Wylie Oaks Healthcare And Rehabilitation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 8 residents (Resident #1) reviewed for ADLs. The facility failed to ensure staff provided consistent showers/baths for Resident #1. The facility failed to ensure Resident#1 fingernails were cleaned and trimmed. These failures could place residents at risk of not receiving needed hygiene care which could cause skin breakdown, infection, a loss of dignity and self-worth. Findings included: Record review of Resident #1's quarterly MDS assessment, dated 12/15/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. She had a BIMS score of 07, which indicated her cognition was severely impaired. Her diagnoses included cancer (a group of diseases characterized by uncontrolled, abnormal cell growth that can invade nearby tissues or spread [metastasize] to distant parts of the body), Non-Alzheimer's Dementia (forms of cognitive decline not caused by Alzheimer's disease), Depression, and pain disorder with related psychological factors. Functional ability-Personal hygiene: Partial/moderate assistance, and Shower/bathe self: Substantial/maximal assistance. Resident required assistance with ADLs. Record review of Resident #1's care plan, initiated on 12/24/25, reflected, Problem-Category: ADLs Functional Status/Rehabilitation Potential Resident experiences differences in ability to perform ADL. Goal: Resident will complete ADL during morning or evening with use of limit assistive thru the Next review date. Approach: Provide assistance for ADL as eating -supervision x1 , toileting extensive x1, bathing dependent x1, dressing extensive assist, transfer x1 . Resident requires hospice R/T disease process.Record review on 12/30/25 of Doctor order summary dated 04/23/24 revealed admitted to Founders Plaza with hospice. Record review of Resident #1's encounter notes by the hospice agency staff member dated 12/22/25, 12/23/25, 12/24/25,12/29/25 and 12/30/25 revealed no documentation for Resident#1 ADLs. Review of the hospice agency and the facility communication file for Resident#1 revealed no indication of Resident#1 receiving or refusing shower/bed bath. Review of Resident#1' nurses progress notes revealed no indication of resident refusing shower/bed bath, and nail care. In an interview and observation with Resident #1 on 12/30/25 at 09:49 a.m., The resident was observed lying in bed, covered with a blanket. Her hair was uncombed; had an unpleasant body odor. Resident#1 had approximately a 1/5 inch of facial hair on her chin, her fingernails on both hands were long approximately 1/4 inches in length, with brown matter underneath. Resident#1 stated she was not getting her showers. She stated she could not remember the last time she had her shower and stated it had been weeks since she had one. When asked if she was getting a bed bath, she replied no. Resident#1 stated she did not care about the facial hair, but would like to get shower, have her fingernails cleaned and trimmed. In observation and interview on 12/30/25 at 10:45 a.m., CNA A looked at Resident#1 fingernails and stated they were long and needed to be cleaned. CNA A stated Resident#1 was on hospice services and the hospice aides came in daily to visit Resident#1 ADLs Mondays through Fridays. CNA A stated the hospice aides were supposed to do Resident#1 ADLs including showers and fingernails care. CNA A stated she saw HA B visiting Resident#1 this morning but did not know which kind of care was given to the Resident. CNA A asked Resident#1 if she had a shower or bed bath by HA B on 12/30/25; 12/29/25, 12/26/25 and 12/25/25 and the Resident replied no. CNA A asked Resident#1 when was the last time she received shower/bed bath and Resident#1 stated it had been weeks. CNA A stated it was the responsibility of the CNAs to make sure Resident#1 received proper care, and report to the nurses in charge if the residents refused the care. CNA A stated risk to residents loss of dignity, skin break down, scratching self, and development of infection. In a telephone interview on 12/30/25 at 12:53 p.m., CNA C stated she worked weekends, and she offered Resident#1 shower on Saturday 12/27/25, but Resident#1 refused, and she washed her waist down in the bathroom while helping her with incontinent care, and changed her clothes. She stated for residents on hospice services the CNAs only offer them shower/bed bath, because they are supposed to have shower during the hospice Aides visits on the weekdays (Monday through Friday). She stated she did not notify the charge nurse about the refusal of shower for Resident #1. In an interview over the phone on 12/30/25 at 02:12 p.m., HA B stated her last visit with Resident#1 last week was on 12/24/25 and there was another hospice Aide that visit the resident on 12/25/25, 12/26/25. HA B stated during her visits on 12/29/25 and 12/30 Resident#1 refused shower, and she only washed her down. When asked to be more specific, she repeated the same. She stated she did not notify the charge nurse about Resident#1 refusal of shower. HA B stated she cleaned Resident#1 fingernails during her visit on 12/29/25 but because Resident#1 scratch her skin her fingernails get dirty. HA B stated she logged her visit on the Resident's hospice file and did her document on an app on her phone. In an interview on 12/30/25 at 01:37 p.m., LPN D stated the Nurse in charge were responsible for ensuring the resident's showers and ADLs care were performed. He stated the HA B visit Resident#1 daily Monday through Friday for her ADLs care per hospice services including shower, nails care and changing bed lining. He stated HA B called him today to Resident#1 room to help her transfer the Resident#1 from bed to wheelchair, and he left the room after that. He stated he did not know that HA B did not give Resident#1 shower or bed bath. He stated the CNAs/Hospice Aides were supposed to let them know if a resident refused ADLs care or if they were unable to give the scheduled shower or bath. He stated the risk to residents skin break down, and development of infection. In an interview on 12/30/25 at 01:56 p.m., The DON stated she was unable to locate any refusal documentation of shower/bed bath or nails care for Resident#1. She stated residents on hospice services were supposed to get showers and nail care during the hospice Aides visit on the weekdays Mondays through Fridays. She stated HA B had a good relationship with Resident#1 and had been visiting and providing care for her for the last three years. She stated the CNAs were supposed to offer showers for the residents on hospice. She stated the hospice Aides were supposed to communicate to the charges nurses the care rendered to the residents and if there was any refusal of care. The DON stated it was the responsibility of the CNAs and the Charge nurse to make sure residents were kept cleaned, and well-groomed all the time. She stated they were talking with the hospice agency to implement a new system where any refusal had to be documented by the hospice Aides, Charge nurse, and the resident to see if the resident wished for a shower at a different time. She stated the hospice Aides were documenting the care in a separate system belonging to the hospice agency, and the facility was looking to have the documentation forwarded to the facility. She stated ultimately the Charge nurses need to be ensuring the care is provided. The DON stated the risk to residents not getting their showers and nails care was skin issues, hygiene, development of infection, and loss of dignity. In an interview on 12/30/25 at 2:26 p.m., The ED stated the hospice services were supposed to fulfill their contract and provide the services agreed upon to the residents. He stated the DON and the ADON were in servicing CNAs and charge nurses on better communication with the hospice staff, and to make sure the residents received their care daily. He stated he was in contact with the hospice service for the facility to start getting the documentation of the care provided by the hospice staff. Review of the facility policy titled Nursing Policies and Procedures Subject Hospice Care revised 5/5/2023 revealed .2. The Hospice retains primary responsibility for the provision of hospice care and services, based upon the resident's assessment, including but not limited to the following: .nursing (including assigning a hospice aide as needed to support the resident's on-going care) .8. The facility and hospice will have ongoing collaborative communication. Review of the facility policy titled Nursing Policies and Procedures Subject Activities of Daily Living , Optimal Function revised 5/5/2023 revealed Activities of daily living (ADLs), refer to tasks related to personal care including, grooming, dressing, oral hygiene, transfer, bed mobility, eating, bathing and communication system.The facility provides necessary care to all residents that are unable to carry out activities of daily living on their own to ensure they maintain proper nutrition, grooming, and hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of 4 residents reviewed for respiratory care.The facility failed to ensure Resident #1's nebulizer mask (device used to deliver medication in a mist form through the mouth) was stored in a bag when not in use on 10/30/2025.This failure could place residents at risk of respiratory infection and not having their respiratory needs met.Findings include: Record review of Resident #1's Face Sheet, dated 10/30/2025, reflected the resident was a [AGE] year-old male who admitted on [DATE]. Resident #1 had diagnoses which included hypertension (elevated blood pressure), atrial fibrillation (irregular heart rhythm), and COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs).Record review of Resident #1's MDS (tool used to measure health status) Quarterly Assessment, dated 09/08/2025, reflected moderately impaired cognition with a BIMS (tool used to measure cognitive status) score of 10. Section I (Active Diagnoses) reflected Resident #1 was treated for COPD.Record review of Resident #1's Comprehensive Care Plan, dated 08/28/2025, reflected the resident received nebulizer treatments related to COPD. One intervention was to provide breathing treatments as ordered.Record review of Resident #1's Physician's Orders, dated 07/02/2025, reflected to administer Albuterol Sulfate (medication that makes it easier to breathe) inhalation solution 2.5 milligrams/3 milliliters every four hours as needed for COPD.During an observation and interview on 10/30/2025 at 11:49 AM, Resident #1's nebulizer with tubing attached to a face mask was on top of a small refrigerator on the resident's bedside table. The face mask was not stored in a bag. Resident #1 was sitting in a wheelchair next to his bed. Resident #1 replied no when asked if he had a breathing treatment that day. He stated he did not receive a breathing treatment every day.During an interview on 10/30/2025 at 1:51 PM, the ADON stated Resident #1's nebulizer mask should have been in a bag to prevent it from getting dirty. He stated it was unsanitary to leave it uncovered. The ADON stated it was important to prevent infection.During an interview on 10/30/2025 at 2:11 PM, the DON stated Resident #1's nebulizer mask should have been stored in a bag. She stated the facility did not have a policy specifically about storing respiratory items when not in use. The DON stated the facility had already begun in-service training on storing respiratory items. She stated it was an important measure to help prevention infection.During an interview on 10/30/2025 at 1:34 PM, LVN B stated Resident #1's nebulizer mask should have been in a bag. She stated the facility had an in-service the previous Friday about storing respiratory items in a bag when not in use. LVN B stated she had already replaced the nebulizer mask and tubing and bagged the items. She stated it was important to prevent contamination and infection.Record review of the facility's policy Respiratory Policies and Procedures: Small Volume Nebulizer, revised 02/12/2024, did not reflect how to store respiratory items when they were not in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to treat each resident with respect, dignity, and care in a manner and environment that promoted maintenance or enhancement of his or her quality of life for one (Resident #53) of one resident reviewed for Confidentiality of Records.
The facility failed to ensure LVN B secured Resident #53's medical information when she left her cart unattended on [DATE].
This failure could place the residents at risk of their medical information being exposed to unauthorized individuals.
Findings included:
Record review of Resident #53's Face Sheet, dated [DATE], reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with gastrostomy status (having done a surgical procedure that creates artificial opening into the stomach to provide nutritional support), restlessness, agitation, anxiety (intense or excessive fear or worry), depression (persistent feeling of sadness or loss of interest), pain, and amyotrophic lateral sclerosis (a disorder that affects the brain and the spinal cord that results to loss of movement to both upper and lower extremities). The Face Sheet indicated that the resident was on hospice and had a directive of DNR (a legal and medical document that tells the providers the patient does not want to be revived when he stops breathing).
Record review of Resident #53's Comprehensive MDS Assessment (tool used to assess functional capabilities and health needs), dated [DATE], reflected the resident was unable to complete the interview to determine the BIMS (tool used to assess cognition) score. The Comprehensive MDS Assessment indicated that the resident was on hospice, had anxiety, depression, amyotrophic lateral sclerosis, with unspecified pain, and with g-tube.
Record review of Resident #53's Comprehensive Care Plan, dated [DATE], reflected the resident was care planned for antidepressant, antianxiety, hospice, g-tube, ALS, and pain.
Record review of Resident #53's Physician Order, dated [DATE], reflected Every SHIFT (3) Check resident for level of pain utilizing numeric rating scale 0-10 or verbal
descriptor scale (M)Mild, (Mo)Moderate, (S)Severe, (VS)Very Severe.
Record review of Resident #53's Physician Order, dated [DATE], reflected lorazepam 2 mg/mL 0.5ml Every Day at bedtime Restlessness and agitation. Anxiety
Record review of Resident #53's Physician Order, dated [DATE], reflected Monitor for side effects every shift: ANTIANXIETY LORAZEPAM. SIDE EFFECTS: 0. NONE 1. Hypotension 2. Sedation 3. Dizziness 4. Dry Mouth 5. Blurred Vision 6.Urinary Retention 7. Drowsiness, Fatigue 8. Slurred Speech 9. Confusion 10. Nightmares 11. Appetite Changes.
Record review of Resident #53's Physician Order, dated [DATE], reflected Monitor for side effects every shift: ANTIDEPRESSANTS TRAZODONE, SIDE EFFECTS: 0. NONE 1. Dry Mouth 2. Blurred Vision 3. Constipation 4. Urinary Retention 5.Hypotension 6. Appetite Changes 7. Headache 8. Insomnia 9. Dyspepsia 10. Weight Changes 11.Suicidal ideations; Wishes of death; Attempts to harm self.
In an interview and observation on [DATE] at 8:40 AM, LVN B was about to do Resident #53's bolus feeding and at the same time administer his medications. She said she would wash her hands first before she prepares the resident's medications. She parked her nurse's cart beside the resident's door and went inside the resident's bathroom to wash her hands. It was observed that there was a laptop on top of the cart. The laptop was open, facing the hallway, and displayed the resident's name, directive, was on hospice, primary physician, emergency contact, allergies, and that the resident was on NPO and tube feeding. Physician orders to monitor the resident for pain and the side effects of antianxiety and antidepressant were also visible. LVN B went back to her cart after washing her hands and saw that her laptop was open. She closed the laptop and said she forgot to close it before washing her hands. She said she should have locked, minimized, or closed the monitor of her laptop every time she left the cart. She said the purpose was to protect the health or personal information of the residents. She said she should be mindful to close her computer every time she left it.
In an interview on [DATE] at 6:29 AM, the ADON stated the staff should make sure that no information about any resident be left on top of the cart before leaving the cart unattended because it was HIPAA violation. He said the resident's information were confidential and should not be seen by unauthorized individuals. He said the expectation was for the staff not to leave any personal or medical information about a resident. He said he would coordinate with the DON to do an in-service about privacy and confidentiality.
In an interview on [DATE] at 7:00 AM, the DON stated personal and medical information about a resident should be protected and not be visible for everybody to see because those were confidential information. She said the health information of a resident could not be shared without the permission of the resident or the resident's responsible party. She said the staff should have closed the monitor, minimized the monitor, or parked the cart not facing the hallway before going inside the resident's room. She said if the confidential information were exposed, non-nursing staff, other resident, and visitors will be able to see it. She said all staff were expected to provide full privacy and confidentiality of all the residents' personal and medical information. The DON stated she would start an in-service about privacy and confidentiality of the residents' information.
In an interview on [DATE] at 7:29 AM, the Administrator stated the staff must make sure the residents' information was not exposed because it was a violation of the resident's privacy and confidentiality of the care/treatment they were receiving. He said it was a HIPAA violation when unauthorized individuals saw the medical information. He said the expectation was for all the staff to make sure the personal and medical information of a resident were secured and their laptop were closed to prevent exposure of the said information. He said she would collaborate with the DON and the ADON to do an in-service about privacy and confidentiality.
Record review of the facility's policy, INFORMATION SECURITY Leadership Policies and Procedures revised [DATE] revealed POLICY . 3. Users who logon to a computer system . log off of the system and network or, at minimum, lock
the computer or laptop prior to leaving the workstation . Procedures . 2. Proper Treatment . E. Shared workstations . 1) Users log-off when leaving the workstation unattended . F. Dedicated workstations . 1) Users lock the workstation when unattended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 10 of 15 resident rooms on the 100 hall (Resident rooms #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10), and residents eating in the dining room, reviewed for environment.
1.
The facility failed to ensure Resident rooms #1, #2, #3, #5, #6, #7,#8,#9 and #10, were thoroughly cleaned and sanitized.
2.
The facility failed to ensure the trash can in the dining room had a lid on it while residents were dining.
These failures deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.
