, titled, Oral Care, on page two of eight, revealed, Mouth care should be given in the morning, at bedtime and after meals and on page seven of eight, under the section titled, Personal Hygiene, revealed, this includes combing hair, brushing teeth, shaving, applying makeup, washing/drying of face and hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and policy review, the facility failed to assess and monitor comfort care (end of life) for one of three residents (Resident (R)122) reviewed for comfort care out of 31 total sampled residents and failed to follow physician orders for an ordered medication (Hyoscyamine Sulfate) for one of 31 residents. These failures had the potential for R122 not to receive the comfort care measures that she deserved at the end of life and not to receive physician ordered medication to control increased secretions which would cause R122 to have difficulty breathing.Findings include:Review of R122's undated Face Sheet, located under the Profile tab in the electronic medical record (EMR) indicated R122 was admitted to the facility on [DATE] with diagnoses of unspecified dementia, severe, with other behavioral disturbance, anxiety disorder, and chronic pain.Review of R122's annual Minimum Data Set (MDS), located under the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 09/12/24, indicated R122 had a Brief Interview for Mental Status (BIMS) score of two out of 15 which indicated R122 was severely cognitively impaired. Review of R122's Care Plan, located under the Care Plan tab in the EMR and dated 11/09/22 indicated R122 had a Focus of [R122] is on comfort care. Interventions were to . Assess for pain levels and contact physician for pain management with uncontrolled pain. Comfort Care: No hospitalization, No lab work, No tube feeding, No IV [intravenous] fluids, No weights, Yes liberalized diet and supplement, Yes antibiotics, Yes medication d/c [discontinue] per provider review.Review of the Progress Notes, located under the Progress Note tab in the EMR revealed a Provider Note dated 10/30/24 in which the Nurse Practitioner (NP) documented . slowly declining. There was no documentation that R122 was experiencing pain at that visit.Continued review of the Progress Notes, indicated from 10/31/24 through 11/07/24 the nursing progress notes did not reflect documentation of R122 having increased pain or shortness of breath (SOB).Review of R122's Medication Administration Record (MAR), dated November 2024 indicated from 11/01/24 through11/08/24 documentation reflected pain was assessed every shift using the Behavioral Pain Scale which indicated R122 had a pain level of 0 during this time.Further review of the Progress Notes, documentation indicated on 11/08/24, the NP (Nurse Practitioner) documented, . Nursing reported patient to have decreased oral intake. Patient lying in bed on room air without respiratory distress. displays no signs/symptoms of pain/discomfort. Plan: .Excessive secretions: None at this time. Ordered Hyoscyamine Sulfate [Levsin] sublingual 0.125 mg [milligram]. Give 1 [sic] tablet sublingually. Agitation/restlessness: None at this time. Ordered continue lorazepam 0.5 mg every 6 [sic] hours as needed. Pain/Shortness of breath: None at this time. Morphine Sulfate (Concentrate) 20 MG/ML [milligram per milliliter], 0.25 ml every 4 [sic] hours as needed.Review of the Nursing Progress Note, dated 11/08/24 at 4:29 PM located under the Progress Notes tab in the EMR indicated, Resident continues to decline and have poor intake. NP made aware.Review of the Administrative Note, dated 11/12/24 at 12:00 AM, located under the Progress Notes tab in the EMR revealed the nurse documented Morphine Sulfate (Concentrate) 20 MG/ML Give 0.25 ml by mouth every 4 [sic] hours as needed for Pain/SOB/Comfort. Resident was in distress and was given Morphine for comfort. The nurse did not complete a nurse note to document what distress R122 was having at this time.Review of the MAR for 11/12/24 at 12:00 AM, indicated R122's pain level was documented as a 4 out of 10 using the behavioral assessment but, the MAR did not provide documentation of how the pain level of four was determined at that time. There was no nursing note dated and timed for this administration of Morphine to indicate how the pain level of four was obtained using the behavioral assessment.Review of a Nurses Note, dated 11/12/24 at 11:51 AM, located under the Progress Notes tab in the EMR revealed the nurse documented, Resident with decreased responsiveness and not able to take po [by mouth] food/fluids. Daughter at bedside and requesting PRN [as needed] Roxanol [Morphine Sulfate] be routine to help keep resident comfortable. NP made aware of above and assessed resident. New order to add Roxanol 5 [sic] mg SL [sublingual] every 4 [sic] hours along with PRN as previously ordered.Continued review of R122's MAR dated 11/12/24, revealed R122 was assessed every shift and on day shift for this date, R122 was experiencing a pain level of 4 but the MAR did not provide documentation of how the pain level of four was determined at that time. The EMR did not contain a nursing note dated and timed for this administration of Morphine to indicate how the pain level of four was obtained using the behavioral assessment.Review of the Progress Note, dated 11/14/24, located under the Progress Notes tab in the EMR revealed the NP made a visit with R122 and changed . Hyoscyamine Sulfate 0.125 mg every 4 [sic] hours routinely.Further review of the nursing progress notes for R122 from 11/12/24 through 11/21/24 did not reflect assessments of R122 and indicate if R122 was experiencing any declines. Review of the Nursing Note, dated 11/21/24 at 10:33 AM, located under the Progress Note tab in the EMR indicated, Resident seen by NP for increased secretions. New order: Increase Levsin 0.25 Q2h [sic] [every two hours] for increased secretions/end of life. Order updated in MAR.Review of the Administrative Note, dated 11/21/24 at 9:44 PM, located under the Progress Note tab in the EMR indicated the nurse documented Hyoscyamine Sulfate Oral Tablet 0.125 mg Give 1 [sic] tablet by mouth every 2 hours for increased secretions/end of life Resident not able to swallow.Review of the Nursing Progress Note, dated 11/22/14 at 3:27 AM, located under the Progress Note tab in the EMR indicated Resident stopped breathing at 0215.Review of the nursing notes from 1/21/24 at 9:44 PM through 11/22/24 at 3:27 AM, the nursing notes did not reflect an assessment of R122 or if there were any further signs of R122's of impending death.During an interview on 01/29/26 at 5:15 PM, Registered Nurse/Unit Manager (RN/UM)1 stated, [R122] was only alert to self. The nurse does a behavioral assessment for pain which comes up each shift and each time you administer pain medication. The behavioral assessment has certain different behaviors that you assess and depending on what you are seeing then you click on that behavior and at the end, the computer gives you a number pain level. RN/UM1 confirmed the only training/education she received was in nursing school and she stated she graduated from this in 2010. The RN/UM1 was asked what resources she as a supervisor used to make sure your staff deliver the most updated care to a resident on comfort care. RN/UM1 stated, I would follow the orders that the MD [medical doctor] or NP wrote for us to follow.During an interview on 01/29/26 at 5:30 PM, the Infection Preventionist/Staff Coordinator (IP/SC) stated, I have only been in this role for 29 days. I have not prepared for any additional education other than what staff gets on hire in orientation. We empower the staff to call the provider if they have any questions about unclear orders or if there is a problem with the order that has been given. For pain assessments, the nurse can assess particular behaviors if the resident is unable to verbalize pain and for alert residents the nurse can ask the resident to describe the level of pain they are experiencing. If the nurse is performing a behavioral pain assessment, the nurse goes through each behavior on the behavioral assessment and at the end the computer will add up the nurses' responses and a pain level will be documented as a number that correlates with the nurses' responses. The IP/SC was asked how the surveyor could review the responses that the nurse clicked on to get the pain level number and she stated, I don't believe that you can. The nurse should make a note as to her assessment of what she is seeing at the time the pain medication was given along with the pain level score. If the nurse notices a decline in the resident's condition, then that should be documented as well.During an interview on 01/30/26 at 2:53 PM, the Director of Nursing (DON) reviewed the nursing progress notes, under the evaluations and vital signs tab, and MAR from 11/01/26 through 11/07/26 and stated, I don't see anything documented before the 8th of November that the resident was experiencing pain. I see where they discontinued the order for Levsin 0.125 mg for one tablet every two hours and put in an order for Levsin 0.125 mg Give two tablets every two hours but under the administrative times, the boxes have x's in them and no documentation of this order being given to [R122]. I can't explain why this happened. The nurses' chart by exception and only chart if there is a noted change in condition of the resident. Asked the DON when the medication changes were made for increased pain medication, increased secretions or the resident was unable to swallow, would these be changes in condition that would warrant alert charting. The DON stated, The nurse could have started the alert charting at that time. Anyone can initiate alert charting when it is needed. The nurses receive education on comfort care in the module on Advance Directives. We do not have a Comfort Care Policy, but we have a Palliate/Hospice Care Policy.During an interview on 01/30/26 at 7:46 AM, Licensed Practical Nurse (LPN)2 was asked about her assessment on the night shift on 11/21/24 and LPN2 stated, I didn't document in detail what she was doing. I should have documented exactly what I was seeing. She also stated, From what I saw in my documentation that I read last night she [R122] was restless and I gave her Morphine. I should have documented her restlessness instead of distress. I don't see any assessments charted. LPN2 was asked if assessments should have been completed for this resident? LPN2 replied Yes, we should have definitely charted assessments done on this resident. LPN2 stated ,[The RN/UM1] usually does that when she was asked who could initiate alert charting. Asked LPN2 if she initiated the alert charting during her shift on 11/21/24 due to the resident not being able to swallow on 11/21/24 at 9:44 PM. LPN2 stated, No, I didn't but I should have. LPN2 was asked if she had received any education on comfort care during her employment with the facility and LPN2 stated, No, what we have is usually on Relais that we do. I had some education on comfort care in nursing school and I graduated in 2006. LPN2 was asked if she assessed the resident on her shift and noted any changes in these assessments in the nursing progress notes. LPN2 stated, I probably went in there every two hours to check in on her, but I did not make any notes of this in her chart. I had some education on comfort care in nursing school and I charted this way. I have had patients pass away lately and it is more detailed than this. LPN2 was asked what should have been charted/documented and LPN2 stated, That I checked her vital signs, and notified the supervisor, checked for lung sounds, heart rate, and temperature. I see that I should document everything even if they are not on alert charting. I cannot believe that I charted this way and left important information out that should have been charted.Review of staff education for Comfort Care provided during training on Advance Directives . Comfort Care stated, Residents on hospice, palliative care and comfort care should have orders for pain medication. Morphine is often ordered for end of life as a pain regimen and to help with shortness of breath/air hunger.Review of the facility's policy titled, Alert Charting, dated 01/09/26 indicated, . Whenever a significant change occurs in a resident's condition, the resident may be placed on alert charting. Residents placed on alert charting are assessed by the nurse each shift and assessment data entered into nursing notes. Nursing judgement determines when a resident is placed on and removed from alert charting notes. Document objective data related to the resident's condition. presence or absence of pain, and response or lack of response to treatment.The facility did not have a comfort care policy to direct the nursing care of the resident receiving this service while in the facility.Review of the online training module titled, Advance Directives, under the section Comfort Measures indicated, Residents on hospice, palliative, and comfort care should have orders for pain medication. Morphine is often ordered to end of life care as a pain regimen and to help with shortness of breath/air hunger.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and policy review, the facility failed to administer oxygen in accordance with physician orders for one of one resident (Resident (R) 4) reviewed for oxygen therapy out of a total of 31 residents sampled. This failure had the potential to cause R4 to retain carbon dioxide and increased the risk of oxygen toxicity.Findings Include:Review of R4's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R4 was admitted to the facility on [DATE] with the diagnosis of chronic obstructive pulmonary disease (COPD).Review of R4's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 01/01/26 indicated R4 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated R4 was cognitively intact. R4 was also coded as receiving oxygen therapy while a resident in the facility. Review of R4's Care Plan located under the Care Plan tab in the EMR and dated 07/22/24 indicated a Focus which stated, [R4] has altered respiratory status/difficulty breathing r/t [related to] Chronic [sic] respiratory failure, COPD, CHF [congested heart failure], Sleep Apnea [sic]. The intervention indicated, Oxygen as ordered.Review of R4's Physician Orders located under the Orders tab in the EMR indicated an order dated 06/30/25 for Oxygen at 4 LPM [liters per minute] via [by] NC [nasal cannula] . During observations on 01/27/26 at 12:45 PM, 01/28/26 at 11:25 AM, and 01/30/26 at 10:40 AM, R4 was lying in bed with the oxygen concentrator approximately two feet from the left side of the bed, administering oxygen at 4.5 LPM via nasal cannula.On 10/30/26 at 10:43 AM, Registered Nurse/Unit Manager (RN/UM) 1 accompanied the surveyor to R4's room. RN/UM1 confirmed the oxygen was being administered at 4.5 LPM via nasal cannula. RN/UM1 reviewed the Physician Orders in the surveyor's laptop and confirmed the order for R4's oxygen administration was to be at 4 LPM instead of 4.5 LPM. RN/UM1 adjusted the oxygen concentrator to administer oxygen to R4 at 4 LPM. When asked if R4 was able to get out of bed to adjust the oxygen concentrator on her own, RN/UM1 stated, No. She [R4] cannot.During an interview on 01/30/26 at 2:36 PM, the Director of Nursing (DON) confirmed the orders for R4's oxygen were for 4 LPM.Review of the facility's policy titled, Nasal Oxygen Administration, dated 01/13/26, indicated, . Read and note the physician's written order for nasal oxygen with stated flow rate in liters per minute.