Findings include:
An observation on 06/10/25 at 10:55 AM of resident room [ROOM NUMBER] reflected the air condition unit filters had thick dust in them. The air condition vents had white and [NAME] stains in them.
An observation on 06/10/25 at 10:59 of resident room [ROOM NUMBER] reflected the air condition unit filters had thick dust in them. The air condition vents had white and [NAME] stains in them.
An observation on 06/10/25 at 11:02 AM of resident room [ROOM NUMBER] reflected the air condition unit filters had thick dust in them. The air condition vents had white and [NAME] stains in them. The shower floor in the bathroom had white and brown stains on it. The corners and edges of the room floor had white dust build up.
An observation on 06/10/25 at 11:06 AM of resident room [ROOM NUMBER] reflected the air condition unit filters had thick dust in them. The air condition vents had white and [NAME] stains in them. The bathroom floor had white and brown stains on along the corners of the floor and behind the toilet. The corners and edges of the room floor had white dust build up.
An observation on 06/10/25 at 11:08 AM of resident room [ROOM NUMBER] reflected the air condition unit filters had thick dust in them. The air condition vents had white and [NAME] stains in them. The bathroom floor had white and brown stains on along the corners of the floor and behind the toilet.
An observation on 06/10/25 at 11:15 AM of resident room [ROOM NUMBER] reflected the air condition unit filters had thick dust in them. The air condition vents had white and [NAME] stains in them. A black personal fan had thick dust on the fan blades and inside of the casing. The bathroom shower floor had large yellow and black stains all over it. the floor. The corners and edges of the room floor had white dust and black dirt build up.
An observation on 06/10/25 at 11:20 AM of resident room [ROOM NUMBER] reflected the air condition unit filter had thick dust in them. One of the filters was missing from the air condition unit. The air condition vents had white and [NAME] stains in them. The corners and edges of the room floor had black dirt build up.
An observation on 06/10/25 at 11:24 AM of resident room [ROOM NUMBER] reflected the air condition unit filters had thick dust in them. The air condition vents had white and [NAME] stains in them. The bathroom shower floor had black stains along the edges of the floor. The bathroom floor had white and brown stains on along the corners of the floor and behind the toilet. The corners and edges of the room floor had black dirt build up.
An observation on 06/10/25 at 11:30 AM of resident room [ROOM NUMBER] reflected the air condition unit filters had thick dust in them. The air condition vents had white and [NAME] stains in them. The bathroom shower floor had black stains along the edges of the floor. The bathroom floor had white and brown stains on along the corners of the floor and behind the toilet.
An observation on 06/10/25 at 11:33 AM of resident room [ROOM NUMBER] reflected the air condition unit filters had thick dust in them. The air condition vents had white and [NAME] stains in them. The bathroom shower floor had yellow and black stains along the edges of the floor. The bathroom floor had white and brown stains on along the corners of the floor and behind the toilet. A white personal fan had thick dust on the fan blades and the inside of the casing.
An observation on 06/10/25 at 12:33 PM in the facility's only dining room revealed a large trash can located in the dining area near a table where a resident was dining , with the lid removed from it. The trash can had trash in it and it had a vulgar smell coming from it.
In an interview on 06/11/25 at 12:50 PM, the Dietary Manager was advised about a trash can being in the dining room without the top placed on it and it had an odor. She stated housekeeping and the nursing staff were responsible for ensuring the lid wasare placed back on the trashcans as food wasis being dumped into it. She stated the concerns of not covering it was that it could smell and not be pleasant for the residents.
In an interview on 06/11/25 at 1:50 PM, Housekeeping R stated housekeeping ensured the trash cans had lids on them before the start of meals. He stated the kitchen aide was responsible for ensuring the lids remained on the trash cans during meals because it was a safety hazard if the trash cans did not have the lids on them. He stated housekeeping dumped the trays at the end of the meals and emptied the trash cans at the end of each meals, but sometimes the CNAs dump the trays and do not ensure the lids were placed back on them.
In an interview on 06/12/25 at 9:17 AM, Housekeeping R stated he had been at the facility for 2 years. He was shown pictures of the concerns Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, and #10. He stated housekeeping was responsible for cleaning the air filters in the room and when he works Wednesdays, Thursdays, and Fridays, he cleaned them. He stated he had reported to the Housekeeping Supervisor about his peers not cleaning the room thoroughly. He stated he also reported the concerns of the room floors and the shower floors needing a machine to scrub the built-up dirt. He stated the Housekeeping Supervisor told staff that the personal fans in resident rooms were not to be touched by housekeeping. He stated not cleaning the room thoroughly could result in residents getting an infection.
In an interview on 06/12/25 at 9:17 AM, the Housekeeping Supervisor stated she had been at the facility for 3 years and in her role as supervisor for 9 months. She stated staff were responsible for cleaning the entire room, from top to bottom. She stated maintenance was responsible for cleaning the air condition unit filters and the vents of the units but they were responsible for wiping down the outside of the units. She stated housekeeping cleaned the floors in the resident rooms and bathrooms. She stated she deep cleaned the floors at least once a month. She stated they were probably supposed to clean the personal fans in the resident rooms, but her staff had not been cleaning them. She was shown pictures of Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, and #10. She stated maintenance was responsible for deep cleaning the shower floors or repainting them and she had let them know. She stated the risk of not cleaning the areas mentioned could impact the resident's living experience.
In an interview on 06/12/25 at 9:17 AM, the Director of Maintenance [NAME] stated he had been at the facility for 2 years. He stated housekeeping was responsible for cleaning the air filters and they cleaned the air condition units. He stated housekeeping was responsible for scrubbing the floors. He was shown pictures of the concerns observed in Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, and #10, and he stated housekeeping was responsible for cleaning the floors and they were responsible for reporting any maintenance concerns such as the air filter missing in the air condition units so he could replace them. He stated maintenance cleansed the air condition units and he checked them once a month. He stated if the areas were not addressed, it could impact their allergies.
In an interview on 06/12/25 at 10:45 AM, the Administrator stated he had spoken with his housekeeping supervisor about the concerns observed in Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, and #10. He stated housekeeping was responsible for ensuring the rooms wereare thoroughly cleaned, including the room and bathroom floors. He stated housekeeping was responsible for cleaning the air filters, but maintenance was responsible for ensuring the air condition unit was cleaned. He stated he would have maintenance include to their schedule to clean the air condition units on a more regular basis. He stated they would try to deep clean the bathroom shower floors to see if they can clean it or repaint it if needed. He stated the trashcans in the dining rooms were maintained by the kitchen staff, but the nursing staff should be monitoring them during the meals to ensure the trashcans had a lid on them throughout the resident's dining experience. He stated the concerns mentioned could impact the resident's homelike experience and it could be a biological hazard for them.
Record review of the facility's policy on Environment That Preserves Dignity-Resident Right For 11/01/2017) reflected The facility staff will provide the patient/resident with the right to an environment that preserves dignity and contributes to a positive self image.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 1 of 6 residents (Residents #53) reviewed for accident prevention.
The facility failed to ensure HA D would not transfer Resident #53 using a Hoyer lift (a mechanical lift used to transfer an individual with limited mobility) by herself on 06/10/2025.
These failures could prevent the residents from having an environment that was free and clear of accidents and hazards.
Findings include:
Record review of Resident #53's Face Sheet, dated 06/10/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with amyotrophic lateral sclerosis (a disorder that affects the brain and the spinal cord that results to loss of movement to both upper and lower extremities).
Record review of Resident #53's Comprehensive MDS Assessment, dated 04/18/2025, reflected the resident was unable to complete the interview to determine the BIMS score. The Comprehensive MDS Assessment indicated that the resident had amyotrophic lateral sclerosis, used a wheelchair, was dependent on staff for transfer, and required two or more helpers to complete the transfer.
Record review of Resident #53's Comprehensive Care Plan, dated 4/11/2025, reflected the resident required the use of Hoyer lift to transfer and one of the approaches was ensure 2 X staff assist transfer.
Record review of Resident #53's Physician Order, dated 04/10/2023, reflected TRANSFER with assist X 2 via Hoyer lift.
Observation and interview on 06/10/2025 at 9:42 AM revealed HA D was done dressing Resident #53. She said she would transfer the resident to his wheelchair using the Hoyer lift. HA D rolled the resident and fixed the Hoyer sling onto the resident's back. After fixing the Hoyer sling, she went to the resident's wheelchair parked at the base of the resident's roommate bed and lowered the backrest of the wheelchair. She then hooked the loops of the Hoyer sling to the sling attachment points of the Hoyer lift and started to raise the resident by holding the remote control using her right hand. When the Hoyer sling with the resident on it was up, she started to move the Hoyer lift away from the bed and towards the wheelchair located at the base of the resident's roommate. Once the Hoyer lift was near the wheelchair, she spread the legs of the Hoyer lift, and continued to push the Hoyer lift towards the wheelchair. HA D then lowered the resident to the wheelchair with the right hand holding the remote control and with the left hand guiding the Hoyer sling as it descends to the wheelchair. Once the resident was already in the wheelchair, she unhooked the loops of the Hoyer sling from the Hoyer lift, and pulled the Hoyer lift away from the wheelchair. She did not call any staff to help her transfer the resident using a Hoyer lift.
In an interview on 06/10/2025 at 9:51 AM, HA D stated she did transfer Resident #53 to his wheelchair after giving him a bath using a Hoyer lift. She said she did not call any staff to help her because she could do it by herself. She said nobody told her that she should call another staff when transferring the resident.
In an interview and observation on 06/10/2025 at 9:54 AM, LVN B stated HA D should have called her or another aide when she was ready to transfer Resident #53 from bed to wheelchair to make sure that the transfer was safe and no injuries would happen to the resident. She said the staff always helped HA D when she called them for any assistance like if she was ready to transfer the resident via Hoyer lift. She said she would talk to HA D about the risk of transferring a resident via Hoyer lift by herself. LVN B went inside the resident's room and talked to HA D.
In an interview on 06/12/2025 at 6:29 AM, the ADON stated he was made aware by HA D about the issue in transfer. He said two aides were required every time a resident was transferred using a Hoyer lift to ensure safety of the resident during the transfer. He said one staff would operate the lift and the other one would handle the resident. He said the resident might fall out of the sling and the staff would not be able to catch the resident. He said the facility was responsible in making sure all the staff caring for the residents were trained in using the Hoyer lift, even though they were from an outside agency, like Hospice. He said they would also check for the competency of staff from outside agency. He said the DON already called the Hospice agency to report what happened and started an in-service about safe transfer to inhouse staff. He said the expectation was for all the staff would follow the considerations of transferring via Hoyer lift to any safety issues pertaining to transfer.
In an interview on 06/12/2025 at 7:00 AM, the DON stated she was made aware by LVN B regarding HA D transferring Resident #53 using a Hoyer lift by herself. She said it was a no-no to transfer a resident using a Hoyer lift with just one staff. She said the facility's staff said they always assist HA D everytime she called for help with transfer or repositioning Resident #53 so she did not know why HA D did not call anybody when she transferred the resident. She said one-person transfer via Hoyer lift could present safety issue to the resident and to the staff also. She said the resident might fall that could result to injuries. Or the machine could tilt to one side and fell on the staff. She said she already reported HA D to Hospice DON. She said she already made a plan on how to check the competency of the the staff from outside agency. She said she already instructed a head-to-toe assessment for Resident #53. She said the expectation was for all the staff to be knowledgeable on how to transfer the resident and that she already started an in-service about the said issue.
In an interview on 06/12/2025 at 7:29 AM, the Administrator stated he already knew the incident about the transfer and they already started an in-service about safe transferring. He said even though the staff was from an external agency, the facility was still responsible in ensuring that all the staff caring for the resident were competent and were compliant with the procedure of safe transfer. He said the expectation was residents would be transferred safely, not only using the Hoyer lift but also using the other forms of transfer.
Record review of the facility's policy, MECHANICAL LIFTS: GENERAL GUIDELINES Nursing Policies and Procedures revised May 05, 2023 revealed POLICY: The Facility may employee the use of mechanical lifts to assist with transfers to ensure the safety of patients, residents, and staff . PROCEDURE . 3. Prior to initiating use of mechanical lift . C. Determine how many caregivers are necessary to safely lift the patient or resident. In most cases and for safety, a minimum of 2 caregivers is recommended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Resident #15 and Resident #222) of 14 residents reviewed for respiratory care.
1.
The facility failed to ensure Resident #15's breathing mask (used to receive medications by breathing in mist through nose and mouth) was properly stored when not in use on 06/10/2025 and that there was an order to assess the resident before and after the breathing treatment.
2.
The facility failed to ensure a sign was placed outside of Resident #222's room to indicate oxygen was in use on 06/10/2025.
These failures could place residents at risk for respiratory infection and not having their respiratory needs met.
Findings included:
1.
Record review of Resident #15's Face Sheet, dated 06/10/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with heart failure (condition in which the heart cannot pump blood well enough to meet the body's needs), shortness of breath, and anxiety (intense or excessive fear or worry).
Record review of Resident #15's Quarterly MDS Assessment, dated 05/07/2025, reflected the resident was cognitively intact with a BIMS score of 14. The Quarterly MDS Assessment indicated the resident had heart failure, shortness of breath, and anxiety.
Record review of Resident #15's Comprehensive Care Plan, dated 05/09/2025, reflected the resident had congestive heart failure and shortness of breath and the approaches were to monitor for shortness of breath and administer medications as ordered.
Record review of Resident #15's Physician's Order, dated 06/25/2024, reflected Ipratropium-albuterol solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 mL Shortness of breath 1 VIAL VIA NEBULIZER (a machine that converts liquid medication into fine mist) TWO TIMES A DAY AS NEEDED. There was no order to assess the resident's breath sound, respiratory rate, and oxygen saturation before and after the administration of the breathing treatment.
Record review of Resident #15's Progress Notes, dated 05/30/2025 reflected Resident c/o SOB, V/S 118/67, 74, 97.6, 18,92% RA. DuoNeb administered as prn ordered O2 sat 94% RA.
Observation and interview on 06/10/2025 at 9:20 AM revealed Resident #15 was sitting at the side of her bed. It was observed that the resident had a nebulization machine on her side table with a breathing mask attached to it. The breathing mask was not bagged and was on top of reading material on a chair beside the side the table. She said she seldom used the breathing mask. She said if she could remember it right, she only used the breathing mask two weeks ago because she experienced shortness of breath. She said the breathing mask had been on the chair since then.
Observation and interview on 06/10/2025 at 9:37 AM, LVN B stated Resident #15 had an as needed breathing treatment but only used it once. She said if the resident was not using the breathing mask, it should be inside a clean plastic bag to ensure cleanliness for the next use. She went inside the resident's room and saw the breathing mask on the chair. She disconnected the breathing mask and threw it in the trash can and said she did not notice it when she did her morning round. She said she would get another one and make sure it was inside the plastic bag to prevent any respiratory infection.
In an interview on 06/11/2025 at 9:12 AM, Resident #15 stated they replaced her breathing mask and put it in a plastic bag. She said it only made sense that her breathing mask would be clean in case she would need it again.
Observation and interview on 06/11/2025 at 11:08 AM, LVN B stated when a resident was administered a breathing treatment, the staff should assess the resident before and after the treatment to see if the treatment was effective. She opened Resident #15's profile and saw that the resident only had a physician's order to administer the breathing treatment and did not have a separate order to assess for breathing sound, respiratory rate, and the oxygen saturation before and after the treatment. She said an order for the assessment could be added or incorporated on the instruction part of the order for the breathing treatment. She said if the staff needed to assess the breathing sound, respiratory rate, and the oxygen saturation, then there should be order for the assessment.
Observation and interview on 06/11/2025 at 2:26 PM, RN A stated she did not notice that Resident #15's breathing mask was not bagged when she made her round. She said the resident seldom used it but when she was not using it, it should be inside a plastic bag to prevent it from being dirty. She transcribed the resident's order for the breathing treatment in connection to her anxiety. She said an assessment should be done before and after the treatment to check the effectiveness of the breathing treatment. She said the assessment should be done for routine and as needed breathing treatment. She then opened the resident's profile and added to assess the breath sound, respiratory rate, and oxygen saturation before and after the treatment on the instruction box of order for the treating treatment.
In an interview on 06/12/2025 at 6:05 AM, LVN C stated Resident #15 was administered a breathing treatment due to shortness of breath. She said she was the one who assessed for the effectiveness of the treatment. She said she checked the resident after treatment was done. She said according to the shift report on 05/30/2025, the resident was complaining of shortness of breath that was why she was given a breathing treatment. She said there should be an order to evaluate the effectiveness of the breathing treatment before and after the treatment's administration to see if the treatment was effective. She also said that she did not notice that the resident's breathing mask was on the chair and was not inside a bag on 06/10/2025. She said it should be bagged to maintain cleanliness of the mask for future use.
In an interview on 06/12/2025 at 6:29 AM, the ADON stated the breathing mask should be stored properly inside a plastic bag if the residents were not using them to prevent cross contamination and respiratory infections. He said the staff were responsible in monitoring if the breathing mask was bagged. He said the resident should be assessed before and after giving the breathing treatment to. He said there should be a separate order for the assessment of the breathing treatment or should be incorporated in the order for the breathing treatment. He said the result of the assessment should be recorded in the resident's vital signs documentation. He said the expectation was for the staff to be mindful and bag the breathing mask and make sure there was an order for the assessment. He said the nurses were responsible for bagging the breathing mask as well as transcribing tie order. he said he was responsible in overseeing that they were compliant. He said they already started an in-service about bagging the breathing mask as well as the need for an order for assessing the resident before and after administering the breathing treatment.
In an interview on 06/12/2025 at 7:00 AM, the DON stated Resident #15's breathing mask should be inside a plastic bag even though it was sitting in a chair. She said it was not known when the mask had been sitting in the chair. She said the mask should be inside a bag to maintain its cleanliness as well as its patency. She said it was standard for nurses to assess a resident using a breathing treatment before and after the administration to assess the effectiveness of the treatment. She said even though the nurses knew what to do, there should be an order for the intervention because everything done for the residents needed an order. She the nurses were responsible in transcribing the orders in the resident's profile but she was responsible in checking if the order were complete or if the related orders were also included. She said she already started an in-service about bagging the breathing mask and assessing the resident with breathing treatments before and after for breath sound, respiratory rate, and oxygen saturation. If the treatment was not effective, the staff needed to notify the physician so appropriate interventions could be done.
In an interview on 06/12/2025 at 7:29 AM, the Administrator stated they were vigilant in reminding the staff to bag the respiratory paraphernalia that the residents were using. He said the breathing mask should be inside a plastic bag when the resident was not using it or remove it and just put a new one when needed. He said the risk of the breathing mask lying on the chair were transfer of the germs from the chair to the breathing mask that could eventually cause any respiratory issues. He said the expectation was for the staff to be mindful that when they do their rounds, they should also check if the breathing mask was bagged. he said the DON already started an in-service pertaining to bagging the breathing mask. He said, since he was not a clinician, the DON would take the lead with regards to the order before and after the breathing treatment.
In an interview on 06/12/2025 at 2:56 PM, LVN F stated she administered Resident #15's breathing treatment on the night of 05/30/2025 because the resident verbalized she was having a hard time breathing. She said, in nursing, one of the principles was to assess the resident before administering the breathing treatment so that there would be a comparison after the treatment. She said she did assess the resident but what she was not sure of was if there was an order for it. She said there should be an order to assess before and after the treatment because everything done for the resident should have an order. she said the breathing mask should also be bagged to prevent cross contamination. She said she did not notice that the breathing mask was not bagged on her last shift in the facility.
2.
Record review of Resident #222's Face Sheet, dated 06/12/2025, reflected a [AGE] year-old male who admitted to the facility on [DATE]. Resident #222 had diagnoses which anemia (low blood cell count) and immunodeficiency (disorder that prevents immune system from working correctly).
Record review of Resident #222's Comprehensive MDS Assessment, dated 06/05/2025, reflected the resident had intact cognition with a BIMS score of 14. The Comprehensive MDS Assessment indicated the resident had anemia. Section O (special treatments, procedures, and programs) indicated Resident #222 received continuous oxygen.
Record review of Resident #222's Comprehensive Care Plan, dated 11/04/2024, reflected the resident was at risk for shortness of breath related to the disease process. One of the interventions was to administer oxygen as ordered.
During an interview and observation on 06/10/2025 at 9:10 AM, revealed Resident #222 was sitting up in bed. Resident #222 stated he had been in the facility for about a week and used oxygen all the time. There was no sign on the door indicating oxygen use in the resident's room.
During an interview on 06/11/2025 at 12:45 PM, the ADON stated it was important to have a sign outside the resident's room indicating the use the oxygen in the room. He stated it was dangerous to have anything flammable around oxygen because it risked harm to the resident.
During an interview on 06/11/2025 at 2:20 PM, the Administrator stated all residents who used oxygen continuous or PRN should have a sign outside their room reflecting oxygen in use. He stated the nurse who admitted a resident with oxygen was responsible for placing a sign outside the door. The Administrator stated the signs were kept in the room where oxygen tanks were stored.
During an interview on 06/12/2025 at 9:02 AM, the DON stated the charge nurse who admitted the resident was responsible for placing a sign outside the resident's room indicating oxygen in use. She stated prior to a resident arriving, the staff knew if a resident was on oxygen. She stated the nurse should have an oxygen concentrator in the resident's room and a sign outside the room indicating oxygen in use. She stated the checklist in the admission packet includes putting a sign on the door if a resident is on oxygen. She stated the ADON and DON look at the admission paperwork also. She stated management should also observe when doing guardian angel rounds. The DON stated everyone was responsible for monitoring and ensuring there were signs outside a room reflecting oxygen in use.
Record review of the facility's policy RESPIRATORY TREATMENT, CARE AND SERVICES PROGRAM Nursing Policies and Procedures revised May 05,2023 revealed POLICY: The Facility ensures the safe, appropriate, and effective provision of respiratory treatment, care, and services in accordance with professional standards of practice . PROCEDURES . Infection control practices including standard and transmission-based precautions are . B. Handling of equipment, including cleaning, storage.
Review of the facility's policy, Respiratory Policies and Procedures: Oxygen therapy, revised 02/12/2024, reflected Check the patient's/resident's room to make sure it's safe for oxygen administration, place oxygen precautions sign on the door of the patient's/resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in accordance with currently accepted professional principles for two (Resident #18 and Resident #56) of sixteen residents reviewed for pharmaceutical services.
1.
The facility failed to dispose of Resident #8's expired Advair (medication inhaled to treat asthma) dated 05/21/2025.
2.
The facility failed to ensure that the amount on Resident #56's Lorazepam (antianxiety medication) container was the same with the amount written on the narcotic sheet on 06/11/2025.
These failures could place residents at risk of not receiving the medication's full therapeutic benefits, possible side effects, and not identifying promptly the potential loss of a controlled medication.
The findings included:
1.
Record review of Resident #8's Face Sheet, dated 06/11/2025, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs).
Record review of Resident #8's Comprehensive MDS Assessment, dated 05/29/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 03. The Comprehensive MDS Assessment indicated the resident had chronic obstructive pulmonary disease.
Record review of Resident #8's Comprehensive Care Plan, dated 05/30/2025, reflected the resident had COPD and one of the approaches was to provide medications as ordered.
Record review of Resident #8's Physician's Order, dated 10/11/2024, reflected Advair HFA (fluticasone propion-salmeterol) HFA aerosol inhaler 115-21 mcg/actuation 2 puff.
Observation and interview on 06/11/2025 at 11:50 AM revealed an expired Advair on the hall 200 cart. The date on the inhaler was 05/21/2025. LVN B said she did not notice that Resident #8's expired inhaler was still inside the cart. She said resident had a new one and that was what she was administering to the resident. She said the expired one should not be inside the cart so that staff administering the medication would not mistakenly use the expired one. She said the effectiveness of the medication already diminished when it was expired or there could be adverse reactions from the expired medication. She said she would audit her cart to make sure there was no expired medications. She took the inhaler from the cart and went inside the medication room to dispose it.
2.
Record review of Resident #56's Face Sheet, dated 06/11/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with anxiety disorder.
Record review of Resident #56's Comprehensive MDS Assessment, dated 05/15/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 04. The Comprehensive MDS Assessment indicated that the resident had anxiety disorder (intense or excessive fear or worry).
Record review of Resident #56's Comprehensive Care Plan, dated 05/21/2025, reflected the resident receives antianxiety medication and one of the approaches was to give medications as ordered.
Record review of Resident #56's Physician's Order, dated 05/14/2025, reflected Lorazepam concentrate 2 mg/mL 0.25 give 0.25-1ml q 4hrs PRN Generalized anxiety disorder.
Observation and record review on 06/11/2025 at 11:57 AM revealed a bottle of Resident #56's Lorazepam was inside the refrigerator in the medication room. It was observed that the amount remaining in the bottle was approximately between 15 ml and 20 ml while the recorded amount on Resident #56's Lorazepam narcotic sheet was 21.5 ml. There was a discrepancy of approximately 4 ml between the written compared to the amount in the bottle.
Observation and interview on 06/11/2025 at 12:04 PM revealed the ADON inspected Resident #56's Lorazepam and saw that the amount inside the bottle was not the same when compared to the written amount on Resident #56's Lorazepam narcotic sheet. With the use of a flashlight from his cellphone, he checked again the amount on the bottle and said it was less than 20 ml. He opened the bottle and made sure that the dropper on the bottle was empty but the amount was still less than 20 ml. He said he would notify the DON and the Administrator about the concern and would also start interviewing the staff regarding the discrepancy.
In an interview on 06/11/2025 at 12:15 PM, LVN B stated they always counted the narcotics in the lock box as well as the narcotics inside the refrigerator in the medication room. She said it was an oversight on her part because she did not notice that there was an inconsistency between the actual amount of the Lorazepam and the amount written in the narcotic sheet. She said it was important that both amounts were the same because it seemed like there was a missing medication. She said she did not give Resident #56 's Lorazepam because it was scheduled during bedtime but she was responsible in making sure the amount left was right. She said the incident should never happen again.
In an interview on 06/11/2025 at 2:26 PM, RN A stated she would administer Resident #56's Lorazepam at bedtime. She said she did not notice that the amount on the bottle was not the same with what was written in the narcotic sheet. She said they always counted the narcotics during shift change and did not have any excuse for not seeing the discrepancy. She said she would be mindful in checking the narcotics so she could report it immediately to the DON. She also said that she did not see the expired inhaler in the cart. She said there should be no expired medication inside the cart for the basic reason that it was already expired and could not be used for the resident. She said there might be no so harmful effect but the potency of the medication was already less.
In an interview on 06/12/2025 at 6:05 AM, LVN C stated she would always count the narcotics with the outgoing nurse and the incoming nurse to make sure that the narcotic count was correct. She said it did not occur to her that there was a discrepancy on the amount of Resident #56's Lorazepam. She said she overlooked it and would be careful the next time she would count the narcotics that all narcotics were accounted for. She said she was not aware that there was an expired inhaler inside the hall 200 cart. She said it should have been disposed as soon as it expired so the staff would not accidently use it for the resident.
In an interview on 06/12/2025 at 6:29 AM, the ADON stated there should not be expired medication inside the carts. He said the nurses and medication aides were responsible in ensuring there were no expired medication. He said he was also responsible in checking and auditing the carts for expired medications. He said the expectation was the staff would really check the count and amount of the narcotics during shift change, report immediately if discrepancies were found, and make sure there was no expired medication inside the carts.
In an interview on 06/12/2025 at 7:00 AM, the DON stated she was made aware about the inconsistency on the amount of Resident #56's Lorazepam and she immediately started the in-service. She said she did not how it happened and why it was not discovered during shift change. She said she already talked to the nurses handling the narcotic and they could not explain as well how it happened. She said it was important that the remaining amount in the bottle was the same with what was documented to negate the fact that there were missing Lorazepam. She said the discrepancy should have been noticed during narcotic count every shift change. She said the expired inhaler should not be kept inside the cart so it will not be used for the resident. She said the risk she could mention was that the potency of the medication was already less but one would never know because there might be a harmful effect when an expired medication was used. She said she already started an in-service pertaining to making sure the amount of the narcotics would be the same with what was written in the narcotic sheet and said she would start an in-service that no expired medication be inside the cart. she said her expectation was for the staff to make sure that the count were correct and that the expired medications were disposed accordingly.
In an interview on 06/12/2025 at 7:29 AM, the Administrator stated he was made aware by the DON about the narcotic discrepancy and he already reported it to state and also started the investigation. He said when the staff were administering liquid narcotic, they have to make sure that they were giving the exact amount to prevent any discrepancies in the amount. He said he also checked Resident #56's Lorazepam and saw it was below 20 ml in contrast to the amount written which was 21.5 ml. He said he also suggested the use of a syringe instead of a dropper to get the exact amount. He said expired medications should be disposed as soon as it expired. He said he was not a clinician, but one thing he knew, expired medication cannot be used. He said they already started an in-service regarding the making sure the correct remaining amount of the narcotics were the same with what was written. He said he would coordinate with the DON regarding the expired medication.
In an interview on 06/12/2025 at 2:56 PM, LVN F stated they do narcotic counts every shift change but since there a discrepancy, then they were not doing a great job in making sure the correct count or amount of Resident #56's Lorazepam was observed. She said she also did notice the expired inhaler inside the cart. She said if the medication was expired, the resident might not receive the full benefit of the medication.
Record review of the facility's policy Controlled Substances Pharmacy Services Policies and Procedures revised 04/17/2024 revealed POLICY . 2. The Facility will conduct routine reconciliations of all Controlled Substances to prevent any potential loss or diversion . PROCEDURE . 4. A scheduled reconciliation (shift change count) of controlled substance inventory should be completed at every nursing shift change and documented . D. The oncoming nurse/authorized staff member visually checks this number against the Inventory Record Sheet . E. The nurse/authorized staff should always use the meniscus level of the liquid to estimate the volume of a liquid-controlled substance . F . Any observed discrepancy between the recorded amount and what appears to be remaining in the container should be reported to the DON.
Record review of the facility's policy MEDICATION MANAGEMENT PROGRAM Pharmacy Services Policies and Procedures revised May 05, 2023 revealed POLICY: The Facility implements a Medication Management program to meet the pharmaceutical needs of patients and residents . Administering the Medication Pass . D. Checking for expiration dates and removing any expired products.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #53 and Resident #56) of ten residents reviewed for infection control.
1.
The facility failed to ensure HA D wore a gown while dressing Resident #53, who had a g-tube (gastrostomy feeding tube: a tube that is surgically inserted through the skin of the belly and into the stomach), and was on enhanced barrier precautions, on 06/10/2025.
2.
The facility failed to ensure that LVN H changed his gloves and performed hand hygiene when providing wound care to Resident #56 on 06/11/2025.
These failures could place residents at risk of cross-contamination and development of infections.
Findings included:
1.
Record review of Resident #53's Face Sheet, dated 06/11/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with gastrostomy status (having done a surgical procedure that creates artificial opening into the stomach to provide nutritional support).
Record review of Resident #53's Comprehensive MDS Assessment, dated 04/18/2025, reflected the resident was unable to complete the interview to determine the BIMS score. The Comprehensive MDS Assessment indicated that the resident had a feeding tube (medical device that helps deliver nutrition and medication directly to the person's stomach).
Record review of Resident #53's Comprehensive Care Plan, dated 04/27/2025, reflected the resident was on enhanced barrier precautions for g-tube and one of the goals was infection control.
Record review of Resident #53's Physician Order, dated 04/26/2024, reflected Patient is on ENHANCED BARRIER PRECAUTIONS to help protect the resident from infection every shift.