Based on observation, interview, and document review, the facility failed to ensure the Facility Assessment included an accurate and comprehensive review of the facility's resident population, including an identified population of residents receiving Comfort Care. The failure to update the Facility Assessment to accurately reflect resident needs for this specific resident population receiving care and services meant the facility assessment plan had potentially missed critical care needs specific and unique to this population. This failure had the potential to affect the care provided to the facility population and the training required for both direct and indirect care staff. These failures had the potential to impact all 108 residents in the facility related to safety, pain, person-centered environment, psycho-social services, and the number of adverse events or other resident complications. Cross reference: F684 Quality of Care. Findings include:Review of the Facility Assessment 2025-2026, dated 10/08/25 through 10/29/25, revealed it did not include any indication or recognition of an identified resident population that received Comfort Care within the facility. Facility provided documentation revealed 10 residents received Comfort Care at the facility, making up approximately 9.3% of the current facility population. Only two residents were identified with Hospice services, making up approximately 1.9% of the current facility population. The Comfort Care population was not identified in the current Facility Assessment. The current Facility Assessment identified residents on Hospice and Palliative Care services only. During staff interviews, noted below and cross-referenced with F684, the facility did not identify unique and distinctive characteristics and care need differences between residents receiving Comfort Care and Palliative Care. During an interview on 01/30/26 at 1:40 PM, the Administrator stated that they had provided the most current Facility Assessment for review.During an interview on 01/30/26 at 5:09 PM, the Director of Nursing (DON) provided an Order Listing Report, which she stated revealed the current list of residents receiving Comfort Care. The resident list identified 10 current residents, each documented with Palliative Care-Form on File. The DON said that this was the current list of residents on Comfort Care and that the facility used the term Palliative interchangeably with Comfort Care.During a follow-up interview on 01/30/26 at 6:05 PM, the Administrator confirmed that the facility had been using the terms Palliative and Comfort Care interchangeably. She said that they used a Comfort Care/Palliative Care Assessment in the nursing home setting and it was used like a wish list advanced directive, documenting preferences related to their care. The Administrator stated they were aware that they used the terminology Palliative in the Facility Assessment, and not Comfort Care. She stated that she had been told they were the same thing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the medical record was complete and accurate for one resident (Resident (R) 48) out of 31 total sampled residents. The facility failed to ensure current Physician Orders reflected an active order for R48's Comfort Care Program. This failure had the potential for residents to have unmet care needs. Findings include:Review of R48's admission Record, located under the admission tab of the electronic medical record (EMR) revealed R48 was admitted to the facility on [DATE] with diagnoses that included heart failure, peripheral vascular disease, cerebral infarction with right-sided weakness, history of falls, and chronic obstructive pulmonary disease. Review of R48's Clinical Profile, in the EMR, revealed that R48 had Special Instructions: COMFORT CARE: NO further hospitalization, NO IV fluids, NO discontinuation of medication, NO weights, YES lab work, YES supplements, YES antibiotics.Review of R48's Order Summary, located under the Orders tab in the EMR revealed that the order, COMFORT CARE: NO further hospitalization, NO IV fluids, NO discontinuation of medication, NO weights, YES lab work, YES supplements, YES antibiotics were discontinued on 02/27/25 and 05/29/25. During an interview on 01/30/26 at 9:36 AM, Licensed Practical Nurse (LPN) 4 stated, R48 is able to make her needs known. When she is up to it, she wheels herself around the building. When asked to describe what Comfort Care was, she stated, Comfort care is just one level down palliative care, we make them comfortable, pain free, I believe by the time the patient is on comfort care, I'm trying to find the words to say, they are just trying to be comfortable, no more invasive or aggressive procedure, if with infection such as a Urinary Tract Infection (UTI) it can still be treated. LPN4 was asked how she would know if a resident was on the Comfort Care Program? LPN4 stated, The Unit manager will let us know that the resident was placed on comfort care. For example, I would verify the order with RN/UM2 that she [the resident] was on comfort care. When asked to check for a Comfort Care physician order in the EMR for R48, she stated, There is supposed to be an active order for comfort care for R48. I am checking just to be sure because it might be somewhere else. I might be missing it; I'm looking through, but I don't see it. Not that I can't see. It's just not there.During an interview on 01/30/26 at 9:57 AM, RN/UM2 was asked if there should be an active physician order in R48's list of Physicians' orders and RN/UM2 stated, Do you mean in the orders? Yes, it should be listed in the active orders. RN/UM2 was asked to show where the active physicians' order for Comfort Care was located in the EMR, and she confirmed that there was no active physician order listed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, document review, and review of McGeer's criteria, the facility failed to have an Antibiotic Stewardship Program consistent with current standards of practice for the prescribing of an antibiotic for one of five residents (Resident (R) 71) reviewed for antibiotic stewardship out of a total sample of 31 residents. This failure had the potential to result in the unnecessary use of antibiotics, increasing the risk of antibiotic resistance and adverse medication-related side effects for residents. Findings include:Review of R71's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R71 was admitted to the facility on [DATE] with the diagnosis of Parkinson's Disease.Review of R71's Nursing Progress Notes located under the Progress Note tab in the EMR indicated on 05/25/25 at 12:10 PM the nurse documented, Resident was not feeling well. O2 [Oxygen saturation] 89-90% [percent] on room air. 96% on 2L [liters] of oxygen; right upper lobe congested; [name of NP] notified and order for albuterol nebulizer Q6H [every six hours] prn [as needed] and stat chest x-ray.Review of R71's chest x-ray results dated 05/25/25 and provided by the facility indicated the reason for this test was Wheezing. The findings were . Bilateral lower lobes infiltrates. Right pleural effusion . Review of R71's Physician Orders located under the Orders tab in the EMR indicated an order dated 05/25/25 for Amoxicillin-Clavulanate Potassium (antibiotic medication) 875-125 milligram give one tablet by mouth twice a day for bilateral lobe infiltrates for seven days.Review of R71's Medication Administration Record (MAR) dated May and June 2025, indicated R71 completed the course of the antibiotic that was prescribed on 05/25/25.Review of R71's Potential Infection Evaluation provided by the facility and dated 05/27/25 indicated documentation as follows: -Temperature 97.8 degrees Fahrenheit on 05/25/25-Most Recent O2 sats (saturation) 89% on 05/25/25- . Lower Tract Infection-Does the resident have a fever? . No fever . -Does the resident have chronic obstructive pulmonary disease (COPD)? Yes . -Is the resident over 65? Yes . -Does the resident have a new or increased cough with purulent sputum production? . No [Does not MEET criteria for LRI] . Nursing home protocol criteria are . NOT MET, The resident does not need an immediate prescription for an antibiotic, but may need additional observation . Review of R71's Provider Progress Notes located under the Progress Note tab in the EMR and dated for 05/27/25 indicated, . Plan . Pneumonia, acute - CXR [chest x-ray] showed bilateral lower lobe infiltrates. Pt. [patient] was started on Augmentin for pneumonia on 5/25 . Monitor clinically . Review of the EMR revealed R71 had no lab work completed prior to the start of the antibiotic, had no documented fever, and had no change in function or mental status.Review of the facility's Infection Control Surveillance Log dated January through December 2025 and provided by the facility indicated the logs had missing documentation to reflect the signs and symptoms the resident was experiencing, organism that was present on the culture results if one was obtained, and if the McGeer's criteria were met. During an interview on 01/30/26 at 5:00 PM, the Infection Preventionist/Staff Coordinator (IP/SC) confirmed that R71 did not meet criteria for use of an antibiotic according to the Potential Infection Evaluation form used the facility, since she had no cough. The IP/SC stated that was a form used by the prior IP, and she had not realized it did not coincide with McGeer's criteria, which the facility used.During an interview on 01/30/26 at 5:00 PM, the Director of Nursing was asked her expectations for residents receiving antibiotics and the DON stated, The symptoms that the resident is having meets McGeer's criteria for the use of the antibiotics prescribed.Review of the McGeer's Criteria located at www.nursinghomehelp.org/educational/infection-control-guidelines indicated the following for Revised McGeer Criteria for Infection Control Surveillance Checklist for Pneumonia: Must fulfill 1, 2, and 31. Chest X-ray with pneumonia or a new infiltrate2. At least one of the following criteria-New or increased cough-New or increased sputum production-O2 sat < [less than] 94% on room air, or > [greater than] 3% decrease from baseline O2 sat-New or changed lung exam abnormalities -Pleuritic chest pain-Respiratory rate >/= [greater than or equal] 25 beats/ [per] minute3. At least one of the following criteria -Fever-Leukocytosis-Acute mental changes-Acute functional declineReview of the facility policy Antibiotic Stewardship dated 01/13/26 indicated, It is the policy of [name of facility] to establish an antimicrobial stewardship program that promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance . utilize McGeer's Criteria for assessing residents and appropriate diagnostic testing .