Observation and interview on 06/10/2025 at 9:42 AM, HA D stated she just gave Resident #53 a bath and she was just finishing dressing him. It was observed that the resident had a g-tube and that there was a sign outside the resident's door that enhanced barrier precautions were required when dressing the resident. HA D did not wear a gown while dressing the resident. She said she was not aware that she needed to wear a gown when dressing the resident.
In an interview on 06/10/2025 at 9:51 AM, HA D stated she should have worn a gown when he was dressing Resident #53 because he had a g-tube and the gown was used to prevent cross contamination to a resident that was vulnerable. She said she did not know what happened that she forgot to wear a gown.
In an interview on 06/10/2025 at 9:54 AM, LVN B stated HA D should wear a gown when dressing Resident #53 because the resident had a g-tube. She said there was sign outside the door to remind the staff that when doing a high contact care like dressing the resident, a gown should be worn to protect the resident from infection. She said the enhanced barrier protection was used to minimize the spread of resistant organisms. She said she would talk to HA D and remind her to wear a gown as ordered.
In an interview on 06/12/2025 at 6:29 AM, the ADON stated when a resident had a g-tube, open wound, or catheter, the staff should wear a gown because those residents were on enhanced barrier precautions. He said the purpose of which was to prevent cross contamination and development of infection to resident with indwelling medical devices. He said the expectation was all the staff would wear a gown when performing high contact care to the resident who required enhanced barrier precautions. He said the DON already started an in-service about enhanced barrier precautions as soon as LVN B told them the issue of HA D not wearing a gown when required to.
In an interview on 06/12/2025 at 7:00 AM, the DON stated if a resident was on enhanced barrier precautions, the staff should wear a gown when providing care to them. She said residents with feeding tubes required enhanced barrier precautions to decrease their exposure to pathogens that could cause infection. She said the expectation was for the staff wear gowns when caring for residents on enhanced barrier precautions. She said she already started an in-service about enhanced barrier precautions when LVN B made them aware about the issue. She said she would personally monitor the staff's adherence to the policy and procedure of enhanced barrier precautions. She said since HA D was from a hospice agency, she already made a plan on how to check the competency of staff from outside agency.
In an interview on 06/12/2025 at 7:29 AM, the Administrator stated that staff must be mindful in preventing spread of germs and development of infection, especially for the vulnerable. He said there was a sign outside the Resident #53's door to remind the staff that they should wear a gown when caring for the resident. He said he was not a clinician and would let the DON take the lead about the issue. He said the DON already started an in-service regarding enhanced barrier precautions.
2.
Record Review of Resident #56's Face Sheet, dated 06/12/2025, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #56 had diagnoses which included malignant neoplasm (cancerous tumor) of the liver (essential organ that filters blood and makes substances needed by the body), hypertension (high blood pressure), and a pressure ulcer (damage to skin caused by prolonged pressure) on the right heel.
Record review of Resident #56's Quarterly MDS (tool used to assess functional capabilities and health needs) Assessment, dated 05/15/2025, reflected the resident had severely impaired cognition with a BIMS (tool used to assess cognition) score of 04. Section M (skin conditions) reflected the resident received skin treatment for a pressure ulcer.
Record review of Resident #56's Comprehensive Care Plan, dated 08/28/2024, reflected the resident had a pressure ulcer on the right heel. One intervention was to provide wound care as ordered.
During an observation and interview on 06/11/2025 at 9:20 AM, revealed LVN H was preparing to provide wound care for Resident #56. LVN H washed his hands in the resident's restroom. LVN H used a sanitizing wipe to clean the resident's bedside table. He removed his gloves, used hand sanitizer, and put on clean gloves. LVN H draped wax paper over the bedside table and placed the wound care supplies on it. LVN H removed the gloves and used hand sanitizer. LVN H entered Resident #56's room, explained to the resident what he was going to do, and pulled the curtain to provide privacy. LVN H used hand sanitizer and put on clean gloves. LVN H removed the soiled dressing and used moistened gauze to clean the wound on Resident #56's heel. LVN H removed his gloves and did not use hand sanitizer before putting on clean gloves. LVN H used a cotton swab to remove the medicated ointment from a small medicine cup. He applied it to the wound and placed xeroform (non-adherent wound dressing that promotes healing) on the wound. LVN H changed his gloves, used hand sanitizer, and covered the wound with a dry dressing that was dated and initialed. LVN H removed his gloves and used hand sanitizer. LVN stated he should have used hand sanitizer after removing the soiled dressing and cleaning Resident #56's wound. He stated it was important to wash their hands or use hand sanitizer when changing gloves. LVN H stated it was important to prevent contamination from the wound and soiled dressing.
During an interview on 06/11/25 at 12:27 PM, the ADON stated LVN H should have cleaned his hands after removing the soiled gloves. He stated it was important to prevent infection. He stated the failure could prevent the wound from healing like it should.
During an interview on 06/11/25 at 12:35 PM, the DON stated precautions were in place to add protection for the resident and caregiver, and to prevent the spread of infection. She stated the facility provided mandatory in-services and always talked to staff about infection control. She stated in-services included return demonstration by staff. The DON stated she would immediately provide an in-service on infection control.
Record review of the facility's policy, TRANSMISSION BASED STANDARD PRECAUTIONS, AND ENHANCED BARRIER PRECAUTIONS Infection Prevention and Control Policies and Procedures revised May 15, 2023 revealed PROCEDURES: Enhanced Barrier Precautions . Enhanced Barrier Precautions expand the use of PPE (gowns and gloves) during high contact resident care activities . A. EBP will be implemented for all residents . 2) Wounds . feeding tube . B. EBP will be implemented during . 1) Dressing .
Review of the facility's policy Hand Hygiene/Handwashing, revised 05/15/2023, reflected Hand hygiene/handwashing is done .H. After removal of medical/surgical or utility gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed the medication was labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions for one (Resident #53) of six residents reviewed for labelling of drugs and biologicals.
The facility failed to ensure a change of instruction label was placed on Resident #53's Lorazepam after a change to the order.
This failure could place residents at risk of wrong medication administration, mismanagement of care, adverse effects, and physical harm.
Findings included:
Record review of Resident #53's Face Sheet, dated 06/11/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with anxiety (intense or excessive fear or worry).
Record review of Resident #53's Comprehensive MDS Assessment, dated 04/18/2025, reflected the resident was unable to complete the interview to determine the BIMS score. The Comprehensive MDS Assessment indicated that the resident had anxiety.
Record review of Resident #53's Comprehensive Care Plan, dated 4/21/2025, reflected the resident received antianxiety medication and one of the approaches was to give medication as ordered.
Record review of Resident #53's Physician's Order, dated 12/20/2024, reflected Lorazepam concentrate 2 mg/mL 0.5 ml Every Day Restlessness and agitation Antianxiety.
Observation and interview on 06/11/2025 at 8:02 AM revealed Resident #53's order for Lorazepam was to give every day routinely. There was no order for as needed. It was observed that the order on the medication bottle was to give as needed. LVN B stated the order for the resident's Lorazepam were both routine and as needed. She checked the resident's profile and did not see an order for PRN. She went inside the medication room and said there was no other bottle for the resident's Lorazepam. She said if the staff were still using the Lorazepam with an order for PRN, there should be a sticker on the container notifying the staff that there was a change in instruction. She said or put a note on the container the order was changed to prevent confusion in administering the medication.
Observation and interview on 06/11/2025 at 8:09 AM, the ADON stated when administering medications, the staff giving the medications should make sure they were reading the order in the bottle and comparing it with the order in the system. He said if there was change in order, the container should have a note of change of direction to avoid medication error, undermedication, overmedication, or confusion among the staff. The ADON added the nurses could place a change in order instruction on the bottle. He checked Resident #53's Lorazepam and saw that the order in the bottle was to give as needed. He checked the order on the system and saw the order was to give routinely. The ADON concluded he would monitor the staff administering the medications, give re-education, audit the medication carts, and make sure the medications correlate with the eMAR and the order in the package.
In an interview on 06/12/2025 at 7:00 AM, the DON stated the staff should have placed a change in order instruction on Resident #53's Lorazepam to avoid confusion. The DON said the staff should have been alerted if they saw there was a difference with the order in the bottle and the order in the system. The DON said the risk were overmedication or undermedication which could have an adverse effect for the residents. The DON said the expectation was to provide the right dosage of medication as per order. She said she already started an in-service regarding proper labelling.
In an interview on 06/12/2025 at 7:29 AM, the Administrator stated he would let the clinician answer about the administering medications. The Administrator said whatever the procedure was in giving the medications, it should have been followed to prevent any errors.
Record review of the facility's policy MEDICATION MANAGEMENT PROGRAM Pharmacy Services Policies and Procedures revised May 05, 2023 revealed POLICY: The Facility implements a Medication Management program to meet the pharmaceutical needs of patients and residents . Administering the Medication Pass . 5. The authorized staff member validates the following information is documented on the MAR . A. Correct physician's order and diagnosis for each medication . B. Medication and label are correct.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 4 residents reviewed for quality of care.
On [DATE] RN A failed to monitor Resident #1 but documented doing vitals during a timeframe which she had become deceased .
On [DATE] RN A insisted to Police Officer C Resident #1 was alive when he checked on her at 6:30 AM. RN A documented the vitals for Resident #1 at 7:04 AM. CMA (Certified Medication Aide) B found Resident #1 unresponsive at 7:00 AM during a routine morning medication pass. Police Officer C stated Resident #1 showed obvious signs that were incompatible with life at 7:44 AM and indicated she had most likely already been deceased prior to when RN A checked on her at 6:30 AM. In an interview with RN A, he later stated he did not check on Resident #1 before CMA B found her unresponsive at 7:00 AM and the vitals he uploaded were a mistake.
This was determined to be past non-compliance immediate jeopardy from [DATE] to [DATE] due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey.
This failure could place residents at risk of serious injury or death.
The findings included:
Review of Resident #1's Face Sheet documented Resident #1 was a [AGE] year old female admitted on [DATE]. Resident #1 had a pacemaker. Resident #1 had diagnoses including atrial fibrillation (irregular heart rhythm that begins in the heart's upper chambers), hypertension (high blood pressure, motion sickness (motion caused nausea, vomiting, cold sweat, headache, dizziness, tiredness, loss of appetite, and increased salivation), acute pharyngitis (sore throat inflammation), dementia (decline in cognitive function), depressive disorder (persistent feelings of sadness or loss of interest), abdominal distension (swelling or enlargement of the abdomen), constipation (difficulty passing stools or infrequent bowel movements), muscle weakness (lack of muscle strength), asthma (inflammation of airways), gastro-esophageal reflux diseases (stomach acid flows back into the esophagus), anxiety (feeling of tension or worried thoughts), insomnia (sleep disorder that causes a difficulty in falling asleep or sleeping), dysphagia (difficulty swallowing), and gout (pain and inflammation of the joints).
Review of Resident #1's Care Plan dated [DATE] documented Resident #1 had a pacemaker.
Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was assessed for a Brief Interview for Mental Status (BIMS) and received a score of 14 which indicated that her cognition was intact.
Review of Resident #1's vital signs documented by RN A, dated [DATE] at 7:04 AM revealed Resident #1 BP: 130/69, SPO2: 96%, HR: 68, Resp: 18, and Temp: 97.
Review of Resident #1's vital signs documented by RN H, dated [DATE] at 1:35 AM revealed Resident #1 BP: 112/68, SPO2: 98%, HR: 68, Resp: 18, and Temp: 97.
Review of Resident #1's progress notes written by RN A, dated [DATE] at 10:30 AM documented Around 7 am The floor Med tech informed this nurse the patient is unresponsive .This nurse and the other nurses rush to the patient room and patient observed lying on the bed unresponsive and code blue initiated. pulse was not detective CPR started and then pulse detected by the machine reading varies from 62-122 .The emergency personnel arrived and took over .MD,Family, notified change of condition .The emergency personnel informed this nurse they could not get rhythm and told this nurse to inform the family that she expired . and was pronounced dead by paramedics at 9:33am and they going to call the medical examiner .this nurse notified the family and the MD and the ADON.
Review of the Medical Examiner Report notes dated [DATE] documented the synopsis was a facility hospice death. There was no trauma. Resident #1 had diagnoses of A-FIB, pacemaker, obesity, GI, pressure ulcers, bladder issues, asthma, hypertension, heart disease, intestinal obstruction, and failure to thrive. Police Officer C stated a caretaker reported he took vitals on the decedent at 0630 hours. A MedTech found the decedent unresponsive at 0700 hours. CPR was started and FD was contacted. The FD reported the decedent was in full rigor (postmortem stiffening of the muscles that occurs after death, typically starting 2 to 6 hours after death and peaking around 12 hours postmortem) at 0740 hours. Police Officer C confirmed rigor was present in the jaw, neck, and arms. The PD was satisfied there was no foul play or trauma. Case was released to Police Officer C.
Record review of a facility statement from RN A documented he was alerted to Resident #1's by CMA B who stated the patient was unresponsive. When RN A arrived, LPN F was already there. He checked the patient's pulse; they did not get a pulse. He stated he started CPR on Resident #1. RN A documented the incident in his progress notes. When Administrator G questioned RN A about the vitals, he stated he did not do vitals on the resident prior and only when he went into the room for CPR.
Record review of a facility statement from LVN Q documented she was at the nurse's station when she saw LPN F running down the 300 Hall with the crash cart. She immediately followed to assist. Upon entering Resident #1's room, she checked the patient's pulse but was unable to detect one. She noted the patient appeared stiff and was cool to the touch. CPR was initiated by RN A. EMS arrived shortly after.
In an interview on [DATE] at 11:20 AM, CMA B stated she started work at 6:00 AM. She was going room to room passing medicine until she got to Resident #1's room. She stated when she entered, she said Good Morning but there was no response. She stated normally she responds. She stated the door was already open, but the lights were still off. She stated she said Good Morning three times total. She turned on the lights and saw Resident #1 lying on her side on the bed. She stated she knew something was wrong immediately and began to shiver. She rushed to get LPN F. She stated they ran back to the room together and began listening to Resident #1's heart. They put her hand on her head to feel her temperature, supplied oxygen, and started CPR. CNA O was working the hall and was told to go inform RN A of the situation. The paramedics arrived after 6 or 7 minutes of notifying them. RN A arrived at the room and started checking the pulse for Resident #1 and taking her vitals. CMA B stated she never observed RN A checking on Resident #1. She stated she was able to tell something was wrong immediately and if RN A had checked on Resident #1, he should have also been able to tell something was wrong when he entered her room. She stated she did not remember for sure what Resident #1's skin temperature felt like to the touch. She stated the facility performed in-services on the same day. The in-service was about making sure the staff checked on the residents and documented correctly. She stated ADON D was the one who performed the in-service.
In an interview on [DATE] at 11:41 AM, LVN P stated they immediately responded when CMA B found Resident #1 unresponsive. They stated RN A, CMA B, and LPN F were all assisting. They stated they heard CMA B and immediately brought the crash cart (emergency medical cart) to the room. LVN P was responsible for checking to see if Resident #1 had an advanced directive or not. Resident #1 was full code (patient wished to receive all available medical interventions). Resident #1 was laying on her right side facing towards the door. RN A delegated LVN P to call 911. It took EMS 5-10 minutes to arrive. Resident #1 was unresponsive. She was not responding to anything. LVN P stated they could not detect a pulse and Resident #1 was not responding to anything verbal. They stated Resident #1 was a little cold to the touch. Resident #1 was stiff. It took 3 people to roll her over. LVN P, RN A, and LPN F began CPR. Once the paramedics arrived, they took over. The facility performed in-services on the same day. The risk of not checking on a resident would be not being able to give a thorough assessment of the resident at that time that you are supposed to be checking on them.
In an interview on [DATE] at 12:00 PM, CNA O stated they were working the hall that morning. The situation with Resident #1 happened at the beginning of her shift. She stated she noticed CMA B going into Resident #1's room and heard her immediately call for help. She stated she ran over towards her and that's when they found Resident #1 unresponsive. She stated she assisted LPN F with repositioning Resident #1 while CMA B went to get help. As soon as the crash cart arrived with LVN P they began giving CPR to Resident #1. RN A had also arrived to assist with checking vitals. CNA O stated they did not remember seeing RN A going into Resident #1's room before the start of the incident. She stated she did not remember seeing him go into anyone else's room either. She stated she did see one call light that was on at 6:30 AM for a different resident so she went into that resident's room. If RN A had gone to check on residents on the hall while CNA O was in that resident's room, then she wouldn't know. She stated the facility performed in-services for abuse/neglect and documentation.
In an interview on [DATE] at 12:15 PM, LVN Q stated that there is a risk of missing the required resident check timings if you are not checking on a resident when you are supposed to. If the timings are incorrect then there is a risk that a resident could be crashing. That would not be right for the resident because had they been checked on like they were supposed to be then maybe something could have been noticed to prevent the resident from injury, accident, or worse.
In an interview on [DATE] at 2:41 PM, RN H stated she was the overnight nurse that worked the hall before RN A. She stated during her shift there were no condition changes. She stated she performed her resident check rounds in the beginning of her shift. She stated around 1 AM, Resident #1 was asking to have the AC cooled down. She performed vitals for Resident #1 at 1:30 AM and she was stable at that time. She stated at that time Resident #1 was okay. She stated she performed another round at 4 AM. Resident #1 was observed laying down in her bed. She stated she performed a quick round because Resident #1 did not have to take medications overnight. She stated she briefly looked inside the room and asked if Resident #1 was okay but there was no response. She didn't want to disturb Resident #1's sleep because she wasn't saying anything. She was laying on her side with her face towards the window. When asked if she checked to see if Resident #1 was breathing, she stated she only went into the room to perform a quick round because she didn't want to disturb Resident #1.
In a telephone interview on [DATE] at 12:30 PM, Physician E stated he was informed of the change in condition and was also told by the facility, RN A had got lazy with his charting. He stated he was told RN A documented he had checked on Resident #1 instead of actually checking on Resident #1 and put vitals that were not accurate but once someone else checked on her they realized she was deceased . He stated the EMS said she most likely passed away prior to any of the checks that were documented. He stated this resident was a high risk for cardiac arrest because she had a pacemaker but it was still a surprise and out of the ordinary. He did not think whether RN A checked on Resident #1 or not would have changed the outcome for Resident #1. He stated the risk of injury was high to all residents if the facility was not checking on residents and falsely documenting. He stated if this occurred to a resident who had been in better health then it definitely could have changed the resident's outcome and been preventable.
In a telephone interview on [DATE] at 12:51 PM, RN A stated he came to work around 6:05 AM. He stated when he came to work, he usually did rounds on his halls. He stated he did not remember if he checked on Resident #1 or not during that time. He stated he was alerted of Resident #1 not responding by CMA B and rushed to her room. He stated he checked Resident #1's pulse but could not detect it. He stated she was sleeping with her face towards the door. He stated the nurses called a code blue, and everyone began rushing into the room to assist. He stated it took 5-10 minutes for EMS services to arrive. He stated he went to check on Resident #1 after taking over from the night shift nurse (RN H) around 7:00 AM. He stated he was told the resident was unresponsive around 7 AM to 7:30 AM. He stated Resident #1 was not stiff but she was a little cold to the touch. He stated he attempted to take her pulse with her finger, and it gave a pulse. He stated his documentation and vital checks were wrong. He stated he thought the pulse was around 68/122 He stated he did detect a pulse and the resident did have oxygen at that time. He stated the documentation that he put in the vitals could have been for another resident, he wasn't sure. He stated he always checked on his residents every morning but in this scenario he didn't have time to check on her yet. He stated he didn't know what the risk would be of not checking on the resident. He stated she was independent and was someone that would let you know if she needed something.
In an interview on [DATE] at 12:35 PM, Assistant Director of Nurses (ADON) D revealed it was the facilities policy to check on the residents at the beginning of their shift and every 2 hours. He stated there was a concern RN A didn't document correctly. He stated the response the facility had upon finding resident was done correctly but it coincided with RN A not checking or documenting correctly. If a nurse were to go into her room in the morning and see her sleeping, then you would assume she was sleeping. She doesn't normally wake up until around 8 AM. This resident was good at using her call light and letting you know if she needed anything. He stated he expected his employees to check on the residents before they take over the shift during shift change. He stated when a nurse takes report you should do your checks. He stated at nighttime this was not a disoriented patient and there was nothing saying you specifically have to take vitals at nighttime for a resident such as this if they were sleeping. He stated for people who didn't talk you should go take their vitals but in this instance she was verbal. He stated he still expected his staff to make sure a resident was breathing and maybe say hi to see if the resident would respond. Otherwise, just let them sleep but make sure they were breathing. This was not a resident we were expecting. This was unexpected.
In an interview on [DATE] at 3:16 PM, Police Officer C stated he was responding to a call at the facility at 7:44 AM. He stated once he arrived Resident #1 was not conscious and not breathing. He stated Resident #1 was found to be deceased with obvious signs incompatible with life. He interviewed RN A and RN A insisted Resident #1 was alive when he checked on her and took her vitals at 6:30 AM. He stated RN A later uploaded those vitals into the charting software at 7:04 AM. CMA B was passing medications and found Resident #1 was unresponsive at 7:00 AM. He shared his concern with Administrator G that he believed Resident #1 was in rigor mortis when CMA B found Resident #1 and appeared to have been deceased prior to when RN A claims they checked on her and took her vitals.
It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation on [DATE]. The facility took the following actions to correct the non-compliance on [DATE]:
Interview on [DATE] at 11:00 AM with Administrator G revealed he believed RN A falsified the vitals for Resident #1, documenting he had checked on Resident #1 when he had not. Resident #1 was most likely already deceased before CMA B discovered her. Administrator G stated RN A was immediately suspended on the day of the accident [DATE]. He stated the facility has already completed a plan of correction, plan of removal, and were continuing to monitor. Staff have been in-serviced on Abuse and Neglect. Staff have been in-serviced on how to correctly document. Staff have been in-serviced on resident checks.
Record review of facility In-services conducted by the ADON dated [DATE] and signed by all staff on the following:
a. Nursing Policies and Procedures
b. Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property.
Interview on [DATE] at 12:35 PM with Assistant Director of Nursing D stated in-services have been completed for all floor staff and would continue to be conducted until every PRN staff member that has not presented to work has received the in-service at the start of their shift.
Record Review of the Audit of Random Vital Signs Form revealed the facility performed random monitoring by observation and supervision thereafter by the DON and the ADON to monitor proper documentation of the residents in the facility. The document revealed the staff needed to correctly document resident vitals and pass an audit of random resident vital signs that were supported by resident testimony. The DON and the ADON would be conducting audits three times a week until every staff member continued to demonstrate proficiency and thereafter. The document included a section for dates and two random resident audits for documentation.
Review of the Suspension Form dated [DATE] documented RN A was suspended.
Interview on [DATE] at 11:20 AM with CMA B revealed they understood the policies regarding Abuse/Neglect and Nursing Policies and Procedures. They indicated they recently received in-service training on [DATE]. They stated they understood the importance of checking on residents and documenting correctly.
Interview on [DATE] at 11:41 AM with LVN P revealed they understood the policies regarding Abuse/Neglect and Nursing Policies and Procedures. They indicated they recently received in-service training on [DATE]. They stated they understood the importance of checking on residents and documenting correctly.
Interview on [DATE] at 12:00 PM with CNA O revealed they understood the policies regarding Abuse/Neglect and Nursing Policies and Procedures. They indicated they recently received in-service training on [DATE]. They stated they understood the importance of checking on residents and documenting correctly.
Interview on [DATE] at 12:15 PM with LVN Q revealed they understood the policies regarding Abuse/Neglect and Nursing Policies and Procedures. They indicated they recently received in-service training on [DATE]. They stated they understood the importance of checking on residents and documenting correctly.
Interview on [DATE] at 2:40 PM with RN I revealed they understood the policies regarding Abuse/Neglect and Nursing Policies and Procedures. They indicated they recently received in-service training on [DATE]. They stated they understood the importance of checking on residents and documenting correctly.
Interview on [DATE] at 2:45 PM with CMA J revealed they understood the policies regarding Abuse/Neglect and Nursing Policies and Procedures. They indicated they recently received in-service training on [DATE]. They stated they understood the importance of checking on residents and documenting correctly.
Interview on [DATE] at 2:50 PM with CMA K revealed they understood the policies regarding Abuse/Neglect and Nursing Policies and Procedures. They indicated they recently received in-service training on [DATE]. They stated they understood the importance of checking on residents and documenting correctly.
Interview on [DATE] at 2:55 PM with CMA L revealed they understood the policies regarding Abuse/Neglect and Nursing Policies and Procedures. They indicated they recently received in-service training on [DATE]. They stated they understood the importance of checking on residents and documenting correctly.
Interview on [DATE] at 3:00 PM with CNA M revealed they understood the policies regarding Abuse/Neglect and Nursing Policies and Procedures. They indicated they recently received in-service training on [DATE]. They stated they understood the importance of checking on residents and documenting correctly.
Interview on [DATE] at 3:05 PM with CNA N revealed they understood the policies regarding Abuse/Neglect and Nursing Policies and Procedures. They indicated they recently received in-service training on [DATE]. They stated they understood the importance of checking on residents and documenting correctly.
This was determined to be past non-compliance immediate jeopardy from [DATE] to [DATE] due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 (Resident #1) of 4 residents reviewed for accuracy of medical records.
The facility failed to ensure the nursing notes accurately reflected Resident #1's condition when the ADL sheet incorrectly documented a rash on 01/03/2025 to her buttocks .
These failures could place residents at risk for medication and /or treatment errors and omissions in care.
Findings included:
Review of Resident #1's electronic face sheet printed 02/25/2024 revealed an [AGE] year-old female admitted to the facility initially on 12/30/2024 with diagnosis that included but not senile degeneration of brain (decline in an individual's memory, behavior, and cognitive abilities).
Review of Resident #1's admission MDS dated [DATE] revealed a BIMS score was not completed.
Review of Resident #1's care plan revised 01/02/2025 revealed skin integrity issues as skin tears and intervention to include turn/ reposition and complete skin checks.
Review of Resident #1's point of care history form dated 12/30/2024-01/05/2025 indicated rashes on the buttocks documented by CNA A on 01/03/2505 at 11:09PM.
Review of nursing notes dated from 12/30/2024-01/04/2025 revealed no documentation of skin issues.
Interview on 02/25/2025 at 1:05 PM with the Wound Nurse revealed nurses reviewed shower sheets daily and if the CNAs indicated any skin issues, then the nurse would let her know and she would assess the resident. The Wound Care Nurse stated she was not informed of any skin issues for Resident #1 during her stay. The Wound Care Nurse stated a shower sheet was not completed by CNA A on 01/03/2025 because shower sheets were not completed during the night shift. The Wound care nurse stated she also discharged Resident #1 and did not notice any skin issues upon discharge assessment.
In a phone interview on 02/25/2025 at 2:50 PM with CNA A revealed she did not remember details about Resident #1 but stated she may have clicked that rashes were present by mistake.
Interview on 02/25/2025 at 3:37 PM the DON stated she was not aware of any skin issues regarding Resident #1. The DON stated she spoke with CNA A over the phone today (2/25/2025) and CNA A informed her that she may have mistakenly documented that Resident #1 had a rash when there was not a rash present.
Interview on 02/25/2025 at 4:00 PM with the Administrator revealed resident files were audited daily and quarterly to ensure documentation was updated and correct. The Administrator stated he was not sure how management missed that a rash was documented incorrectly. The Administrator stated the risk of not properly documenting would be that residents could get care that was not needed or miss out on care that was needed. A policy regarding documented was requested from the Administrator however he stated there was not a policy that addressed documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the medications for four (Resident #1, Resident #2, and Resident #3) of fifteen residents were provided a safe and secured storage with limited access.
1.
The facility failed to ensure Resident 1's bottle of One-A-Day multivitamins was not left on top of the resident's right side table on 10/22/2024.
2.
The facility failed to ensure Resident 2's Benadryl cream was not left on top of the resident's left side table on 10/22/2024.
3.
The facility failed to ensure Resident 3's zinc oxide was not left on top of the resident's left side table on 10/22/2024.
These failures could place the residents at risk of not receiving medications, accidental overdose, or misuse of medications.
Findings included:
1.
Review of Resident #1's Face Sheet, dated 10/22/2024, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #1 was diagnosed with dementia (term used to describe a group of symptoms affecting memory and thinking) with unspecified severity.
Review of Resident #1's Comprehensive MDS Assessment, dated 08/01/2024, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment also indicated the resident had medically complex conditions.
Review of Resident #1's Comprehensive Care Plan, dated 10/18/2024, reflected the resident was at risk of memory problem related to dementia and one of the approaches was minimize distractions.
Review of Resident #1's Physician Orders on 10/22/2024 reflected no order for multivitamins.
Review of Resident #1's Baseline Care Plan, dated 02/12/2024, reflected the resident may not self-administer medications.
Review of Resident #1's List of Assessments on 10/22/2024 reflected no assessment for self-administration of medications, no clear instructions for self-administrations, and no assessment that the resident was competent to manage his own medications.
Observation and interview with Resident #1 on 10/22/2024 at 1:47 PM revealed the resident was in her bed, awake. It was noted that the resident had a container of One-A-Day multivitamins on her right side table. The resident said she has not taken her vitamins for almost two weeks. She opened the container of multivitamins and it was noted that the container was hallway full.
2.
Review of Resident #2's Face Sheet, dated 10/22/2024, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #2 was diagnosed with dementia.
Review of Resident #2's Comprehensive MDS Assessment, dated 09/20/2024, reflected the resident had a severe impairment in cognition with a BIMS score of 01. Resident #2's Comprehensive MDS Assessment indicated the resident had dementia.
Review of Resident #2's Comprehensive Care Plan on 08/29/2024 reflected the resident was at risk of memory problem related to dementia and one of the approaches was minimize distractions. The resident did not have a care plan for self-medication.
Review of Resident #2's Physician Orders on 10/22/2024 reflected the resident did not have an order for Benadryl cream.
Review of Resident #2's List of Assessments on 10/22/2024 reflected no assessment for self-administration of medications, no clear instructions for self-administrations, and no assessment that the resident was competent to manage his own medications.
Observation and interview with Resident #2 on 10/22/2024 at 1:57 PM revealed Resident #2 was in her bed, awake. It was observed that there was a tube of Benadryl cream on the resident's right side table. When asked if she was using the Benadryl, the resident did not answer.
Observation and interview with LVN A on 10/22/2024 at 2:12 PM, LVN A stated she did not notice that there was a bottle of multivitamin on Resident #1' side table and was not aware how long the medication had been sitting on the table. LVN A entered Resident #1's room and saw the container of multivitamins at the side table. She told Resident #1 that she would keep the multivitamins first and would check if there was an order for her multivitamins. The resident told LVN A that she have not taken her multivitamins for almost two weeks. LVN A then went inside Resident #2's room and saw the tube of Benadryl on the resident's side table. She told the resident that she should keep the Benadryl first and would check if there was an order for Benadryl. LVN A said there should be no medications inside the residents' rooms or anywhere accessible to other residents and visitors. She said it could be accidently ingested and children could mistake it for candies. She said she would look at the rooms of other residents and make sure there were no medications were inside the rooms. She said, also confused residents might overdose if they can not remember if they had already taken the medication or not.
3.
Review of Resident #3's Face Sheet, dated 10/22/2024, reflected the resident was an [AGE] year-old female admitted on [DATE]. Resident #3 was diagnosed Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills).
Review of Resident #3's Comprehensive MDS Assessment, dated 09/06/2024, reflected the resident had a moderate impairment in cognition with a BIMS score of 12. The Comprehensive MDS Assessment also indicated the resident was always incontinent for bladder and bowel.