Based on observation, interview, record review and review of other facility documentation, it was determined that for one (R1) out of three residents sampled for accidents, the facility failed to ensure that R1received adequate supervision to prevent accidents. R1, a completely dependent resident, fell on her face from the bed to the floor while receiving care from a staff member and sustained multiple rib fractures, clavicle fracture and splenic laceration. The facility's failure to provide adequate supervision caused harm to R1. Findings include: 1/20/09 - A facility document entitled, Fall Assessment, Prevention, and Management, revised 1/20/23 and 1/3/25 included, It is the policy of [name of facility] to assess for all risks and implement measure to prevent and manage the identified risks. The document also included, Factors that may result in resident falls include, but are not limited to. environmental hazards. functional impairments.R1's clinical record revealed:3/17/21 - R1 was admitted to the facility with diagnoses including but not limited to dementia, muscle weakness, contractures of left knee and both ankles, hemiplegia and hemiparesis.3/18/21 - R1's admission fall care plan [revised 5/28/24] documented, At risk for falls related to weakness, cognitive deficits, incontinence.3/29/21 - R1's activities of daily living [ADLs]care plan [revised 9/21/21] documented, .ADLs - self-care performance deficient r/t [related to] muscle weakness, decreased mobility. The interventions included, Assist with daily hygiene, eating toileting, dressing .The care plan lacked documentation of how many staff members were needed to assist with the ADLs.4/3/24 - R1's mobility/transfer form documented, Potential for impaired mobility. The interventions included, Resident requires Hoyer lift [mechanical lift] with transfers (assist of 2.) Resident requires assist of two [persons] with rolling side to side.5/29/25 - R1's clinical record documented, LAL [low air loss mattress].R1's clinical record lacked evidence of a care plan for safety/bed mobility for the use of the low air loss mattress.11/4/25 - R1's quarterly MDS assessment documented impairments on both upper and lower extremities, required set up/clean up assistance with eating, and complete dependence on staff for all other activities of daily living, including incontinence care and rolling from side to side in bed.11/5/25 - R1's quarterly fall assessment documented a fall risk score of 5 (high).11/7/25 10:51 AM - R1's clinical record documented, .Resident was receiving morning care by CNA. When turning onto her right side, resident was rolled onto the floor. When nurse responded, resident was seen lying face down leaning on her left side.11/7/25 2:08 PM - A facility reported document submitted to the Division documented, Fall from bed to floor, resident c/o [complained of] pain to her head, and left flank. Physician present and made aware, orders obtained to transfer her to the ER [emergency room] for further evaluation.11/9/25 7:45 PM - A hospital reported document submitted to the Division documented, Immobile pt. [patient] fell out of bed while being changed. Multiple rib fx [fractures], clavicular fx and splenic lac [laceration].11/13/25 1:15 PM - During an interview, E7 (UM) stated, The residents' transfer, and bed mobility status are in the closet. That is how the staff knows how to transfer and move them. [R1] required 2 persons for rolling from side to side, and 2 persons with the Hoyer lift for transfers.11/13/25 1:30 PM - During an interview, E4 (OT) stated, [R1] required 2 persons assistance to roll from side to side for the staff to wash and clean her. She was not able to help with her care.11/13/25 2:00 PM - During a telephone interview, E5 (CNA) stated, I have been an aide for four years, but I was new to this facility. I was told that this resident [R1] was on my assignment for the shift. I rolled her on her side to clean her bottom, and she rolled out of the bed on to her face. The Surveyor asked E5 if she knew where the transfer/bed mobility/rolling side to side information for the resident was located. E5 stated, I was told it was in the closet, but I was not actually shown where it was located. I saw other aides take care of her by themselves, so I thought I have to do her care by myself. No one ever told me I had to have another aide with me when I was taking care of her. The Surveyor asked E5 whether R1 was able to move, hold herself to the side in the bed or assist in her ADLs, E5 stated, No, she was not able to move herself or help with anything. The staff did everything for her.11/13/24 2:20 PM - The facility 5 day follow up report submitted to the Division included, .Resident remains hospitalized at this time. Upon return she is to be evaluated by therapy and care plan will be updated to include concave LAL and bilateral fall mats while in bed.11/14/25 10:00 AM - During a combined interview with E1 (NHA) and E2 (DON), the Surveyor asked what the facility's investigation revealed to be the root cause of R1's fall. E1 stated, The aide did not position her properly in the bed and she rolled out. The Surveyor asked E1 whether the facility had identified that the R1's plan of care for two persons assistance with rolling side to side was not implemented during incontinent care. E1 stated, The resident did not have to be rolled side to side for incontinent care. The aide's statement said that she had positioned her [R1] on her side for 5 minutes before she rolled out of the bed.11/14/25 2:00 PM - During an interview, E2 provided the Surveyor with an undated document, entitled, Plan of Correction. The document included, The facility conducted a root cause analysis, and it was determined that the assigned CNA did not safely position the resident during incontinence care to avoid the resident from rolling out of bed. Ad hoc QAPI meeting was conducted facility leadership. Employee was immediately educated and suspended pending investigation. A house wide audit was conducted of all mobility care plans for residents who are assist of two. No issues were identified. All nurses and CNAs were re-inserviced on safe positioning during care and transfer status/bed mobility care plans.The facility's investigation failed to identify that R1, a completely dependent resident, who was care planned for the assistance of two staff members with rolling side to side, required two persons assistance for moving and turning in bed to prevent her from rolling out of the bed during incontinence care.The facility failed to ensure that R1's incontinence care was completed with the required number of staff members according to her plan of care. This failure resulted in R1 falling from the bed and sustaining injuries.11/14/25 2:30 PM - Findings were reviewed with E1 (NHA) and E2 (DON) at the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that for one (R1) out of three residents reviewed for Neglect, the facility failed to identify and report an allegation of neglect when on [DATE], R1 had a choking episode and the present staff failed to provide essential services (airway clearance, assess lung air movement and initiate CPR) required to intervene on behalf of R1. Findings include: Cross refer F678 and F726Facility's Abuse, Neglect. policy stated, Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress and includes: lack of attention to physical needs of the resident; . Identification- Abuse may be identified through assessment of residents with unexplained changes in behavior and/or suspicious injuries and review of grievances and events for patterns and trends. Reviewed [DATE]. [DATE] - R1 was admitted to the facility with diagnoses including, but were not limited to, stroke with right-sided paralysis, chronic respiratory failure with hypoxia (low oxygen concentration), and dysphagia (trouble swallowing)XXX[DATE] approximately 3:41 PM - From the paramedic records, E9 (paramedic) arrived at the facility and found R1 pulseless with agonal (irregular, gasping breaths that occur when the body is not receiving enough oxygen) respirations. The report documented that staff provided no life-saving interventions for the patient and failed to recognize the patient was in cardiac arrest. [DATE] 1:30 PM - During a telephone interview, E8 (LPN) stated that F1 (R1's wife) approached him around 4:30 PM (sic) stating, [R1] is choking. Come here, hurry up. E8 stated that he obtained vital signs and R1's pulse oximetry was 64% with a heart rate of 149 or 150. E8 stated that he checked R1's supplemental oxygen flow and increased it. When asked about lung sounds, E8 stated, I did not listen to her lungs. E8 stated that the paramedics took over once they were on the scene and the paramedics were the people who initiated CPR (cardio-pulmonary resuscitation) on R1. The facility failed to identify and report of an allegation of neglect when staff failed to provide lifesaving servicesXXX[DATE] 9:30 AM - During an interview, E2 (DON) stated that the facility did not report the incident to the State as he was unaware that of any allegations of inappropriate care.The facility failed to identify and report that nursing staff failed to perform an essential assessment of R1's airway after a choking incident. [DATE] - Findings were reviewed at the exit conference with E1 (NHA), E2 (DON), E3 (ADON) and E4 (CNO).

Based on observation, interview, record review and review of other documentation as indicated, it was determined for one (R1) out of three residents reviewed for change of condition, the facility failed to initiate CPR for R1, who was choking and became hypoxic and unresponsive. The RN supervisor did not assess R1's airway or respiratory status after choking and only delegated applying a non-rebreather mask and preparing for transfer without initiating CPR or further emergency intervention. The facility's failure resulted in R1 death. Due to this failure an Immediate Jeopardy (IJ) was called at 1:58 PM on 7/3/25. Findings include: Cross Refer F726A facility policy last reviewed 1/3/25 for Code Status Policy documented. Staff will initiate CPR when cardiac or respiratory arrest occurs for residents who have requested CPR on their Code Status Form. Review of R1's clinical record revealed:6/6/25 - R1 was admitted to the facility with diagnoses including, but were not limited to, stroke with right-sided paralysis, chronic respiratory failure with hypoxia (low oxygen concentration), and dysphagia (trouble swallowing).6/12/25 - R1's admission MDS revealed R1 was cognitively intact. 6/20/25 - R1's facility resuscitation form for CPR revealed. Full code means use CPR to attempt resuscitation. The form was signed and dated by R1 on 6/20/25. 6/29/25 3:35 PM - E8 (LPN) was notified by R1's F1(wife) the resident was choking. 6/29/25 3:43:20 PM - Review of a prehospital paramedic report revealed upon arrival to the facility on patient contact BLS (Basic Life Support) advised staff member was holding the head of R1 in a neutral sniffing position and R1 was gasping for air. CPR was started R1 was placed on monitor and found to be in asystole. A tube was attempted to be placed in R1's throat and was met with resistance then chewed up food was observed coming up the tube.7/2/25 10:03 AM - During a phone interview E9 (Paramedic) revealed and confirmed. EMT's arrived a minute, before the Paramedics. R1 was sitting up in the wheelchair in the chin to chest position, very pale and did not appear to be breathing. A nurse standing behind R1 and no CPR was being performed. R1 was transferred to the stretcher took a gasping breath and was pulseless and in cardiac arrest (heart stops beating) Paramedics started CPR. 7/2/25 1:03 PM - During a phone interview, F1 revealed. The family brought food in from a restaurant and R1 had cheesesteak. R1 was eating the meat out of the bread so she could have more meat and less bread, R1 choked and inhaled after coughing and somehow inhaled part of the cheesesteak. F1 stated, I told [E8] [R1] was choking. The RN supervisor came and looked at her and talked to her, and then [E7 (RN Supervisor)] called 911. F1 confirmed, [R1] was not able to speak words. 7/2/25 1:14 PM - During a phone interview, E7 stated, I was notified that [R1] had choked while eating and was hypoxic, [R1] exhibited signs of respiratory distress and was not verbally responsive I instructed [E8] to put a non-rebreather mask on [R1], I went to call 911. E7 confirmed and stated, No I did not listen to [R1's] lungs.7/2/25 1:30 PM - During a phone interview, E8 reported that the nurse was notified R1 was choking on food. R1 was unable to speak in full sentences and was slow to respond. At the time, R1 was receiving continuous oxygen at 3/lpm via nasal cannula, with an oxygen saturation of 64% and a heart rate ranging from 149 - 150 bpm. R1 was brought back to the room and switched to an oxygen concentrator; however, the non-rebreather mask was not inflating. R1 was then placed back on the oxygen tank at a flow rate of 15/lpm. R1's oxygen saturation improved slightly to around 77%, with respirations noted at 10 per minute. E8 stated, Typically [R1'] s oxygen saturation is 92% or higher. E8 also confirmed, I did not listen to [R1's] lungs during this time.The RN supervisor and other staff did not assess R1's airway or respiratory status, nor did they take appropriate emergency measures such as listening to lung sounds or abdominal thrusts. The facility also failed to initiate CPR for R1 who was hypoxic and unresponsive, despite R1's documented full code status. 7/3/25 1:58 PM - The facility's response to abatement for R1's incident was reviewed. All staff in the facility and staff reporting for scheduled shifts were provided with In-service education on responding appropriately to clinical emergencies inclusive of conducting thorough assessments and initiating appropriate interventions, for airway management, complete physical assessments and the initiation of life-saving interventions presented by the staff educator. A clinical tool was created Rapid Response Team/Code Blue. The RN Supervisor will utilize this form to document the residents' clinical situation, background, assessment, intervention (staff member to stay with resident until condition resolves or transfer to hospital, code and outcome.) Facility staff interviews were conducted starting 7/3/25 to verify in-service education, staff interviews concluded on 7/7/25 at 2:30 PM. Staff training records were reviewed; the facility's date of abatement is 7/5/25 at 4:00 PM. 7/7/25 2:45 PM - Findings were reviewed with E1(NHA), E2 (DON), E3 (ADON) and E4 (CNO) at the exit conference.

Based on observation, interview, and record review it was determined that for one (R1) out of three residents reviewed for change in condition the facility failed to ensure that licensed nursing staff had the skill set to recognize an emergent situation. R1 had a choking episode that progressed to respiratory distress which compromised R1's breathing. Nursing staff failed to provide competent nursing care for R1 that included assessments and interventions for a resident that had a change in respiratory status. Additionally, R1 was a full code and staff failed to initiate CPR on R1's behalf. The facility's failure resulted in R1's in death. Due to this failure an Immediate Jeopardy (IJ) was called at 2:20 PM on 7/3/25. Findings include:Cross Refer F678A facility policy last reviewed 1/23/25 for Provider Notification of Resident Change in Medical Condition documented. That a resident experiencing a significant change in condition is monitored continuously until the resident is stable or transferred to another level of care. A review of R1's clinical record revealed:6/6/25 - R1 was admitted to the facility with a diagnosis including, but were not limited to, stroke with right sided paralysis, chronic respiratory failure with hypoxia (low oxygen concentration) trouble swallowing. 6/20/25 - R1's facility resuscitation form for CPR revealed. Full code means use CPR to attempt resuscitation. The form was signed and dated by R1 on 6/20/25. 6/29/25 1:22 PM - A review of R1's vital signs documented. Oxygen saturation of 95% via nasal cannula. 6/29/25 3:35 PM - E8 (LPN) was notified by R1's F1 (wife) the resident was choking. E8 reported R1 was in respiratory distress. R1's oxygen saturation was 64% on 3 Liters of oxygen and heart rate was 149 - 150 beats a minute. 6/29/25 3:40 PM - Facility video surveillance revealed R1 was taken back to the room in the wheelchair with her head down and chin to chest. 6/29/25 3:48 PM - A review of R1's vital signs documented. Oxygen saturation of 77% via oxygen mask. 6/29/25 3:50:14 PM - Facility video surveillance revealed EMT's arrived to R1's room.PM Paramedics entered [R1's] room at 3:51:12 PM. 7/2/25 10:03 AM - A phone interview, with E9 (Paramedic) revealed upon entering the room R1 was in the wheelchair chin to chest, very pale and did not appear to be breathing. E9 confirmed R1 was pulseless and in asystole in (cardiac arrest) and no CPR had been performed. 7/2/25 1:30 PM - During a phone interview E8 reported that the nurse was notified R1 was choking on food. R1 was unable to speak in full sentences and was slow to respond. At the time, R1 was receiving continuous oxygen 2 liters per minute via nasal cannula, with an oxygen saturation of 64% and a heart rate ranging from 149 to 150 beats per minute. R1 was brought back to the room and switched to an oxygen concentrator; however, the non-rebreather mask was not inflating. R1 was then placed back on the oxygen tank at a flow rate of 15 liters per minute. R1's oxygen saturation improved slightly to 77%, with respirations noted at 10 per minute. E8 stated, Typically R1's oxygen saturation is 92% or higher. E8 also confirmed, I did not listen to [R1's] lung's during this time.7/2/25 9:22 AM - During an interview, E2 (DON) stated, Staff stated R1 was responsive, and she was not choking.7/3/25 1:58 PM - The facility's response to abatement for R1's incident was reviewed. All staff in the facility and staff reporting for scheduled shifts were provided with In-service education on responding appropriately to clinical emergencies inclusive of conducting thorough assessments and initiating appropriate interventions, for airway management, complete physical assessments and the initiation of life - saving interventions presented by the staff educator. A clinical tool was created Rapid Response Team/Code Blue the RN Supervisor will utilize this form to document the residents' clinical situation, background, assessment, intervention (staff member to stay with resident until condition resolves or transfer to hospital, code and outcome.) 7/3/25 4:55 PM - An interview with E8 confirmed, In-service training and education had been provided prior to the start of the 3PM - 11PM shift. 7/5/25 - Review of the facility's attendance in-service training record for Recognizing and Responding to Medical Emergencies confirmed, E7 had been provided in-service training and education prior to the start of the shift.Facility staff interviews were conducted starting 7/3/25 to verify in-service education, staff interviews concluded on 7/7/25 at 2:30 PM. Staff training records was reviewed; the facility's date of abatement is 7/5/25 at 4:00 PM. 7/7/25 2:45 PM -Findings were reviewed with E1 (NHA), E2 (DON), E3 (NHA) and E4 (CNO) at the exit conference.