Review of Resident #3s Comprehensive Care Plan, dated 09/26/2024, reflected the resident had episodes of bladder and bowel incontinence and one of the approaches was to provide incontinent care after each incontinent episodes.
Review of Resident #3's Physician Order dated 06/24/2022, reflected Barrier cream to perineum after each incontinent episode every shift.
Observation and interview with Resident #3 on 10/22/2024 at 10:28 AM revealed the resident was in her bed, awake. A container of zinc oxide was observed on top of the resident's left side table. She said the ointment was used every time the staff cleaned her and changed her brief.
In an interview with CNA B on 10/22/2024 at 10:46 AM, CNA B stated the zinc oxide should not be left on the side table because the resident might be confused and mistakenly swallowed the cream. She said they might be harmed if the ointment was ingested. CNA B went inside Resident #3's room and put the zinc oxide inside the resident's drawer. She said she would check the other rooms and made sure the skin protection ointment was inside the drawers and with limited access to other residents and visitors.
In an interview with the DON on 10/22/2024 at 3:24 AM, the DON stated all the medications should be inside the medication carts. She said they should check the rooms during their rounds if there were medications inside the rooms of the residents of which they were not aware. She said if a family member was the one bringing the medications, the family member should be educated of the harm if the medications were accessible to others. She said the multivitamins and the Benadryl should be inside the cart. She said the zinc oxide, used during incontinent care, should be placed inside the drawer of the side tables after using it. She said if the resident or a visitor ingested it, there could be adverse reactions especially if somebody who accidentally ingested the medications were allergic to the medications. A child who accidentally swallowed the medication could choke from it. She said the expectation was no medications would be inside the room and the ointment used for incontinent care be placed inside the drawer to secure it. She said another expectation was for the staff to be mindful and observant that if they see any medication, they should take appropriate actions to prevent adverse outcomes such as chocking and overdose. She said they would collaborate with the physician if the medications were really needed, make and an order for it, and place them in the cart for the nurses' or aide administer it. She said she would do an in-service about medication administration and making sure no medications were inside the room.
In an interview with the Administrator on 10/22/2024 at 3:45 AM, the Administrator stated all medications should be in the cart and not inside the residents' room. He said the ointment used for incontinent care should be in the drawer or somewhere secured. He said if there were medications inside the residents' rooms, it could result to accidental ingestion and overdose, especially if nobody was monitoring it. He said the residents could also choke if they were self-medicating and nobody would know. He said the expectation was for the staff to make sure no medications were inside the room or where easily accessible to other residents and visitors. He said he would coordinate with the DON so the issue would not happen again.
Record review of facility policy, MEDICATION MANAGEMENT PROGRAM Nursing Policies and Procedures revised May, 05, 2023 revealed POLICY:
The Facility implements a Medication Management program to meet the pharmaceutical needs of patients and residents . SCOPE AND ROLES . 4. Prescribed medications and supplements are only administered by qualified, certified, or licensed personnel.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choice one (Resident #1) of three residents reviewed for quality of care.
The facility failed to complete a weekly skin assessment for Resident#1
This failure could place the resident at risk for diminished quality of care.
Findings included:
Resident #1's electronic face sheet printed 07/08/2024 reflected a [AGE] year-old female who admitted to the facility initially on 02/12/2024 and re admitted on [DATE] with diagnosis that included but not limited to heart failure(a condition that develops when your heart doesn't pump enough blood for your body's needs), and dementia(impaired ability to remember, think, or make decisions that interferes with doing everyday activities).
Resident #1's MDS assessment dated [DATE] revealed a quarterly BIMS score of 11 which indicated the resident was moderately cognitively impaired.
Review of Resident #1's care plan dated 05/08/2024 revealed Resident #1 was at risk for pressure ulcers due to poor bed mobility with goals for skin to remain intact. Resident #1's care plan included interventions to included keeping skin dry and clean and reporting any signs of skin breakdown.
Review Resident #1's weekly skin assessment dated [DATE] revealed skin was warm, dry ,normal color with no skin alterations. There was not skin assessment after 06/25/2024.
Interview on 07/08/2024 at 1:00PM with Resident #1 revealed she was in pain on her lower back and felt she had some type of skin issue on her lower back and tailbone area. Resident #1 stated staff had not assessed her skin however they were aware that she was having issues
Interview on 07/08/2024 at 3:38PM with RN A stated she was responsible for weekly skin assessments for Resident #1. RN A stated she completed the skin assess on 07/03/2024. However, she forgot to document the assessment. RN A stated all residents received weekly skin assessments. RN A stated Resident #1 did not have any issues with her skin.
Interview on 07/08/2024 at 5:06 PM with the Director of Nursing revealed all residents were to have weekly skin assessments by nursing staff regardless of whether skin issues had been reported. The Director of Nursing stated residents were also assessed daily by CNAs for staff for skin issues as well. The Director of Nursing stated the risk of not completing the weekly skin assessments would be that skin issues would be overlooked and not treated.
Interview on 07/08/2024 at 5:30PM with the Administrator revealed the nurses were responsible for completing skin assessments weekly on all residents. He stated aides were also doing skin assessments daily while providing care to residents. The Administrator stated the risk of the nurse not completing the weekly skin assessment would be that a skin issued could be missed and proper treatment would not be provided.
Review of the facility policy Wound Care policies and procedures reference dated 2017 revealed Weekly skin checks should be performed and documented by licensed staff on all patients/residents paying attention to: The surfaces of the skin that come in contact with the bed and chair.
Bony prominences (heels, tailbone, shoulder blades, elbows, back of the head etc.).The surfaces of the skin that come in contact with each other and any orthotic device, medical device, tube, brace, or positioning device.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care that was developed within 48 hours of a resident's admission for one ( Resident #2) of three residents reviewed for baseline care plans.
The facility failed to ensure Resident #2's baseline care plan was specific to the Resident #2 and contained specific instructions needed to provide effective care.
This failure placed newly admitted residents at risk of not being informed of their initial goals and services, not receiving continuity of care and communication among nursing home staff, decreased resident safety and safeguard against adverse events that are most likely to occur right after admission.
Findings included:
Review of Resident #2's undated electronic admission Record revealed the resident was a [AGE] year-old female admitted to the facility 07/03/224 with diagnoses to include but not limited to dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and hyperlipidemia (an elevated level of lipids)
Review of the baseline care plan dated 07/04/2024 revealed the template for the base line care plan was printed. However, it did not contain any details specific to Resident #2's needs.
An interview on 07/08/2024 at 4:50 PM with the Assistant Director of Nursing revealed he completed the template for the baseline care plan. However the MDS coordinator was responsible for completing the full comprehensive assessment which would then update the care plan. He stated he did not feel there was a risk due to staff having orders that were available to staff.
Interview on 07/08/2024 at 5:06 PM with the Director of Nursing revealed the care plan was going to be updated that day following the care plan conference. However the resident's family decided to discharge the resident following the care plan meeting. The Director of Nursing stated she did not feel there was a risk to the resident due to staff having access to admission orders in point of care (a system for documenting care)
Interview on 07/08/2024 at 5:30PM with the Administrator revealed the baseline care plan template was meant to guide staff on completing the care plan. However, it should still be specific to the resident. The Administrator stated the there was no risk to residents due to the information already being in point of care
Review of the facility Social services polices and procedures policy dated 10/01/2020 revealed Social Services Staff will participate in the development of a baseline and or comprehensive care plan for each patient/resident according to the following time frames and facility procedures: Baseline Care Plan Developed and initiated within 48-hours of admission
The person-centered care plan is interdisciplinary and created to guide facility staff in providing the treatment, care and services necessary for the patient/resident to obtain and maintain the highest physical, mental, and psychosocial well-being possible. The plan is also used to promote patient/resident and family involvement in planning care.

Based on observations, interviews, and record review, the facility failed to provide food and drink that was palatable and in the correct food form for two (Lunch 05/14/2024, Lunch 5/15/2024) of three meals observed for food palatability and food form.
The facility failed to provide a lunch meal on 5/14/2024 and 5/15/2024 that was palatable and that had the puree bread in the correct food form.
This failure could place residents at risk of decline in nutrition status, loss of appetite, and decreased intake placing them at risk for unplanned weight loss.
Findings included:
Observation on 05/14/2024 at 09:30 AM during the initial kitchen tour revealed lunch had already been prepared and was in the warming rack.
Interview on 05/14/2024 at 10:56 AM with Dietary Manager revealed breakfast was served at 7:30 AM, lunch at 12:00 PM, and dinner at 5:00 PM.
Record review of the weekly menu revealed lunch for 05/14/2024 was Chicken Cordon Bleu, mashed potatoes, gravy, seasoned greens, chilled fruit cup, and ice water. Review of weekly menu revealed lunch for 05/15/2024 was hamburger on bun, seasoned French fries, ketchup, lettuce, tomato, onion, pickles, frosted yellow cake, beverage of choice, and ice water. Review of the weekly menu revealed lunch for 05/16/2024 was chili con carne, fluffy brown rice, seasoned carrots, cornbread, margarine, frosted marble cake, and beverage of choice.
Observation on 05/14/2024 at 12:55 PM of lunch test tray for regular and puree diet revealed regular diet was Chicken Cordon Bleu, mashed potatoes, gravy, seasoned greens, chilled fruit cup, and ice water. The puree diet lunch tray contained pureed Chicken Cordon Bleu, puree bread, pureed California vegetables. The puree bread was in ball on the plate, was dark brown, and the texture was tough to cut into with a spoon. The puree' tray was not palatable.
Interview on 05/14/2024 at 12:58 PM with [NAME] T revealed she had prepared the lunch meal and tasted the food. [NAME] T stated that the pureed starch was good, spinach could use some salt, and the chicken tasted okay but needed salt. [NAME] T stated the pureed California vegetables could have used more salt and texture could be a little smoother, sometimes the carrots or broccoli can be challenging to get completely smooth. [NAME] T stated that the puree bread was not the right consistency and was too thick for a puree meal, when tasted it stuck to the roof of the Cook's mouth. [NAME] T stated that the longer puree bread sits in the warming rack the more it cooked and became firmer. [NAME] T stated she was the one who prepared the puree meal, and it was important for the puree meal texture to be smooth to ensure residents do not choke. [NAME] T stated the pureed meat tasted okay and it was important that the food tasted good for residents to enjoy their food because it impacted resident quality of life.
Observation on 05/15/2024 at 12:56 PM revealed lunch test tray for regular diet was hamburger, fries, with lettuce, tomato, onion, pickle on the side, and a slice of yellow cake. Observation of puree diet revealed puree bread, puree tomato, puree, mashed potatoes with gravy, and puree yellow cake. Observation of puree bread revealed it was in a slightly ball like shape. The puree tomato did not taste like tomato and was not palatable.
Interview on 05/15/2024 at 12:56 PM with the Dietary Manager revealed that the cake's frosting was a glaze. There was no frosting visible on the cake. She stated that some cooks prepared the cake differently than others so sometimes the frosting might be thicker than other times. She stated the cooks follow the recipe and this frosting was made with powdered sugar and milk. The Dietary Manager stated that she expected the cooks to taste the food before it goes out and that she expected staff to modify the food to taste good.
In an interview on 05/15/2024 at 1:00 PM with the Dietary Manager revealed puree bread was a little thick and stated it will continue to cook in the steam table and warming rack.
Observation on 05/16/2024 at 12:46 PM revealed the lunch test tray for puree diet only was chili con carne, fluffy brown rice, seasoned carrots, cornbread, and frosted marble cake.
Interview on 05/17/2024 at 12:45 PM with the Dietary Manager revealed she cooked today, and the bread puree was the correct consistency. The Dietary Manager stated that she made the pureed bread for breakfast and set aside the portion for lunch service. She stated she left it on the counter at room temperature until lunch time and then put it in the steam table where it got up to appropriate temperature instead of placing puree bread in the rack warmer until lunch. The Dietary Manager stated she had added milk to the bread to puree and stated a little bit of milk was okay to leave out at room temperature from breakfast to lunch service unless she added something more like eggs because the eggs could spoil. The Dietary Manager was unable to say if milk was a food that required temperature control for safety. The Dietary Manager stated it was important to keep perishable food at a safe temperature to prevent food illness.
Interview on 05/17/2024 at 12:26 PM with the Regional Dietician revealed she had worked with the facility since August 2022 and she visited the facility in-person, 2 days a month to audit kitchen sanitation, sample test trays, and saw residents. She said when offsite she works on resident assessments, diet audits, and supplements. The Regional Dietician stated there were currently 5 residents on a puree diet. The Regional Dietician stated that the broth or milk would be used to blend and thin the bread to the correct consistency. The Regional Dietician stated that puree bread should have a smooth consistency like a thin mashed potato consistency that would hold together on a spoon and not be a thick and solid mass and not so thin it would be like a soup. She stated that the puree rice should be smooth and there should not be any grains. The Regional Dietician stated that it sounded like the education of dietary staff was needed about puree consistency. The Regional Dietician stated that residents on a puree diet cannot have any solid pieces of food because they could choke.
Review of corporate recipe- Number:399 titled Puree Bread/Rolls reflected recipe called for ingredients of puree bread mix, water, and vegetable oil.
Review of corporate recipe titled Fluffy Rice reflected 11. PUREE INSTRUCTIONS: take ½ portion rice, place in blender until smooth. Add broth, milk, and thickener for correct consistency.
Review of facility's food safety policy titled Nutrition Policies and Procedures dated revised 06/20/2023 revealed Food will be reviewed and stored by methods to minimize contamination and bacterial growth . 8. Transfer foods to their appropriate locations as quickly as possible especially Time/Temperature Control for Safety Foods (TCS) that need to be frozen or stored under refrigeration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 2 (Resident #15 and Resident #61) of eight residents reviewed for reasonable accommodation of needs.
The facility failed to ensure the call light system in Resident #15 and Resident #61 rooms was in a position that was accessible to the residents.
This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.
Findings included:
Resident #15
Review of Resident #15's Face Sheet, dated 05/15/2024, reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified lack of coordination, generalized muscle weakness, and joint disorder.
Review of Resident #15's Quarterly MDS Assessment, dated 02/26/2024, reflected Resident #15 had a severe impairment in cognition with a BIMS score of 00. Resident #15 required extensive assistance for bed mobility, eating and toilet use.
Review of Resident #15's Comprehensive Care Plan, dated 02/27/2024, reflected Resident #15 was at risk for falling related to weakness and one of the interventions was to keep the call lights in reach at all times.
Review of Resident #15's Progress Notes on 05/15/2024 denoted Resident #15 had a fall on 02/15/2024.
Observation and interview with Resident #15 on 05/15/2024 at 9:54 AM revealed Resident #15 was on her bed awake. Resident #15's call light was noted on the floor and under the bed of the resident. Resident #15 tried to search for her call light but was not able to find it. Resident #15 stated she cannot even find the cord of the call light to pull it. She said the staff should put her call light where she could reach it because it was hard for her to move.
Observation and interview with CNA E on 05/15/2024 at 9:55 AM, CNA E stated she did incontinent care to Resident #15 but did not notice that the call light was on the floor. CNA E said she did not make sure the call light was with the resident when she left the resident's room. CNA E picked up the call light from the floor, cleaned it and placed the call light across the resident's chest. She said the call light must always within the reach of the residents because they use the call lights to call the staff in cases of emergencies. CNA E added that if the call lights were not with the residents, the residents might fall or the staff will not know the residents were having an emergency. She said she was responsible in ensuring the call lights were within reach for her assigned residents.
Resident #61
Review of Resident #61's Face Sheet, dated 05/16/2024, reflected resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (insufficient oxygen in the brain causing stroke) affecting left non- dominant side, lack of coordination, and disorder of the muscles.
Review of Resident #61's Quarterly MDS Assessment, dated 14/20/2024, reflected Resident #61 had a severe cognitive impairment with a BIMS score of 06. Resident #61 required extensive assist for bed mobility, transfer, and toilet use.
Review of Resident #61's Comprehensive Care Plan, dated 04/23/2024, reflected Resident #61 was at risk of falling related to weakness and one of the interventions was to keep call light in reach at all times.
Observation and interview with Resident #61 on 05/14/24 at 10:40 AM revealed resident was lying in bed. Wheelchair was next to end of his bed, bed on low position, call light not in reach and was on the floor in between the head of the bed and the nightstand. Interview with resident revealed he was experiencing a severe cramp in his leg and stated he could not reach or find call light. Resident #61 stated if the call light wasn't in reach he wasn't able to get help.
Observation and interview with CNA F on 05/14/24 at 10:45 AM, CNA F stated that call light should be within reach of resident and risk to the resident would be he could not get help when he needed it. CNA F picked up the call light and put it next to the resident on his bed.
In an interview with LVN G on 05/14/2024 at 10:45 AM, LVN G entered room and stated the call light was on the floor and stated call light should be clipped next to resident. LVN G said it was important the call light to be in reach, so resident can be helped when needed.
In an interview with RN A on 05/16/2024 at 7:43 AM, RN A stated the call light should be within the reach of the residents at all times. RN A said for some residents, the call light was their sense of protection. She added the call light gave them the perception that when they needed something or was having an emergency, they could call the staff for help. RN A said the residents fall trying to get up and trying to get what they needed. RN A further said, aside from fall, the residents could suffer from injury and might be mad. RN A said everybody was responsible in making sure the call lights were with the residents, whether the resident was independent or not.
In an interview with the ADON on 05/16/2024 at 7:21 AM, the ADON stated the call lights should not be on the floor or in a place where the residents could not reach it. The ADON said the call light must be within reach of the residents at all times because the call light was their method of communication. He said if the call lights were far from the residents, the residents would not be able to call the staff and their needs would not be addressed. The ADON said the expectation was for the staff to make sure the call lights were within the reach of all the residents and the call lights be placed on top of the bed when the residents were up.
In an interview with the DON on 05/16/2024 at 7:35 AM, the DON stated the call lights were inside the residents' rooms for a reason. She added the residents used the call lights to call for assistance, for a glass of water, for a pain medication, or for incontinent care. The DON added without the call lights, the residents would not be able to tell the staff what they needed. The DON further added when the call lights were not within the reach of the residents, unfavorable incidents like falls, minor hurts, or major injuries could happen. The DON said the expectation was for the staff to ensure that the call lights were within reach of the residents at all times. The DON concluded that moving forward, she would be on top of this issue to make sure the staff would check always that the call lights were with the residents at all times.
In an interview with Administrator on 05/16/2024 at 8:34 AM, the Administrator stated the call lights should not be far from the residents. The Administrator said the call lights were used by the residents to call the attention of the staff. The Administrator said the residents might need the staff for basic needs or in an emergency. He said the staff should be cognizant about call light placement. The Administrator said they would re-educate the staff regarding call lights and would monitor for three weeks if the in-service was effective.
Record review of facility's policy Call Lights - Answering Of, Nursing Policies and Procedures, complete revision: 07/01/2016, revealed Policy: The staff will provide an environment that helps meet the patient/resident's needs . Procedure . 7. When leaving the room, be sure the call light is placed within the patient/resident's reach.

Based on observations, interviews, and record review, the facility failed to consider the views of the resident group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility for three (05/9/2024, 04/11/2024, and 03/07/2024) of three Resident Council meetings reviewed for resident group response.
The facility failed to ensure prompt efforts were made by the facility to resolve grievances of the confidential Resident Council reviewed for grievances.
This failure could place facility residents at risk unresolved grievances, a decreased sense of self-worth, and a decline in quality of life.
Findings included:
Record review of Resident Council minutes dated 05/9/2024 reflected residents had concerns wanting more fruit and desert choices, and a monthly menu chat with person responsible noted as Dietary MGT and signed by Activity Director (AD).
Review of Resident Council minutes dated 04/11/2024 revealed residents had concerns with wanting more fruit and desert choices, and a monthly menu chat with person responsible as Dietary MGT and signed by AD.
Review of Resident Council minutes dated 03/07/2024 revealed residents had requested a menu chat monthly and were requesting more desert choices such as pies, cake choices, or brownies and No frosting on cakes!? The Activity Director would report issue to the Administrator and Dietary Management and the person responsible was the Administrator and Dietary Management, signed by AD.
Record review of Grievance logs for the month of March 2024, April 2024, and May 2024 revealed no grievance filed on behalf of the Resident Council.
Confidential group interview on 05/15/2024 revealed Resident Council had repeatedly brought up concerns that the food and dessert menu were repetitive and stated it was brought up as a concern at all of the past 3 months of Resident Council meetings. The group stated that the food was too repetitive and not appetizing because it was the same thing every week and the deserts had no variety and the cake frequently did not have frosting. The group stated that the AD was present and took notes at every Resident Council meeting and had told them he would speak with the Administrator and Dietary Manager, but they had not had a response after the March 2024, April 2024, or May 2024 meetings. The group stated that the AD suggested a monthly meeting between the Dietary staff and the Resident Council but it had not been scheduled.
Observation on 05/14/2024 at 10:56 AM during kitchen inspection of the lunch menu for 05/15/2024 was hamburger on bun, seasoned French fries, ketchup, lettuce tomato, onion, pickles, frosted yellow cake, beverage of choice, and ice water.
In an interview on 05/15/2024 at 11:45 AM with the AD revealed he started working for the facility at the end of November 2023 and attended all Resident Council meetings. AD stated he always attended and took notes and had brought up concerns at the morning meeting following Resident Council. AD stated in March 2024 he brought up the concern and the Administrator asked that the Dietary Manager talk to the Dietician about the resident's concern about variety. The AD stated at the April 2024 meeting the Resident Council brought up the exact same food concerns and he voiced their concerns during the morning meeting and the Administrator instructed him and Dietary Manager to get together and discuss the concerns with Resident Council. The AD stated at the May 2024 meeting, the Resident Council brought up the same food concerns and he brought up the concern during morning meeting and currently did not have anything scheduled for a visit with the Dietary Manager and the Resident Council. The AD stated that he did not file the Resident Council food concerns as a grievance because he did not think of their concerns to warrant the level of being filed as a grievance until now. He had been in contact with the Administrator and the Dietary Manager about the concern and they were aware. The AD stated that a meeting between the Dietary Manager and the Resident Council would be beneficial because it showed that the Resident Council concerns, were heard and there were resolutions. The AD stated that acting promptly and addressing concerns brought up in the Resident Council meeting was important so that residents felt dignity and respect and it was a resident right. The AD stated that the residents enjoying their food was important because it was something that they got to look forward to, it impacted their quality of life.
Observation on 05/15/2024 at 12:55 PM revealed the test lunch tray for regular and puree diet had hamburger, with fries, lettuce, tomato, onion, and pickle on the side, yellow cake that did not appear to be frosted.
In an interview on 05/15/2024 at 12:56 PM with the Dietary Manager, she stated she did not receive any feedback from the Resident Council regarding food concerns since the mock survey in January. She stated that if the Resident Council had concerns about food then the Activity Director was supposed to draft a grievance which would generate a notification to her based on their feedback. She had not received any notices from the past 3 Resident Council meetings.
In an interview on 05/17/2024 at 11:52 AM with the Administrator revealed the facility has a set menu and recalled that Resident Council had voiced concerns regarding the menu receptiveness and deserts options at the March, April, and May meetings at morning meeting by the Activity Director. He stated that the facility had a mock survey in February of 2024 and the residents' concerns about the food were brought up and it was recommended that they set up a meeting time with the dietary staff and the Resident Council. He expected the Dietary Manager and the Activity Director to connect and make time to address the concern and meet with the Resident Council, but it had not happened yet. The Administrator stated he did not follow up about the food concerns because it did not come up to the level of a grievance, they were more like personal preferences. The Administrator stated that if a resident had weight loss or were refusing their meals because they were inedible then that situation would call for a grievance. The Administrator stated that the purpose of the Resident Council was to get feedback on certain topics and monitor for any major grievances and advocate for themselves and other residents. Administrator stated that resident council did not receiving responses to their concerns could make residents feel like their voice did not matter.
Interview on 05/17/24 at 12:26 PM with the Regional Dietician revealed that if the menu says frosted cake, then the food should have frosting that was visible. She said they should follow what the resident preferences were because it impacted their quality of life and was one of the few things they can have a say in.
Review of recipe titled Frosted Yellow Cake revealed the following instructions for frosting: 7. Combine creamed margarine, sugar, and milk. Mix well. Add melted chocolate and vanilla. Beat until fluffy.
Review of facility's Resident Council policy titled Social Services Policies and Procedures dated revised 06/09/2023 revealed The Procedures . 8. The Resident Council or Group can voice group recommendations. 9. The Activities Director will attempt to follow-up on and provide feedback on the Council's/Group's concerns and recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for one (Resident #70) of eight residents reviewed for care plan.
The facility failed to ensure Resident #70's care plan was revised to reflect person centered interventions for hydration.
This failure could place the resident at risk of current needs not being met.
Findings included:
Review of Resident #70's MDS assessment dated [DATE], reflected that the resident was a [AGE] year-old male admitted on [DATE]. His cognition was severely impaired. Relevant diagnoses included Alzheimer's disease, malnutrition, dysphagia (difficulty swallowing), and Down Syndrome. The resident was dependent on staff for oral care and nutrition.
Review of Resident #70's Comprehensive Care Plan dated 01/16/24 reflected:
Resident at risk for dehydration
Interventions included: keep fluids available
An observation on 05/15/24 at 12:50 PM revealed Resident #70 was unable to drink fluids independently. CNA U was administering nectar-thickened liquids to the resident. The resident was non-verbal. Resident #70 drank approximately 120 cc thickened water. CNA U also had to feed the resident his meal. The resident ate 75% of meal.
An interview on 5/16/24 at 10:25 AM with the DON and the ADON revealed the care plan was not appropriate for Resident #70 because he was not able to drink fluids by himself. The DON said she would need to make a more specific care plan for the resident.
Record review of facility policy, Social Services Policies and Procedures, dated 10/02/20, reflected:
Subject: Person-Centered Care Plan Policy:
The resident has the right to be informed of and participate in treatment and the right to participate in the development and implementation of a person-centered plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide the necessary services to maintain good oral hygiene to a resident who was unable to carry out activities of daily living for one of eight residents (Resident #70) reviewed for ADL care.
The facility failed to provide Resident #70, who required extensive assistance, with timely oral care and sufficient fluids to keep the resident's mouth moist.
This failure could place residents at risk of oral hygiene problems including dry mouth, cavities, and infection.
Findings included:
Review of Resident #70's MDS assessment dated [DATE], reflected that the resident was a [AGE] year-old male admitted on [DATE]. His cognition was severely impaired. Relevant diagnoses included Alzheimer's disease, malnutrition, dysphagia (difficulty swallowing), and Down Syndrome. The resident was dependent on staff for oral care and nutrition.
Review of Resident #70's Comprehensive Care Plan dated 01/16/24 reflected:
Resident at risk for dehydration
Interventions included: keep fluids available.
There was not a care plan for oral care .
An observation on 05/15/24 at 11:24 AM revealed Resident #40 was lying in bed. He was awake and alert. His lips were dry and cracked. His teeth were covered in a paste-like substance. He had thick oral secretions and was breathing through his mouth. CNA U was at the bedside and said the resident required assistance with all care. CNA U said she gave the resident fluids with breakfast. CNA U pointed to a cup with approximately 60cc of thickened water missing from the 8-ounce cup. CNA U said it was important for the resident to receive sufficient fluids .
An observation on 05/15/24 at 12:50 PM of Resident #70 and CNA U revealed the resident drank approximately 120 cc thickened water.
An observation and interview on 5/16/24 at 10:25 AM with the DON and the ADON revealed Resident #70 was lying in bed. There was a paste-like substance on his teeth and lips. His lips were dry and cracked. The DON said the denture paste caused the resident's mouth to look dry and cracked. The DON said oral care was supposed to be performed every shift, but that the resident needed oral care at that time. The DON said the resident needed oral care very often and that there was not a care plan for it. The DON said it was important for the resident to receive frequent oral care because it could cause infection and she would need to make him a specific care plan for oral care to ensure it was performed often.
Record review of facility policy, Hydration-Oral, not dated, reflected:
.4. Patients/Residents with swallowing disorders are offered thickened liquids in the proper consistency under the direction of qualified clinical staff. Orders are obtained to provide hydration at specified intervals, for example offering of thickened with each medication pass and between meals. This is documented in the care plan.
Record revoew of the facility policy, Activities of Daily Living, Optimal Function, revised 2017, reflected:
Policy .The Facility provides necessary care to all residents that are unable to carry out activities of daily living on their own to ensure they maintain proper nutrition, grooming, and hygeine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that Residents, who needed respiratory care, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for four (Resident #29, Resident #61, Resident #66, and Resident #71) of ten residents reviewed for respiratory care.
1.
The facility failed to ensure Resident #29's nasal cannula was changed weekly and was properly stored.
2.
The facility failed to ensure Resident #61's nasal cannula was properly stored.
3.
The facility failed to ensure Resident #66's nasal cannula was properly stored.
4.
The facility failed to ensure Resident #71's breathing mask for nebulization was changed weekly and properly stored.
These failures could place the residents at risk for respiratory infection and not having their respiratory needs met.
Findings included:
1.
Review of Resident #29's Face Sheet, dated 05/15/2024, reflected that resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included chronic respiratory failure with hypoxia (insufficient amount of oxygen in the body) and shortness of breath.
Review of Resident #29's Comprehensive MDS Assessment, dated 04/17/2024, reflected resident had a severe impairment in cognition with a BIMS score of 06. The Comprehensive MDS Assessment also indicated resident was on oxygen therapy.
Review of Resident #29's Care Plan, dated 05/08/2024, reflected resident required oxygen therapy 2 - 3 liters per minute related to asthma and respiratory failure and one of the interventions was to administer oxygen as ordered.
Review of Resident 29's Physician Order, dated 03/03/2024, reflected, O2 at __2__ liters per minute via nasal cannula.
Review of Resident 29's Physician Order, dated 03/03/2024, reflected EQUIPMENT: Keep O2 cannula/mask/tubing and/or Nebulizer mask/tubing bagged when not in use.
Review of Resident 29's Physician Order, dated 03/03/2024, reflected EQUIPMENT Oxygen: Change O2 tubing/nasal cannula/mask/humidification system weekly.
Observation on 05/14/2024 at 9:37 AM revealed Resident #29 was on her bed with oxygen at 2 liters per minute via nasal cannula. It was also noted that the resident had an oxygen tank at the back of her wheelchair with a nasal cannula connected to it. The prongs of the nasal cannula were observed on the seat of the wheelchair. It was not bagged. it was also noted that the nasal cannula was dated 04/25/2024.
Observation and interview with CNA C on 05/14/2024 at 9:37 AM revealed CNA C was about to transfer Resident #29 from bed to wheelchair. CNA C positioned the wheelchair parallel to the end of the resident's bed. CNA C said she was the one who put the nasal cannula on the seat of the wheelchair. When CNA C further positioned the wheelchair, the nasal cannula fell on the floor.
Interview and observation with LVN B on 05/14/2024 at 9:43 AM, LVN B stated the nasal cannula should not be on the floor or placed on the wheelchair when not in use. He said it should be bagged to prevent contamination and infection. LVN B picked up the nasal cannula that was on the floor and disconnected it from the oxygen tank and said he would change it. LVN B then saw the date of the nasal cannula which was 04/25/2024. He said the nasal cannula should be changed weekly to make sure there was no growth of microorganisms in the tubing. LVN B left the room and came back with a new nasal cannula and connected it to the oxygen tank behind Resident #29's wheelchair.
2. Review of Resident #61's Face Sheet, dated 05/16/2024, reflected resident was a [AGE] year-old male admitted on [DATE]. One of the relevant diagnoses was wheezing.