Based on record review and interview, it was determined that for one (R1) out three residents reviewed for emergency care, the facility failed to ensure that the facility's assessment included nursing staff competencies, and the skill sets necessary to provide the level and types of care that are needed for the resident population. Findings include: Cross Refer to F678 and F726. A review of R1's records revealed:6/29/25 4:30 PM - E7 (RN) documented in R1's clinical records, Upon entering the (sic) unit at approximately 3:35 PM, E8 (LPM) stated he needed assistance and motioned towards dining room. Resident was in wheelchair with her wife at her side. Resident 66% on 2L of O2, instructed nurse to put on non-rebreather (NRB) and this writer called 911 at approximately 3:40 PM. Nurse took resident by wheelchair to her room. I entered behind them and adjusted the NRB. oxygen between 77% - 79% .EMT's arrived at approximately 3:50 PM.transported patient to ED (emergency department via stretcher at 4:21 PM.The facility's staff failed to identify and intervene when they were informed that R1 was experiencing respiratory distress after she had choked on her food, had decreased oxygen levels and became unresponsive.7/7/25 12:00 PM - A review of a facility document entitled, Facility Assessment Broadmeadow 2024-2025 lacked evidence of staff training and interventions for residents in a medical emergency including but not limited to choking with respiratory distress.7/7/25 2:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON) and E4 (CNO) at the exit conference.

Based on record review and interview, it was determined that for one (R109) out of twenty seven residents reviewed, the facility failed to ensure that the electronic health record was complete and readily accessible. Findings include:
R109's clinical record revealed:
11/27/24 - R109 was admitted to the facility for a principal diagnosis of a fracture and short term therapy.
12/16/24 - R109 was diagnosed with clostridium difficile (Cdiff) and was placed on an antibiotic for 10 days.
12/27/24 at 2:21 PM - A Physician progress note documented, Pt seen and examined. Progress note to follow.
1/16/25 - Review of R109's clinicial record lacked evidence of the detailed 12/27/24 Physician progress note.
1/17/25 - R109 was discharged from the facility.
1/22/25 at 1:51 PM - During an interview, E27 (Physician) was asked about the 12/27/24 progress note. E27 stated that since the resident was discharged , she was unable to access it at the time of the interview on her cell phone. When asked about how the resident's Physician progress notes are included into the facility's electronic clinical record, E27 stated that the progress notes migrate over to the facility's clinical record after they are electronically signed by the Provider. E27 stated that she was not aware how often the migration occurs.
1/22/25 at 3:04 PM - Finding was reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), E8 (Staff Educator), E14 (COO) and E15 (CNO).

Based on observation and interview, it was determined that that for one (R1) out of four residents reviewed for ______,the facility failed to ensure residents were treated with respect and dignity. Findings include:
Review of R1's clinical record revealed the following:
9/1/22 - R1 was admitted to the facility with diagnoses including traumatic brain injury and hemiplegia (half - body paralyzed).
9/2/22 - R1's activity care plan documented that R1 was independent/dependent with meeting activity preferences related to physical limitations with interventions including R1's preference to socialize with loved ones, caregivers and peers as tolerated.
9/9/22 - R1 was care planned for adjustment to her stay in the long term care facility. Interventions included providing R1 with as many situations as possible, with control over her environment and health care delivery.
9/14/22 - R1 had a care plan developed for ADL (Activities of Daily Living) self care performance deficit related to right sided weakness. R1's interventions included but were not limited to R1's use of a power chair (motorized wheelchair) with back cushion on her wheelchair to maximize safety, comfort, and independence in mobility throughout the facility.
11/12/24 - R1's quarterly MDS (Minimum Data Set) assessment revealed that R1's cognition was moderately impaired with a BIMS score of 11. R1 used a motorized wheelchair to make turns and wheel in corridors.
1/17/25 11:07 AM - R1 was observed operating the motorized wheelchair in the hallway and slowed down to navigate a right turn. E20 (Activity Staff) was heard and observed calling to R1. Keep going, slow poke. There were other residents present when this comment was made.
11/17/24 11:08 AM - When asked how R1 felt about the interaction, R1 stated, I'm okay.
1/17/25 11:12 AM - In an interview, E1 (NHA) confirmed that it was not acceptable for the staff be calling R1 a slowpoke as it was disrespectful.
1/22/25 at 3:04 PM - The finding was reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), E8 (Staff Educator), E14 (COO) and E15 (CNO).

Based on record review, observation and interview, it was determined that for one (R98) out of four residents reviewed for medication administration, the facility failed to ensure the staff wore appropriate PPE while administering R98's medications via her PEG tube. Findings include:
Facility's Infection Prevention and Control Policy Program: It is the policy of [facility] to maintain an Infection Prevention and Control program (IPCP) to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections .
Prevention/Isolation: Individuals with suspected or diagnosed communicable disease are placed on the appropriate precaution for that disease, as recommended by the Centers for disease Control and prevention (CDC). Review date: January 2, 2025
3/20/24 - CMS Memorandum (ref QSO-24-08-NH) stated, .In 2019, CDC introduced a new approach to the use of personal protective equipment (PPE) called Enhanced Barrier Precautions (EBP) as a strategy in nursing homes to decrease the transmission of CDC-targeted and epidemiologically important MDROs (multi-drug resistant organisms) when contact precautions do not apply . EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing . EBP are indicated for residents with any of the following: infection or colonization with CDC-targeted MDRO when contact precautions do not otherwise apply; or wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO .Indwelling medical device examples include central lines, urinary catheters, feeding tubes and tracheostomies .
12/16/24 - R98 was admitted to the facility with diagnoses, including but were not limited to, stroke, swallowing difficulties and S/P percutaneous gastrostomy tube (PEG) in place.
12/18/24 - E27 (MD) ordered in R98's electronic medical record (EMR), .Enhanced Barrier precautions r/t (related to) presence of enteral (pertaining to small intestines) tube, history of VRE (vancomycin resistant enterococcus, a MDRO bacteria) and ESBL (extended spectrum beta-lactamase, a MDRO bacteria) .
The indwelling medical device (feeding tube) and the two CDC-targeted MDROs require the use of PPE for Enhanced Barrier precautions.
1/14/25 11:30 AM - the facility was unable to provide evidence of a specific Enhanced Barrier Precaution policy when requested by the surveyor.
1/15/25 10:11 AM - Surveyor observed E30 (LPN) administer nine medications to R98 via R98's PEG feeding tube during med pas facility task. E30 failed to don the required yellow isolation gown while accessing R98's indwelling medical device (PEG feeding tube).
1/15/25 10:35 AM - During an interview, E30 (LPN) stated, .That was high-contact care. You're right. I should have had a yellow gown on .
1/22/25 3:04 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), E8 (Staff Educator), E14 (COO) and E15 (CNO).

Based on record review and interview, it was determined that for two (R3 and R31) out of five residents reviewed for arbitration agreements, the facility failed to ensure that R3 and R31 were capable of understanding the arbitration agreement prior to signing it. Findings include:
Basic Interview for Mental Status (BIMS) test is a standardized cognitive assessment tool mandatory in long-term care facilities in accordance with the Centers for Medicare and Medicaid Services (CMS). The BIMS score interpretation categorizes scores into groups by cognitive status. Any score of 13 to15 is classified as intact indicating normal cognitive response. The moderate impairment classification describes a score from 8 to 12 and suggests that the resident may need assistance with daily activities and may be in cognitive decline. The Severe impairment score indicates that the resident will have significant trouble with cognitive tasks and will likely need extensive help to navigate daily life. A BIMS score from 0 to 7 falls within this classification. CMS website, 2025
1. Review of R3's clinical record revealed:
5/1/24 - R3 was admitted to the facility with diagnoses including, but were not limited to, dementia, anxiety disorder and cognitive communication deficit. R3's Resident Information sheet named F1 (R3's son) as emergency contact #1.
5/1/24 - E16 (admission representative) completed the facility admission documents with R3. R3 signed the legally binding arbitration agreement, which stated, . The parties understand and agree that by signing this arbitration agreement, they are giving up and waiving their statutory and constitutional rights to have any claim, including malpractice and wrongful death claims, decided in a court of law before a judge and jury . If this Agreement is not rescinded within thirty (30) days of the date upon which it is signed, it is binding upon the parties in all matters regarding care and services provided to the resident by the Facility, regardless of subsequent discharges and readmissions . This agreement does not terminate upon the end of the facility's provision of health care or other services to the Resident or upon termination of any other contract or agreement .
Despite having a diagnosis of dementia, the facility had R3 sign multiple documents, including her Resident admission agreement, Consent for Treatment and the binding arbitration agreement.
5/8/24 - R3's admission MDS assessment revealed a Brief Interview for Mental Status (BIMS) score of seven, which was reflective of severe cognitive impairment.
The facility was unable to provide evidence of approaching R3's emergency contact [F1] to review the binding arbitration agreement after determining R3 had a severe cognitive impairment. This determination occurred just seven days after R3's admission to the facility and was still within the 30 day window for the binding arbitration agreement to be rescinded.
2. Review of R31's clinical record revealed:
7/3/24 - R31 was admitted to the facility with diagnoses including, but were not limited to, atrial fibrillation, cognitive communication deficit and adjustment disorder with anxiety. R31's Resident Information sheet named F2 (R31's daughter) as her emergency contact #1.
7/5/24 - E17 (admission assistant representative) completed the facility admission documents with R31. R31 signed the legally binding arbitration agreement, which stated, . The parties understand and agree that by signing this arbitration agreement, they are giving up and waiving their statutory and constitutional rights to have any claim, including malpractice and wrongful death claims, decided in a court of law before a judge and jury . If this Agreement is not rescinded within thirty (30) days of the date upon which it is signed, it is binding upon the parties in all matters regarding care and services provided to the resident by the Facility, regardless of subsequent discharges and readmissions . This agreement does not terminate upon the end of the facility's provision of health care or other services to the Resident or upon termination of any other contract or agreement .
The facility had R31 sign multiple documents including the Resident admission agreement, Consent for Treatment and the binding arbitration agreement.
7/10/24 - R31's admission MDS assessment revealed a BIMS score of ten, which was reflective of moderate cognitive impairment.
The facility was unable to provide evidence of approaching R31's emergency contact [F2] to review the binding arbitration agreement after determining R31 had a moderate cognitive impairment. This determination occurred just 7 days after R31's admission to the facility and was still within the 30 day window for the binding arbitration agreement to be rescinded.
1/22/24 - 11:15 AM - During an interview, E1 (NHA) stated that the facility did not have a policy regarding the process/procedure of obtaining consents from resident with impaired cognition/below normal BIMS scores. E1 did confirm that all facility employees must complete training annually on compliance and ethics as part of the facility's corporate compliance program.
1/22/25 3:04 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), E8 (Staff Educator), E14 (COO) and E15 (CNO).

Based on interview, record review and review of other facility documents, it was determined that for one (R66) out of six residents reviewed for abuse, the facility failed to ensure that that R66 was free from resident to resident physical abuse by R78. Findings include:
A review of the facility's abuse policy titled, Abuse, Neglect, Mistreatment, Misappropriation, Exploitation, and Reasonable Suspicions of Crime, revised January 12, 2023, indicated, . It is the policy of Cadia Healthcare to protect residents and prevent occurrences of abuse .
Cross refer F657
A review of R78's clinical record revealed the following:
2/22/23 - R78 was admitted to the facility with diagnoses including but not limited to dementia, depression, and anxiety disorder.
3/6/23 - R78 was care planned for impaired cognition and interventions included to cue, reorient and supervise as needed and to .monitor/document/report when necessary any changes in cognitive function, .changes in: .difficulty expressing self, difficulty understanding others .
4/25/23 - R78 was care planned for potential physically aggressive behaviors as evidenced by yelling, kicking, hitting, slapping, striking out, etc. Interventions included: allowing R78 10 - 15 minutes to calm down and then reapproach, redirecting when visibly irritated and speaking in a calm voice to keep R78 calm and feel non threatened.
1/25/24 - A review of R66's quarterly MDS assessment revealed that R66's cognition was moderately intact and had used a manual wheelchair for mobility during the review period.
2/15/24 - R78's annual MDS assessment revealed that R78's cognition was moderately impaired, had physical and verbal behaviors occurring 1 to 3 days and had used a manual wheelchair for mobility during the review period.
3/25/24 9:37 PM - A facility incident report submitted to the State Agency documented that on 3/25/24 at 6:20 PM, .After dinner resident [R66] reported to the charge nurse that another resident [R78] hit her on the face and found redness on the left eyelid.
4/2/24 - A facility 5 day follow up summary submitted to the State Agency documented, Were changes made to Care Plan? Yes . Medication changes; Q 1 hr (hour) safety check.
1/16/25 4:00 PM - Finding was discussed with E1 (NHA) and E2 (DON).
The facility failed to ensure that R66 was free from physical abuse by R78 when R66's face was hit by R78 on 3/24/24.
1/22/25 at 3:04 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), E8 (Staff Educator), E14 (COO) and E15 (CNO).

2. R98's clinical record revealed:
12/16/24 - R98 was admitted to the facility with diagnoses, including but were not limited to, stroke, swallowing difficulties and S/P percutaneous gastrostomy tube (PEG) in place.
12/22/24 - R98's admission MDS in Section L Oral/Dental Status, in which option A is Broken or loosely fitting full or partial denture, documented Z. None of the above were present.
1/13/25 2:09 PM - During an interview, F5 (R98's daughter) stated, [R98] is on a pureed diet. When she had a stroke, she lost weight and her dentures don't fit well anymore. I tried to take her to get new dentures .
1/21/25 11:59 AM - During an interview, E9 (RNAC) stated, The nurses' assessments did not document any problems with her teeth. So I didn't know there was an issue . [R98] has two teeth so she is not edentulous. I spoke with her daughter and did let Social Work know to put her to be seen by the dentist once she converts to long term care.
1/22/25 3:04 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), E8 (Staff Educator), E14 (COO) and E15 (CNO).
Based on interview and record review, it was determined that for two (R69 and R98) out of 27 sampled residents reviewed for assessments, the facility failed to accurately reflect each residents' status. Findings include:
1. R69's clinical record revealed:
12/19/24 - R69 was admitted to the facility.
12/24/24 7:00 AM - A physician's order stated, Skin prep bilateral heels every shift for redness bilateral heels and DTI (deep tissue injury) right heel.
12/24/24 3:00 PM - A physician's order stated, green or blue boots ON at all times while in bed every shift for redness bilateral heels and DTI right heel.
Review of the December 2024 eMAR revealed that nursing staff were signing off that the two aforementioned physician orders were completed as ordered.
12/26/24 - The admission MDS assessment, under Section M - Skin Conditions, documented that R69 had no unhealed pressure ulcers and/or unstageable - deep tissue injury.
The facility failed to accurately reflect R69's status regarding the right heel DTI on the assessment.
1/22/24 1:00 PM - Finding was reviewed with E2 (DON) and E15 (CNO).

Based on record review and interview, it was determined that for two (R39, R62) out of two residents reviewed for PASARR, the facility failed to notify the appropriate state-designated authority when the resident's new diagnosis of mental disorder was identified. For R62, the facility failed to request a new PASARR after R62 was diagnosed with visual hallucinations. Additionally, for R39, the facility failed to notify the state-designated authority of a new order for an antipsychotic medication. Findings include:
1. Review of R62's clinical record revealed:
12/4/19 - R62's Preadmission Screening and Resident Review (PASARR) documented, .This patient does not require a Level II PASARR . The individual does have a documented serious mental illness (SMI) or a mental illness other than SMI but further review of level of impairment, recent treatment history, or other circumstances demonstrates a full level II is not required by 42 CRF 483.102 standards .
12/6/19 - R62 was admitted to the facility, with diagnoses including but not limited to, multiple sclerosis, bipolar disorder and anxiety disorder.
3/28/24 - R62 hospitalized for an infection.
4/5/24 - R62's PASARR documented, . Level I Outcome: Convalescence Categorical .Rational: 60 Day Convalescent Care Approval - a 60 day or less stay in the NF (nursing facility) is authorized. Re-screening must occur by or before the 60 day if the individual is expected to remain in the NF beyond the authorization timeframe.
5/8/24 - R62's care plan updated to include, .[R62] has socially inappropriate behavior as evidenced by hallucinations and delusion; claiming there are bugs crawling all over her .
6/6/24 - R62 was diagnosed with delusional disorder.
6/13/24 - R62 hospitalized at [geropsychiatric hospital] for management of her delusions/hallucinations.
6/20/24 - R62 re-admitted to the facility. R62's PASARR stated, . Date Short Term Approval Ends: July 18, 2024 . Due to this being a remote PASARR assessment, your admitting nursing facility must submit a Resident Review to [PASARR company] so you may have an in-person PASARR review . At this time, you meet PASARR inclusion criteria. You have a Level II PASARR condition of Bipolar disorder, mixed with psychotic features . Level I Outcome: Refer for Level II Onsite. Rationale: A PASARR level II evaluation must be conducted. That evaluation will occur as an onsite/face-to-face evaluation.
1/15/24 7:02 AM - During an email correspondence, C1 (DHSS DMMA nursing supervisor) stated, .[R62] should have had a resident review PASARR prior to the expiration of the PASARR on 7/20/24. She was only given a short-term approval NF stay by PASARR. The facility is out of PASARR compliance. You have a resident residing at the facility without a current PASARR on file.
2. Review of R39's clinical records revealed:
R39's admission PASSAR dated 2/23/23 documented, Level 1 PASSAR, no PASSAR Level 2 recommended.
4/10/23 - R39 was admitted to the facility with diagnoses including anxiety disorder, major depressive disorder, and dementia.
4/20/23 - R39's admission MDS documented, No dx [diagnoses] of bipolar disorder.
5/19/23 - R39's clinical records documented, Aripiprazole [antipsychotic medication] oral tablet 5 mg, give 1 tablet by mouth daily for Bipolar/severe anxiety.
6/24/23 - R39's quarterly MDS documented, Yes bipolar dx [diagnoses.]
6/26/23 - R39's care plan documented, . Uses antipsychotic medications r/t [related to] bipolar disorder .
10/1/23 - R39's quarterly MDS documented, Yes bipolar dx [diagnoses.]
1/9/24 - R39's quarterly MDS documented, Yes bipolar dx [diagnoses.]
4/9/24 - R39's annual MDS documented, Yes bipolar dx [diagnoses.]
7/24/24 - R39's quarterly MDS documented, Yes bipolar dx [diagnoses.]
9/26/24 - R39's quarterly MDS documented, Yes bipolar dx [diagnoses.]
12/26/24 - R39's significant change MDS documented, Yes bipolar dx [diagnoses.]
1/16/25 2:00 PM - A review R39's clinical records lacked evidence that a referral was made to the state mental health authority for an updated PASSAR to reflect the new diagnosis of bipolar disorder, and the use of aripiprazole (anti-psychotic medication).
1/17/25 1:00 PM - Findings were confirmed with E8 (RNAC).
1/22/25 3:04 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), E8 (Staff Educator), E14 (COO) and E15 (CNO).

3. R165's clinical record revealed:
12/23/24 - R165 was admitted to the facility.
12/23/24 - R165 was ordered PRN Oxycodone every four hours for moderate pain and Tylenol every six hours for pain.
12/24/24 - R165's was care planned for acute/chronic pain related to osteoarthritis to right knee, osteoporosis, fall and decreased mobility. R165's interventions included:
-Administer analgesia as per orders;
- Evaluate the effectiveness of pain interventions;
- Monitor/document for side effects of pain medication. Report occurrences to the physician.
- Monitor/record/report to Nurse any s/sx (signs/symptoms) of non-verbal pain .;
- Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain.
- Pain evaluation on admission, quarterly, and with significant change.
Review of R165's pain care plan revealed that the facility failed to include non-pharmacological interventions in R165's pain care plan.
1/22/24 at 1:00 PM - Finding was reviewed with E2 (DON) and E15 (CNO).
1/22/25 at 3:04 PM - Finding was reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), E8 (Staff Educator), E14 (COO) and E15 (CNO).
2. R28's clinical records revealed:
6/14/24 - R28 was admitted to the facility with diagnoses including major depressive disorder and anxiety.
6/14/24 - R28's care plan documented, . [R28] uses anti-anxiety medications r/t [related to] anxiety disorder . The interventions included. Administer ANTI-ANXIETY medications as ordered by physician Monitor for side effects and effectiveness
12/10/24 - R28's quarterly MDS assessment documented a BIMS score of 00, indicating severe cognitive impairment.
12/24/24 - R28's clinical records documented, . Lorazepam [antianxiety medication] 0.5 mg/ 1 ml Gel Apply 1 mg transdermally [on the skin] every 6 hours as needed for GAD [general anxiety disorder.]
1/17/25 12:30 PM - A review of R28's anti-anxiety care plan lacked evidence of non-pharmacological interventions prior to the use of the anti-anxiety medication.
1/17/25 1:00 PM - Findings were confirmed with E2 (DON).
Based on interview and record review, it was determined that for two (R28, R97 and R165) out of twenty seven residents reviewed for care plans, it was determined that the facility failed to develop and implement comprehensive, person centered care plans. For R97, the facility failed to implement R97's need for an adaptive cup during non-meal times. For R28 and R165 the facility failed to ensure care plans included non pharmacological interventions prior to the use of PRN antianxiety medication. Findings include:
1. R97's clinical record revealed:
Cross refer F692 and F810
12/19/24 - R97 was admitted to the facility with diagnoses including but were not limited to, dementia and difficulty swallowing.
12/20/24 10:05 AM - E13 (dietician) ordered in R97's EMR, Regular diet .Adaptive equipment: please issue divided plate, built up utensils and Kennedy cup with straw at all meals.
12/20/24 - R97 was care planned for .a potential nutritional problem r/t (related to) advanced age . self-feeding difficulty requiring adaptive equipment .[R97] has an ADL (activities of daily living) self-care performance deficit r/t limited mobility.
1/15/25 1:01 PM - During an interview, E30 (LPN) stated, [R97] gets an adaptive cup on her meal trays.
1/15/25 1:07 PM - During an interview, E32 (OT) stated, [R97] is ordered specialized dining utensils. It is part of the diet order . She is ordered a Kennedy cup because the handle allows her to pick the cup up independently .

Based on record review and interview, it was determined that for one (R78) out of twenty seven sampled residents, the facility failed to ensure that R78's comprehensive care plan was reviewed and revised based on preferences and needs of the resident and in response to current interventions. Findings include:
Cross refer F600
R78's clinical record revealed:
4/25/23 - R78 was care planned for potential physically aggressive behaviors as evidenced by yelling, kicking, hitting, slapping, striking out, etc. Interventions included:
- allowing R78 10-15 minutes to calm down then reapproach,
- redirecting when visibly irritated and,
- speaking in a calm voice to keep R78 calm, and feel non threatened.
3/25/24 9:37 PM - A facility incident report submitted to the State Agency documented that R78 hit R66 on the face.
4/2/24 - A facility 5 day follow up summary documented, Were changes made to Care Plan? Yes . Medication changes; Q 1 hr (hour) safety check.
1/16/23 11:05 AM - A review of R78's potential for physical aggression care plan revealed that it was not revised to include the new safety check interventions.
1/16/2 1:46 PM - In an interview, E2 (DON) confirmed that R78's care plan for physical aggression was not revised and updated after the 3/25/24 resident - to - resident physical altercation between R78 and R66.
1/22/25 at 3:04 PM - Finding was reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), E8 (Staff Educator), E14 (COO) and E15 (CNO).

Based on record review and interview, it was determined that for one (R113) out of one resident reviewed for discharge, the facility failed to have a discharge summary that included a reconciliation of medications. Findings include:
Review of R113's clinical record revealed:
11/6/24 - R113 was admitted to the facility with diagnoses, including but were not limited to, dementia, heart failure and difficulty walking.
11/13/24 9:21 AM - E10 (Director of Social Work) documented in a progress note in R113's EMR, DON (Director of Nursing) from [assisted living facility (ALF)] contacted SSD (social services director) to inform that resident is at baseline and is able to be re-admitted to ALF setting. DON requested d/c (discharge) for Thursday 11/14/24 . Resident will return to [ALF] with her spouse using [home health agency] for HHC (home health care) . ** SSD explained to new DON at [ALF] that [nursing facility] request 48 hours notice for all d/c's. IDT (interdisciplinary team) made aware SS (social Services) will remain available.
11/14/24 10:00 AM - R113 was discharged back to [ALF].
11/14/24 11:06 AM - E31 (LPN) documented in a progress note in R113's EMR, Resident discharged with her belongings, medication, prescriptions and discharge summary. Reviewed mediation administration, prescriptions and discharge instructions with resident/ daughter [F4] and she verbalized understanding.
12/8/24 11:16 AM - E22 (NP) completed R113's Discharge Summary in R113's EMR documenting, . Medication List: see D/C medication list .Plan: .Discharge mediations - see discharge instructions; prescriptions provided .
Of note, this provider discharge summary was completed and accessible in R113's EMR twenty-four days after her discharge from the facility.
1/21/25 10:15 AM - Surveyor reviewed the [facility] Discharge Summary V6 completed by E31 (LPN). The facility discharge summary provided the name and contact information for the home health agency and the community based primary care physician. [Facility] discharge summary documented that Medications given to resident or resident's representative, reviewed directions of use and drug storage with resident or residents (sic) representative, prescriptions sent and care plans given to resident or resident's representative.
The [facility's] discharge summary lacked evidence of R113's list of medications and a reconciliation of all pre-discharge medications with R113's post- discharge medications.
1/22/25 3:15 PM - E2 (DON) stated that the facility provided R113's daughter with a printout of R113's active medication orders at the time of discharge, which included escitalopram 5 mg by mouth daily, ferrous sulfate 325 mg by mouth daily, omeprazole 40 mg by mouth daily, pregabalin 75 mg by mouth daily and calcium + vitamin D3 600-5 mg- mcg by mouth daily.
Of note, neither the facility discharge summary nor the provider discharge summary documented the names, doses and routes of R113's discharge medications.
1/22/25 3:04 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), E8 (Staff Educator), E14 (COO) and E15 (CNO).

Based on record review and interview, it was determined that for one (R31) out of three residents reviewed for quality of care, the facility failed to treat a urinary tract infection for twenty hours, after receiving a positive result of infection. Findings include:
Cross refer F692 and F773
Review of R31's clinical record revealed:
11/3/23 - R31 was admittied to the facility.
3/6/25 12:45 AM - A physician's order documented to obtain a urinalysis, if the urinalysis was positve send for culture and sensitivity for increased confusion and lethargy.
3/9/25 8:03 PM - A lab result report received in the facility EMR system documented that R31's urinalysis noted culture growth of escherichia coli (e coli) with a colony count greater than 100,000 cfu/mL indicating a postive result for urinary tract infection.
3/10/25 9:01 AM - A time stamp noted in the EMR that E6 (NP) reviewed the urine results on the lab result report. The was 11 hours after the facility received the results of a positive UTI.
3/10/25 4:00 PM - A physician's order documented ceftriaxone (antibiotic) one gram inject one gram intramuscularly every twenty four hours for UTI (urinary tract infection) for five days. Give with lidocaine 2.1 mL. This was seven hours after the provider reviewed the positive lab results for a UTI.
3/10/25 4:27 PM - A review of R31's MAR documented that ceftriaxone was administered.
3/10/25 7:00 PM - A change in condition assessment documented R31 was having mental status changes, unable to respond properly to questions asked, lethargy, and neurological changes, and not able to focus. The assessment documented a recommendation of the primary clinician that R31 to be sent to the emergency room for further evaluation.
3/27/25 3:00 PM - An interview with E6 confirmed that R31 had a positive urine culture and that E6 ordered antibiotics. E6 confirmed that she instructed the 3:00 PM to 11:00 PM shift to send R31 to the emergency room due to change in condition. E6 further revealed that staff did not call the urine results to her on 3/9/25.
3/28/25 9:15 AM - An interview with E6 confirmed that she reviewed R31's urine results at 9:00 AM on 3/10/25 and confirmed that R31 needed antibiotics to treat the UTI. E6 stated that she did not need to wait on R31's lab results collected on 3/10/25 to initiate the antibiotics for the UTI.
The facility failed to treat a UTI for 20 hours after the facility received a positive lab result.
3/28/25 3:21 PM - Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference.

Based on record review, observation and interview, it was determined that for one (R101) out of three sampled residents, the facility failed to ensure that care was provided to support R101's hearing loss. Findings include:
Review of R101's clinical records revealed:
9/17/24 - R101 was admitted to the facility with diagnoses including stroke, cognitive communication deficit and major depressive disorder.
9/23/24 - R101's admission MDS documented, Minimum hearing difficulty.
9/30/24 - R101's admission BIMS documented a score of 15, indicating a cognitively intact status.
9/30/24 - R101's communication care plan documented, .[R101] has a communication problem r/t [related to] hearing deficit The interventions included, 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 .
11/16/24 - R101 clinical records documented, Seen by audiologist - recommendation for debrox [ear wax softening medication] 5 drops to both ears x 7 days.
12/18/24 - R101's clinical records documented, .Seen by audiologist - [wax] was removed from ears.
12/19/24 - R101's quarterly MDS documented a BIMS score of 14, indicating a cognitively intact status.
12/19/24 - R101's clinical document titled, Cadia Social Services Assessment documented, [E101] declined dentist, hygienist, hearing, sight this quarter
R101's clinical records documented eye doctor and audiologist visits in November and December 2024.
12/24/24 - R101's quarterly MDS documented, Moderate hearing difficulty follow up with audiology.
1/14/25 9:00 AM - During an interview the Surveyor attempted to speak with R101, but she pointed to both of her ears and shook her head. The surveyor wrote the questions on paper and asked R101 if she could hear what was being said. R101 wrote, No and pointed to her right ear and, little for her left hear. The surveyor further inquired if R101 had any tools e.g. white board or writing paper to communicate with staff, R101 shook her head from side to side, and wrote No. I asked for hearing aids but did not hear back. I would really like to hear a little better.
R101's room lacked evidence of writing paper, white board, or any other type of communication devices.
1/15/25 9:10 AM - The Surveyor communicated with R101 using pen and paper. R101 wrote that she was not offered any type of communication tools and denied refusal of hearing aids or medical appointments.
R101's room lacked evidence of any type of communication devices.
1/17/25 11:10 AM - During an interview R4 (UM) stated, [R101] was offered hearing aids but she refused. She would say she wants them but refuses when offered.
1/21/25 8:07 AM - R101 was observed in her room, no evidence of communication tools or devices were seen in the room.
1/21/25 9:30 AM - During an interview E18 (CNA) stated, I have to get very close to [R101] and talk loudly to her in her left ear. It's hard because her roommate sometimes think I am talking to her.
1/21/25 10:30 AM - During a telephone interview F3 (Family member) stated, I had brought an amplifier to use during the admission in September. They [the facility] had asked me and my aunt about getting her hearing aids. We said yes but I did not hear anything back about it since then. I would like her to be able to hear better.
1/22/25 at 3:04 PM - Finding was reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), E8 (Staff Educator), E14 (COO) and E15 (CNO).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, it was determined that for two (R73 and R66) out of three residents reviewed for bowel and bladder, the facility failed to provide appropriate treament and services to achieve or maintain as much nomal bladder function as possible. For R73, the facility failed to ensure that R73's urinary catheter care was monitored in a manner to prevent infection. For R66, the facility failed to maintain or restore continence. Findings include:
1. Review of R73's clinical record revealed:
2/20/22 - R73 was admitted to the facility with diagnoses including obstructive and reflux uropathy (blockage in the tubes that carry urine to the bladder), and retention of urine.
9/24/23 - R73's clinical records documented, .Catheter Care q [every] shift.
10/26/23 - R73's urinary care plan documented, [R73] has an indwelling catheter . The interventions included, .Position catheter bag and tubing below the level of the bladder . R73's [NAME] (electronic document for the residents' care) documented, Position catheter bag and tubing below the level of the bladder.
1/9/25 - R73's annual MDS documented a BIMS score of 13, indicating a cognitively intact status.
1/13/25 10:30 AM - R73 was observed sitting in the wheelchair in his room. The urinary collection bag was hanging above the bladder, below the left arm rest of the wheelchair.
1/13/25 12:00 PM - R73 was observed sitting in the wheelchair in the dining room eating lunch. The urinary collection bag was hanging above the bladder, below the left arm rest of the wheelchair.
1/13/25 12:45 PM - R73 was observed sitting the wheelchair in the dining room eating lunch. The urinary collection bag was hanging above the bladder, below the left arm rest of the wheelchair.
1/13/25 1:00 PM - Findings were confirmed with E8 (UM.)
2. A review of R66's clinical records revealed the following:
10/19/23 - R66 was admitted to the facility.
11/1/23 - R66 was care planned for the potential for falls related to .incontinence .with interventions including education on call bell use and calling for help prior to attempting transfer .(12/12/23) and keeping pathway to the bathroom clear and clutter free (12/11/23).
11/1/23 - R66 was care planned for bladder incontinence with interventions including on toileting program as ordered (1/30/24).
1/25/24 - R66's quarterly MDS revealed that R66's cognition was moderately impaired and was occasionally incontinent of urine.
4/25/24 - R66's quarterly MDS revealed that R66 had intact cognition and was occasionally incontinent of urine.
7/23/24 - R66's quarterly MDS revealed that R66's cognition was moderately impaired and was occasionally incontinent (loss of control of bladder) of urine.
1/17/25 - A review of R66's fall incident reports from January 2024 through December 2024 revealed the following:
- 3/2/24 6:30 AM - Patient found sitting on floor next to her bed .states she was trying to go to the bathroom - just toileted at 5:00 AM
- 5/8/24 12:12 AM - Patient found sitting on the floor next to her bed and stated I was going to the bathroom
- 7/2/24 11:30 AM - Patient found lying prone on the floor in her room - bed to floor .patient toileted and assisted back to bed .
- 8/16/24 1:29 AM - Patient found sitting on the floor next to the toilet in her bathroom - back leaning against the toilet. Last toileted 12:00 AM. toilet after fall.
1/17/25 - A review of Fall Risk Evaluations from January 2023 through January 2025 revealed that R66 needed assistance with toileting.
1/17/25 3:06 PM - During an interview E24 (CNA) stated that, [R66] is a limited assist with toilet, has fallen a lot. She is continent of bladder and she would ask me to take her to the bathroom. She tells me when she wants me to take her to the bathroom.
1/21/25 9:54 AM - In an interview E23 (LPN) stated that [R66] is mostly continent and she transfers herself to the bathroom. We toilet her .sometimes every hour but she also lets us know if she wants to use the bathroom.
1/21/25 2:35 PM - During an interview, E2 (DON) confirmed that R66's person centered toileting program was not revised. E2 presented to the surveyor a copy of R66's incontinence care plan with interventions reviewed and revised on 1/17/25.
The facility failed to ensure R66's person centered care plan interventions and a personalized toileting program were reviewed to address R66's falls related to R66's need to use the bathroom.
1/21/25 2:40 PM - Findings were discussed with E1 (NHA) and E2.
1/22/25 at 3:04 PM - Finding was reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), E8 (Staff Educator), E14 (COO) and E15 (CNO).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, it was determined that for two (R97 and R114) out of two residents reviewed for hydration, the facility failed to offer R97 sufficient fluid intake in an accessible manner for her to maintain proper hydration. For R114, the facility failed to ensure that R114 received sufficient fluids to maintain proper hydration or provide additional interventions when R114's oral intake significantly dropped. This failure resulted in harm with R114 being transferred to the hospital on 2/28/24 with a BUN of 100. Findings include:
The BUN (blood urea nitrogen) lab measures the amount of urea nitrogen in the blood. The BUN is directly related to the metabolic function of the liver and the excretory function of the kidney . BUN levels also may vary according to the state of hydration, with increased levels seen in dehydration and decreased levels seen in overhydration. Mosby's Diagnostic and Laboratory Test Reference 2023
1. Review of R114's clinical record revealed:
6/17/22 - R114 was admitted to the facility with diagnoses including but were not limited to, dementia and stroke with resultant difficulty swallowing and language/speech deficits.
6/20/22 - R114 was care planned for several problems including: has nutritional problem d/t (due to) . hx (history) need for feeding assistance, advanced age, .poor intake .Interventions for this problem included: . Monitor intake and record q (every) meal .provide assistance cueing meals as needed .
6/29/22 - R114's care plan was updated with several additional problems including: .(1) has the potential for pressure ulcers, decreeased functional mobility .Interventions for this problem included : .encourage adequate nutrition/hydration . (2) has an ADL (activities of daily living) self- care performance deficit r/t (related to) weakness . Interventions for this problem included: . Eating- [R114] is supervision of one person with feeding .
6/19/23 - E33 (dietician) documented in R114's EMR, . [Facility] Nutrition Risk Assessment . Estimated fluids - ml (milliliter) -1200 - 1440 . Feeding status - Needs some assistance with meal set up or eating . Assessment - .[R114] is able to feed herself after set up with some cueing . [R114] meets criteria for malnutrition d/t (due to) dementia and variable intake .
8/10/23 - E27 (MD) ordered in R114's EMR, .Med Pass (medication pass) three times a day 120 ml (additional water) .
This order added 360 mls of additional water that R114 consumed each day.
1/19/24 - E34 (NP) documented in R114's EMR a follow up progress note, .History of present illness: Pt (patient) appears clinically stable . Labs 8/2/23 . Na (sodium) 141 mmol (millimole)/L (liter) (normal range 137-145) . BUN 20.0 mg (milligram) /dL (deciLiter) (normal range 7.0-17.0), creatinine 0.70 mg/dL (normal range 0.52 - 1.04) . Plan: weight stable: appetite variable but mostly acceptable . Continue Remeron .and encourage fluids .
R114's BUN at the time of this encounter was elevated at 20.0, which was reflective of R114 being intravascularly dry or dehydrated.
Of note, this note was not signed by the provider until 5/2/24, which was five and a half months after the encounter. The notes are only available to be read in the resident's EMR after they are signed off by the provider so this note was not available to be read until 5/2/24.
2/1/24 - E22 (NP) reviewed R114's labs, which documented a sodium level of 141, a BUN of 18 and a creatinine level of 0.90.
The BUN was slightly elevated at 18, where the normal range was 7.0 to 17.0.
The daily totals of R114's oral intake was:
2/18/24 - 1560 mls, 51-75% consumption of meals for 2 out of 3 meals, dinner was 0 - 25% consumed,
2/19/24 - 1440 mls, 51-75% consumption of meals for 2 out of 3 meals, dinner was 0 - 25% consumed,
2/20/24 - 1320 mls, 51-75% consumption of meals for 2 out of 3 meals, dinner was 76 -100% consumed,
2/21/24 - 1320 mls, 26- 50% consumption of 2 out of 3 meals, dinner was 76 - 100% consumed.
2/21/24 - E35 (RN supervisor) documented in R114's EMR, [R114] is asymptomatic. Roommate with positive results [COVID]. Resident with room change to [room number] and contact/droplet isolation precautions initiated per protocol .
2/22/24 - 1380 mls, 26 - 50% consumption of breakfast, lunch and dinner were 0-25% consumed,
2/23/24 - 1080 mls, 0 - 25% consumption of breakfast and lunch, dinner was 26-50% consumed. CNA documented under ADL - Eating Self performance task that the Activity (eating) did not occur for lunch.
2/24/24 - 960 mls, 0 - 25 % consumption of all 3 meals,
2/25/24 - 880 mls, 0 - 25 % consumption of breakfast and lunch, dinner was 26-50% consumed. CNA documented under ADL - Eating Self performance task that the Activity (eating) did not occur for lunch.
2/26/24 - 1080 mls, 0 - 25 % consumption for all 3 meals. CNA documented under ADL - Eating Self performance task that the Activity (eating) did not occur for breakfast.
2/27/24 - 780 mls, 0 - 25 % consumption for breakfast, lunch and dinner were 26-50% consumed.
Of note, R114's oral intake dramatically dropped after she was placed on isolation precautions for a COVID exposure on 2/21/24. R114's oral intake for the four days prior to the isolation precautions all fell within R114's normal oral intake range. For the seven days that R114 was on isolation precautions prior to her transfer tot he hospital, on six of those days R114's oral intake was documented to be significantly lower then normal.
Additionally from 2/22/24 to 2/28/24, out of the twenty meals offered during these seven days, R114 was documented as not eating an entire meal five times. R114 failed to eat twenty-five percent of her meals during this period. The facility failed to ensure R114 met her stated hydration goals by supervising, cueing and monitoring R114's intake at meals. R114's EMR lacked evidence that the facility notified the providers of R114's decrease in oral intake.
2/28/24 6:17 AM- E22 gave a verbal telephone order entered into R114's EMR, CBC (complete blood count) CMP (complete metabolic panel) one time only for increase in lethargy for 1 day.
2/28/24 6:23 AM - E36 (LPN) documented in R114's EMR progress note, Noted with increase lethargy. Hydration unsuccessful. New order for CBC, CMP .
Until this 2/28/24 note, despite five days (2/23 to 2/27/24) of R114 poor oral intake, the facility lacked evidence that this decrease in R114's oral intake was acknowledged by the staff and/or reported to the providers.
2/28/24- 300 mls, 0 - 25 % consumption of breakfast and lunch prior to transfer to the hospital. CNA documented under ADL - Eating Self performance task that the Activity (eating) did not occur for both breakfast and lunch.
2/28/24 12:58 PM - Per the [county paramedic's] Prehospital Care Report, R114 was transferred to the hospital for an altered mental status . patient is noted to be in Atrial fibrillation at a rate of 170 bpm (beats per minute). Patient is also tachypnic (sic) (rapid breathing) at a rate of about 40. Patient is an obligate mouth breather and her oral cavity is noted to be dry .
2/28/24 2:27 PM - R114's facility lab results documented a sodium of 158 mmol/dL (normal range 137-145), creatinine 1.80 mg/dL (normal range 0.52- 1.04). There was no reported BUN value on this lab report.
2/28/24 2:01 PM - [Hospital] laboratory report documented R97's admission/emergency room labwork with a BUN result of 101mg/dL, with this lab's normal range as 8- 22 mg/dL.
From 2/1/25 to 2/28/25, R114's BUN elevated from 18 (2/1/25 lab work) to 100 (2/28/25 hospital lab work).
2/29/24 00:25 AM - C2's [hospital] history and physical documented in R114's hospital EMR, . [R114]'s lab work was significant for sodium of 157 and a creatinine of 2.21 from a baseline of 0.9, and a BUN of 101 .Assessment/Plan: Sepsis, unspecified organism- unclear source but patient has mulit-organ failure including her kidneys, her liver as well as evidence of new onset A-fib .
2/29/24 - R114 expired at [hospital] on hospice service.
1/21/25 11:45 AM - Review of R114's EMR progress notes lacked evidence of any notation regarding R114's decreased oral fluid intake or any notification of R114's providers regarding her decreased oral intake until 2/28/24 6:23 AM progress note in which E36 (LPN) documented, .Hydration unsuccessful .
1/21/25 2:33 PM - During an interview, E4 (RN/unit manager) stated, It was not unusual for [R114] to ignore you if she did not want to deal with you. She played possum. She often refused her meds. Her vital signs were normal but as the day [2/28/25] progressed she became tachycardic and her breathing changed so we sent her out. She had had labs drawn that morning but they were not back when we sent her out.
1/22/25 8:16 AM - During an interview, E36 (LPN) stated, . [R114] was her normal self. (neurologically) I was trying to give her water to drink because I was worried about dehydration.
Cross refer F656 and F810.
2. Review of R97's clinical record revealed:
12/19/24 - R97 was admitted to the facility with diagnoses including but were not limited to, dementia and difficulty swallowing.
12/20/24 9:56 AM - E13 (dietician) documented on the [facility] Nutrition Risk Assessment in R97's EMR, . Estimated fluids- ml (milliliter) - 1500 - 1800 ml (25-30 ml/kg) (kilogram) . Feeding status - Needs some assistance with meal set up or eating . Assessment - .Daughter reports good oral intake but has had to assist with meals .
12/20/24 10:05 AM - E13 (dietician) ordered in R97S EMR, Regular diet .Adaptove equipment: please issue divided plate, built up utensils ands [NAME] cup with straw at all meals.
12/20/24 1:00 PM - E27 (MD) ordered in R97's EMR, Med Pass one time a day 120 mls and Juven two times a day for 4 weeks. Mix with 240 mls water.
These two orders accounted for 600 mls of R97's documented oral intake during this time period.
12/20/24 - R97 was care planned for several problems including: .(1) a potential nutritional problem r/t (related to) advanced age, . self-feeding difficulty requiring adaptive equipment . Interventions for this problem included: provide adaptive equipment for feeding as needed .Monitor intake and record .[R97] has an ADL (activities of daily living) self-care performance deficit r/t limited mobility . (2) has impaired cognitive function/dementia . Interventions for this problem included: Cue, reorient and supervise as needed . (3) has an ADL (activities of daily living) self-care performance deficit r/t (related to) limited mobility .Interventions for this problem included: Assist with eating as needed .
The daily totals of R97's fluid intake were:
1/2/25 - 1440 mls
1/3/25 - 1200 mls.
1/4/25 - 1680 mls.
1/5/25 - 1080 mls.
1/6/25 - 1800 mls.
1/7/25 - 1410 mls.
1/8/25 - 1800 mls.
1/9/25 - 1760 mls.
1/10/25 - 1560 mls.
1/10/25 1:31 PM - R97's lab revealed a BUN (blood urea nitrogen) level of 61.0 mg(milligrams)/ dL (deciliter). The BUN normal reference level for this lab was 7.0 to 17.0 mg/dL so R97's BUN result of 61.0 was elevated and reflective of a state of dehydration.
1/10/25 2:32 PM - E29 (NP) documented in R97's EMR reviewing these lab results. R97's EMR lacked evidence of E29 addressing R97's elevated BUN in either a progress note or with any new orders.
1/11/25 - 1920 mls.
1/12/25 - 1680 mls.
1/13/25 - 1320 mls.
1/13/25 4:06 PM- The surveyor observed R97's bedside table with a full, white styrofoam cup with a straw and ice water in it.
1/14/25 10:30 AM - The surveyor observed R97's bedside table with a full, white styrofoam cup with a straw and ice water in it
1/14/25 - 1310 mls.
1/15/25 - 1430 mls
R97's stated hydration goals were 1500 - 1800 mls per day. From 1/2/25 to 1/14/25, there were seven out of fourteen days, where it was documented that R97's oral fluid intake was less than her documented minimum fluid goal. The facility failed to ensure R97 met her stated hydration goal by failing to provide bedside water in a Kennedyadaptive cup that R97 could independently consume, failing to assist and cue R97 to drink her bedside water, and failing to address R97's decreased oral fluid intake with R97's provider.
From 1/2/25 to 1/14/25, the CNA staff documented in R97's CNA tasks list report under Eating Self-performance- How resident eats and drinks, regardless of skill? that for twenty-nine times of the thirty-nine recorded entries, R97 was Total dependence - full staff performance with regards to this task.
1/15/25 10:30 AM - Review of R97's EMR progress notes lacked evidence of any notation regarding R97's decreased oral fluid intake or any notification of R97's providers regarding her decreased oral intake.
1/15/25 1:01 PM - During an interview, E30 (LPN) stated, [R97] gets an adaptive cup on her meal trays. But I have never seen one on her bedside tray during non-mealtimes. She usually gets her bedside water in a white styrofoam cup .
1/15/25 1:07 PM - During an Interview, E32 (OT) stated, [R97] is ordered specialized dining utensils. it is part of the diet order . She [R97] is ordered a Kennedy cup because the handle allows her to pick the cup up independently.
1/16/25 1:35 PM - Review of R97's orders and CNA tasks list report lacked evidence of an order related to R97 utilizing a [NAME] adaptive cup outside of her meal tray.
1/16/25 2:45 PM - During an interview, E24 (CNA) stated, When we pass the [bedside] water, we use the white styrofoam cups for [R97]. There is no any documentation in the tasks regarding specialty cups. There is not an order. If there3 is a specialty cup on her bedside table, I would pour the water from the styrofoam cup to the specialty cup. Most times, the specil cups come on the food trays.
1/21/25 3:28 PM - E15 (CNO) presented the surveyor with a copy of a new order for R97 stating offer water in Kennedy cup q (every) shift. E15 also provided a copy of R97's CNA tasks list report with a new task Provide Q (every) shift water in Kennedy cup.
1/22/25 3:04 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), E8 (Staff Educator), E14 (COO) and E15 (CNO).

Based on record review and interview, it was determined that for one (R91) out of twenty-seven residents reviewed for physician services, the facility failed to ensure that R91's required visits were coordinated and alternated between the physician and the NP. Findings include:
Review of R91's clinical record revealed:
9/18/23 - R91 was admitted to the facility with diagnoses including, but were not limited to, dementia and anxiety disorder.
12/21/23 - E27 (MD) assessed and wrote a progress note for R91.
5/20/24 - E28 (NP) assessed and wrote a progress note for R91.
R91 went 151 days without being seen by a provider at the facility. This reflected R91 missing two required 60 day visits by a provider.
6/20/24 - E29 (NP) assessed and wrote a progress note for R91.
Based on the 5/20/24 encounter was provided by a nurse practitioner, R91 was required to be seen by the physician by 7/20/24. The facility was not able to provide evidence of R91 being seen by a physician on or around 7/20/24.
7/31/24 - E29 (NP) assessed and wrote a progress note for R91.
8/7/24 - E29 (NP) assessed and wrote a progress note for R91.
8/8/24 - E27 (MD) assessed and wrote a progress note for R91.
R91 went 231 days between physician visits.
1/22/25 3:04 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), E8 (Staff Educator), E14 (COO) and E15 (CNO).

2. R90's clinical record revealed:
10/21/24 - R90 was admitted to the facility.
10/21/24 - The Consultant Pharmacist admission Review recommended that R90 have an apical pulse parameter with the administration of Amiodarone medication.
The undated handwritten response on the 10/21/24 pharmacist recommendation was signed by E22 (NP) and documented, (Will refer to cardiology).
Review of R90's clinical record lacked evidence that this recommendation for cardiology were carried out and the documented action that was taken.
1/17/24 at 8:55 AM - During an interview, E6 (UM/RN) confirmed that the recommendation was signed but not dated by E22 (NP). E6 reviewed R90's cardiology consultant notes from 10/22/24 and 10/29/24 and confirmed that this pharmacy recommendation was not addressed in either of those notes.
1/22/25 at 3:04 PM - Finding was reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), E8 (Staff Educator), E14 (COO) and E15 (CNO).
Based on record review and interview, it was determined that for two (R78 and R90) out of five residents reviewed for medication review, the facility failed to ensure the provider documented that irregularities were reviewed. In addition, the facility failed to ensure the Drug Regimen Review policy included all of the time frame requirements. Findings include:
1. Review of R78's clinical record revealed:
a. 2/25/24 - Review of R78's drug regimen reviews found the pharmacist identified an irregularity and asked if a repeat TSH (Thyroid Stimulating Hormone) test be of benefit at this time since R78's TSH drawn on 1/10/23 was high at 12.911 but improved from prior level on 12/11/23. There was no evidence that the physician reviewed this pharmacy concern.
1/16/25 10:00 AM - In an interview, E2 (DON) confirmed that the 2/25/24 pharmacy recommendation was not signed off by the physician and that a signed copy of the facility's response could not be found on R78's medical records.
b. 1/16/25 8:42 AM - A review of the facility's policy titled, Consultant Pharmacist Chart Review Reports and Records, revealed a lack of information of the facility's time frame to respond to the pharmacy recommendations based on identified irregularities.
1/16/25 9:49 AM - In an interview, E15 (CNO) confirmed that facility's time frame to respond to the pharmacy recommendations based on identified irregularities was not identified in the current policy and that the policy will be reviewed and revised.
1/21/25 2:40 PM - Findings were discussed with E1 (NHA) and E2.

Based on interview and record review, it was determined that for one (R28) out of five residents sampled for unneccary medication review, it was determined that the facility failed to ensure that the targeted behaviors were documented and non- pharmacological interventions were implemented prior to the use administration of PRN antianxiety medication. Findings include:
Review of R28's clinical records revealed:
6/14/24 - R28 was admitted to the facility with diagnoses including major depressive disorder and anxiety.
6/14/24 - R28's care plans documented, . [R28] uses anti-anxiety medications r/t [related to] anxiety disorder . The interventions included. Administer ANTI-ANXIETY medications as ordered by physician Monitor for side effects and effectiveness
R28's care plan lacked evidence of non-pharmacological interventions prior to the use of the PRN antianxiety medication.
11/26/24 - R28's MAR documented, .Target behavior: sad, withdrawn, teary-eyed, restlessness, combative, agitation, At the end of each shift note: Frequency - #times behavior occurred; Interventions - A= Redirected, B= Activity provided, C= Refer to Nurses note, D=Toilet, E=Gave food, F=Gave fluids, G= Changed position, H= Back rub.
12/10/24 - R28's quarterly MDS assessment documented a BIMS score of 00, indicating severe cognitive impairment.
12/24/24 - R28's clinical records documented, . Lorazepam 0.5 mg/ 1 ml Gel Apply 1 mg transdermally [on the skin] every 6 hours as needed for GAD [general anxiety disorder.]
1/17/25 12:30 PM - A review of R28's Medication Administration Records (MAR) revealed a lack of documentation of the number of times that the targeted behaviors occurred, and non-pharmacological implemented for the following dates and times the PRN Ativan [lorazepam] 0.5mg gel was used:
12/4/24 at 1:34 PM
12/7/24 at 2:15 AM
12/26/24 at 2:48 PM
1/1/25 at 3:27 AM
1/3/25 at 8:03 AM
1/8/25 at 9:00 AM
1/9/25 at 8:32 AM
1/13/25 at 9: 00 AM
1/14/25 at 1:44 AM
The facility failed to document the number of targeted behaviors and non-pharmacological interventions for nine out of sixteen opportunities for the use of PRN anti-anxiety medications.
1/17/25 1:30 PM - Findings were confirmed with E8 (RN).
1/22/25 at 3:04 PM - Finding was reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), E8 (Staff Educator), E14 (COO) and E15 (CNO).

Based on record review and interview, it was determined that for one (R90) out of five residents reviewed for unnecessary medications, the facility failed to ensure that laboratory services were obtained only when ordered by a provider. Findings include:
R90's clinical record revealed:
12/28/24 - R90 had a blood draw performed for three labs (CBC, CMP, Mg).
Review of R90's clinical record lacked evidence of a physician order for the 12/28/24 labs.
The facility failed to obtain laboratory services only when ordered by a provider.
1/22/24 at 1:00 PM - Finding was reviewed with E2 (DON) and E15 (CNO).
1/22/25 at 3:04 PM - Finding was reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), E8 (Staff Educator), E14 (COO) and E15 (CNO).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, it was determined that for one (R97) out of four residents reviewed for ADLs (activities of daily living), the facility failed to supply R97's bedside water in a [NAME] adaptive cup. Findings include:
Facility Adaptive Feeding Equipment policy: It is the policy of [facility] that residents requiring adaptive feeding equipment will receive such equipment.
Cross refer F656 and F692
A Kennedy cup is an adaptive cup that prevents liquid from spilling even when turned upside down and has an ergonomic handle for ease of holding.
Review of R97's clinical record revealed:
12/19/24 - R97 was admitted to the facility with diagnoses including but were not limited to, dementia and difficulty swallowing.
12/20/24 10:05 AM - E13 (dietician) ordered in R97's EMR, Regular diet .Adaptive equipment: please issue divided plate, built up utensils and Kennedy cup with straw at all meals.
12/20/24 - R97 was care planned for .a potential nutritional problem r/t (related to) advanced age . self-feeding difficulty requiring adaptive equipment .[R97] has an ADL (activities of daily living) self-care performance deficit r/t limited mobility.
12/31/24 - R97 was care planned for .[R97] has actual contracture .decreased functional mobility .
1/13/25 4:06 PM - During an interview, F6 (R97's daughter) stated that her mom [R97] needs her bedside water in an adaptive cup. F6 stated, The staff gives her water every shift in a Styrofoam white cup and she [R97] cannot pick it up due to her stroke. So only when the family or staff offer to hold her water cup can she drink it. She likes water and will drink it, if she could pick up the cup.
1/13/25 4:06 PM - The surveyor observed R97's bedside table with a full, white Styrofoam cup with a straw and ice water in it.
1/14/25 10:30 AM - The surveyor observed R97's bedside table with a full, white Styrofoam cup with a straw and ice water in it.
1/15/25 1:07 PM - During an interview, E32 (OT) stated, [R97] is ordered specialized dining utensils. It is part of the diet order. The ([NAME]) cup is not left at the bedside because it has to be cleaned. Usually, I talk to the family and have them buy another ([NAME]) cup for the resident to use for their water cup.
The facility failed to provide R97 with an adaptive cup that she could independently drink from during non-meal times.
1/22/25 3:04 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), E8 (Staff Educator), E14 (COO) and E15 (CNO).

Based on observation and interview, it was determined that the facility failed to ensure food was stored and served in a manner that prevents food borne illness to the residents. Findings include:
1. 1/13/25 9:03 AM - An observation in the dry storage room revealed several food item bags that were opened but not dated. There were three bags of bread and a bag of cake mix powder. The findings were confirmed with E25 (Assistant Food Service Director) on site.
2. 1/13/25 9:11 AM - An observation in the walk-in freezer revealed some food debris on the floor. An opened bag of shrimp did not have a date. The findings were confirmed with E25 on site.
3. 1/13/25 9:15 AM - An observation in the walk-in refrigerator revealed a dated half bag of poultry meat stored together with two bags of un-opened same type of poultry meat without dates. The surveyors were not certain whether they belonged to the same batch. There were also a bottle of apple juice and a grape jelly undated, and a discolored vegetable salad dated 1/3/25 which was removed by E25 upon noticed.
4. 1/14/25 2:17 PM - A review of the three-month food temperature log from October to December, 2024 revealed that the temperature of 22 out of 279 (7.9%) meals were not recorded in the log.
1/15/25 11:20 AM - Findings were discussed and confirmed with E12 (Food Service Director), E25 and E13 (Registered Dietitian).
1/15/25 11:55 AM - Findings were discussed with E1 (NHA) and E2 (DON).
1/22/25 at 3:04 PM - Findings were reviewed during the exit conference with E1, E2, E3 (ADON), E8 (Staff Educator), E14 (COO) and E15 (CNO).