Review of Resident #61's Quarterly MDS Assessment, dated 14/20/2024, reflected Resident #61 had a severe cognitive impairment with a BIMS score of 06. Resident #61 required extensive assist for bed mobility, transfer, and toilet use.
Review of Resident #61's Comprehensive Care Plan, dated 04/23/2024, reflected resident was at risk for SOB and one of the interventions was to administer oxygen as ordered.
Review of Resident #61's Physician Order, dated 05/14/2024, reflected O2 at __2-3__ liters per minute via nasal cannula PRN for SOB.
Review of Resident 61's Physician Order, dated 03/10/2023, reflected EQUIPMENT: Keep O2 cannula/mask/tubing and/or Nebulizer mask/tubing bagged when not in us.
Observation on 05/14/24 at 10:40 AM revealed Resident #61was lying in bed. It was noted that the resident's nasal cannula was not bagged and was lying coiled on the floor in between the oxygen machine and the nightstand.
Observation and interview with LVN G on 05/14/2024 at 10:45 AM, LVN G entered the room and stated the nasal cannula should be bagged and off the floor. LVN G disconnected the nasal cannula from the oxygen concentrator and said she would change it.
3. Review of Resident #66's Face Sheet, dated 05/15/2024, reflected that resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included acute chronic respiratory failure with hypoxia and shortness of breath.
Review of Resident #66's Quarterly MDS Assessment, dated 04/30/2024, reflected that Resident #66 had an intact cognition with a BIMS score of 15. The Quarterly MDS also indicated that the resident was on oxygen therapy while a resident of the facility.
Review of Resident #66's Comprehensive Care Plan, dated 05/08/2024, reflected resident required oxygen therapy related to respiratory failure and SOB and one of the interventions was administer oxygen as order.
Review of Resident #66's Physician Order, dated 04/26/2024, revealed O2 at 3 liters per minute via nasal cannula.
Observation and interview with Resident #66 on 05/14/2024 at 11:46 AM revealed the resident was on his wheelchair inside the room. It was noted resident had an oxygen concentrator at bedside. A nasal cannula was connected to the oxygen concentrator and was hanging on top of the concentrator. Resident #66 also had an oxygen tank behind his wheelchair with a nasal cannula connected to it. The cord of the nasal cannula was coiled around the oxygen tank with the prongs of the nasal cannula touching the top of the oxygen tank. Both nasal cannulas were not bagged. According to the resident, he was on oxygen since he came back from the hospital. He said he never saw a bag for his nasal cannula, nor has anyone told him to put the nasal cannula in a bag.
4. Review of Resident #71's Face Sheet, dated 05/15/2024, reflected the resident was a [AGE] year-old female admitted on [DATE]. One of the relevant diagnoses included acute respiratory failure with hypoxia.
Review of Resident #71's Quarterly MDS Assessment, dated 04/24/2024, reflected that Resident #71 had a severe impairment in cognition with a BIMS score of 00.
Review of Resident #71's Comprehensive Care Plan, dated 04/25/2024, reflected that Resident #71 was at risk for respiratory failure and one of the interventions was administer medications as ordered.
Review of Resident #71's Physician's Order, dated 04/25/2024, reflected, Pharmacy Dispensed Drug: Ipratropium-Albuterol 0.5-2.5 (3) MG/3ML Solution
Pharmacy Directions: 1 VIAL VIA NEBULIZER EVERY FOUR HOURS AS NEEDED.
Observation and interview with Resident #71 on 05/14/2024 at 11:24 AM revealed the resident was on her bed, awake. It was also noted that her breathing mask used for the nebulizer was inside the drawer. The breathing mask was not bagged. According to the resident, she had breathing treatment every morning. She said the nurse would be the one to put it on and the one who took it off. It was noted the breathing mask was dated 04/25/2024.
Interview and observation on 05/14/2024 at 12:17 PM, LVN B stated he administered Resident #71's breathing treatment. LVN B opened the resident's side table drawer and acknowledged he was not able to put the breathing mask inside the bag after the resident's breathing treatment was done. He said the breathing mask should also be bagged just like the nasal cannula to prevent infection. He said he would change the breathing mask and would put it in a bag. He said he did not notice that Resident #66's nasal cannula was on the oxygen concentrator and behind the wheelchair not bagged.
In an interview with the ADON on 05/16/2024 at 7:21 AM, the ADON stated the breathing mask, and the nasal cannula should be bagged when not in use. The ADON said it was the proper way to store the breathing mask and the nasal cannula. He said if those breathing apparatuses were not bagged, exposed, or touching surfaces that were not clean, then oxygen administration could be compromised. The ADON also said the nasal cannula and the breathing mask should be changed weekly. He said the staff, including him, were responsible for monitoring that the apparatus used in oxygen therapy were bagged when not in use and changed weekly. He said he would in-service regarding proper storage and changing of the nasal cannula and breathing mask.
In an interview with the DON on 05/16/2024 at 7:35 AM, the DON stated the nasal cannula, and the nebulizer should be bagged when not in use. She said there should be an available bag on the drawer of the resident where the nurse could put the breathing mask after every breathing treatment. She added there should also be an available plastic bag on the concentrator where the staff could put the nasal cannula when not in use. She said the nasal cannula at the back of the wheelchair should also be bagged when the resident was not using it. The DON explained the nasal cannula should not be touching the seat of the wheelchair, the sides of the concentrator, or the oxygen tank because it could cause contamination that could lead to respiratory infection. She also said the nasal cannula should be changed every week to make sure there prevent accumulation of microorganism that could compromise the respiratory system. She said everybody was responsible for checking if the nasal cannula and the breathing mask were changed or bagged. She said the expectation was the breathing mask and the nasal cannula would be stored properly. The DON concluded she would continually remind the staff to be diligent in making sure the procedures for respiratory care were followed.
In an interview with the Administrator on 05/16/2024 at 8:34 AM, the Administrator stated the breathing masks, and the nasal cannulas should be stored properly to prevent potential respiratory infections. He added the nasal cannula, and the breathing mask should be changed weekly as per doctor's order. He said the staff should be cognizant about proper storage of the nasal cannula and the breathing mask, as well as when to change them. The Administrator said they would re-educate the staff regarding the issue and would monitor for three weeks if the in-service was effective.
Record review of facility's policy, EQUIPMENT CHANGE SCHEDULE, RESPIRATORY POLICIES AND PROCEDURES revised 2/1/2020 revealed Policy: The Facility shall have a schedule for changing disposable equipment . Procedure: Equipment will be changed as follows: . tubing and aerosol nebulizer . Every week . place in clean, dry plastic bag . write date change in tubing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that pain management was provided for 2 (Resident#4 and Resident #36) of 8 residents reviewed for pain.
1. The facility failed to provide effective pain management for Resident #36 after she experienced a fall on 05/09/2024 she was observed by staff resulting in signs of pain such as grimancing and screaming with movement.
2. The facility failed to provide effective pain management for Resident #4 when his pain medication was reduced without his knowledge resulting in him experiencing unnecessary pain and suffering and psychosocial harm.
On 05/16/2024 at 4:51 PM an immediate jeopardy was identified. While the IJ was removed on 05/17/2024 at 11:21 AM the facility remained out of compliance at a scope of pattern with a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and the effectiveness of their Plan of Removal.
These failures placed residents at risk for prolonged and unnecessary pain and suffering and a decreased quality of life.
Findings included:
1. Review of Resident #36's Quarterly MDS dated [DATE] reflected she was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of Alzheimer's disease (loss of cognition), stroke, depression (low mood), muscles weakness, unspecified lack of coordination, abnormal position, neurocognitive disorder with Lewy bodies (abnormal deposits of protein in brain leading to loss of cognition, balance, alertness), and a BIMS score of 3 (severe cognitive impairment).
Review of Resident #36's Care Plan reflected problem start date of 03/30/2022 that the resident had difficulty making self-understood and had unclear speech. Review of care plan reflected problem start date of 03/10/2022 that the resident was at risk of complaints of chronic pain and used narcotic pain medication due to disease process with approaches of: monitor and record any complaints of pain: location, frequency, effect on function, intensity, alleviating factors, aggravating factors . monitor and record any non-verbal signs of pain, complaints of pain, and evaluate effectiveness of pain management interventions.
Record review of Resident #36's Physical Therapy Treatment Encounter Notes with date of service of 05/06/2024, signed by PTA CC 05/06/2024 at 11:08 AM revealed the resident showed no signs of pain, was treated in the gym and showed no signs of pain. The summary of skilled services included gait training, bilateral lower extremity exercises focused on progressive resistive exercise and bike exercises to enhance muscle strength.
Record review of Resident #36's Occupational Therapy Treatment Encounter Notes with date of service of 05/06/2024, signed by OT BB 05/06/2024 at 6:29 PM revealed Resident #36 showed no signs of pain.
Review of Resident #36's resident progress notes dated 05/09/2024 by LVN N revealed the resident had a witnessed fall on 05/09/2024 around 5:45 AM when the resident was observed in the hallway wobbling and then fell sliding into the ground on her right knee. The resident was provided a head-to-toe assessment, neuro checks were started, and the resident could not say why she was out of bed. The only injury noted was to her right knee, it was slightly red and sore. LVN N noted that the resident was put to bed. The resident was noted to have dementia and did not know why she was up.
Review of Resident #36's progress notes for 05/09/2024 by LVN N at 1:43 AM revealed the resident continued on neuro checks for fall, no delayed injury noted. Right slightly red no swelling noted and resident was reminded to use walker and with supervision.
Review of Resident #36's progress notes for 05/09/2024 by LVN P at 11:19 AM revealed Resident #36 had no delayed injuries due to pain and denied any pain or discomfort.
Review of Resident #36's progress notes for 05/09/2024 by RN H at 4:33 PM revealed Resident #36 had no post fall injuries and the resident denied pain.
Record review of Resident #36's Occupational Therapy Treatment Encounter Notes with date of service of 05/09/2024, signed by OT BB 05/09/2024 at 6:15 PM, revealed resident showed signs of pain that included grimacing, protective behaviors to areas of pain, limited resident ability to sit up at the edge of the bed and transfers, pain was relieved by sitting still and exacerbated with prolonged activity, and resident had a fall on the morning of 05/09/2024 and complained of pain to her lower right extremity.
Review of Resident #36's progress notes for 05/09/2024 by RN H at 9:39 PM revealed Resident#36 was noted moaning, holding her right leg any time she is given incontinent care. Resident assessed. Right hip to ankle painful to touch, no redness no swelling noted. Tramadol 50mg tab routine admin [sic]. NP notified no new order received.
Review of Resident #36's progress notes for 05/10/2024 by LVN N at 5:54 AM revealed there was an incident with Resident #36 and her roommate, and the resident was assessed head to toe, was asleep, had no discoloration or any injuries, denied any pain, and was moved to a different room.
Review of Resident #36's progress notes dated 05/10/2024 by MDS LVN between 11:33-11:45 AM revealed a cognitive assessment of Resident #36 was completed and revealed that the resident was able to repeat 2 words, was unable to recall the correct year, month, or day of the week, resident speech was unclear, and resident stated that occasional pain, rarely disturb for sleep, activity, therapy activity, pain scale 7. Will continue to monitor.
Review of Resident #36's progress notes dated 05/10/2024 at 12:49 PM by LVN Q revealed resident had no delayed injury, no neuro deficits.
Review of Resident #36's progress notes dated 05/10/2024 at 8:46 PM by RN H revealed Resident #36 had continued neuro checks for fall, no post fall injury noted or reported, resident denied pain, and care was given as needed by staff.
Review of Resident #36's progress notes dated 05/11/2024 at 2:38 AM by LVN N revealed Resident #36 needed assistance with all activity of daily living, had neuro checks due to fall, and was adjusting to room change.
Review of Resident #36's progress notes dated 05/12/2024 at 7:34 PM by LVN R revealed Resident #36 was post fall and noted grimacing in pain during ADL's. Notified NP [Nurse Practitioner DD]. No new orders.
Review of Resident #36's progress notes dated 05/12/2024 at 8:40 AM by LVN S revealed the Nurse Practitioner DD for Physician K was notified and a new order was received for an x-ray because Resident #36 was observed in therapy with a nurse aide screaming by holding her right hip. The pain increase [sic] when patient moves her right leg, turn to left side, and during care. Tylenol 500 mg for pain given.
Record review of Resident #36's Physical Therapy Treatment Encounter Notes with date of service of 05/13/2024, signed by Physical Therapist GG 05/13/2024 at 3:40 PM revealed resident consistently stated increased pain on the right lower extremity at the start of therapy session and was unable to complete bed mobility exercises due to increased pain and nursing was notified.
Record review of Resident #36's Occupational Therapy Treatment Encounter Notes with date of service of 05/13/2024, signed by OT BB 05/13/2024 at 6:24 PM revealed the resident showed signs of pain to her lower right extremity that included reflexive behaviors such as saying ouch, stop, protecting, moaning, holding area of pain, limited resident ability to sit up for meals, and pain was relieved by remaining still and exacerbated with sitting and prolonged activity. OT BB noted that resident complained of severe pain with movement to lower right extremity and that Director of Rehabilitation reported the resident had an x-ray of the knee with negative results and a hip x-ray was recommended to be done.
Record review of Resident #36's Physical Therapy Treatment Encounter Notes with date of service of 05/14/2024, signed by PTA CC 05/14/2024 at 11:35 AM revealed the resident had increased pain on both sides of her lower extremities and nurse was aware and arranging for an x-ray series for bilateral hip assessment.
Review of Resident #36's orders revealed there was a prescription for pain medication Tramadol 50 mg, one tablet, by mouth, twice a day for unspecified pain with a start date of 11/17/2022 through 05/15/2024 and an order for 500 mg of Tylenol, PRN (as needed) with a start date of 11/17/2022 through 05/15/2024 .
Review of Resident #36's Medication Administration Report (MAR) for 05/01/2024 through 05/19/2024 revealed the resident had a PRN (as needed) order for Tylenol 500mg and was not given any PRN doses after her fall on 05/09/2024 until 05/14/2024 at 8:38 AM by LVN S for pain.
Review of Resident #36's Medication Administration Report (MAR) for 05/01/2024 through 05/19/2024 revealed the resident had a PRN (as needed) order for Ibuprofen 200mg with a start date of 11/17/2022 and was not given any PRN doses after her fall on 05/09/2024.
Review of Resident #36's MAR for 05/01/2024 through 05/19/2024 revealed resident was given Tramadol 50 mg, one tablet, by mouth twice a day for unspecified pain at 9:00 AM and 8:00 PM from 05/01/2024 through 05/15/2024. Review of MAR revealed Resident #36 order was changed to Tramadol 50 mg, one tablet, by mouth, 3 times a day starting on 05/15/2024.
Review of X-Ray report with date of service of 05/15/2024 for Resident #36 reflected there is a possible nondisplaced intertrochanteric fracture of the right femur of indeterminate age.
Review of X-Ray report with date of service of 05/14/2024 for Resident #36 reflected resident had an x-ray of her left and right hip due to unspecified pain with the findings of a nondisplaced right intertrochanteric fracture of indeterminate age with clinical follow up recommended.
Observation on 05/14/2024 at 2:16 PM revealed Resident #36 was lying in bed, hair appeared clean, and was wearing a hospital gown and had a blanket. Resident #36 asked to be cleaned and did not appear to know how to use the call button that was within reach. RN H was informed that the resident was in need of assistance and stated she would help the resident immediately.
Observation and interview on 05/15/2024 at 3:05 PM revealed X-ray Technician waiting outside of Resident #36's room with a portable x-ray. He stated he was waiting for RN H to assist him because the last time the resident was screaming.
Observation on 05/15/2024 at 3:13 PM the resident was heard from outside the room with the door closed saying ow.
Interview on 05/15/2024 at 3:30 PM with RN H revealed that Resident #36 recently had a witnessed fall on 05/09/2024 and that she assessed resident the day of the fall and observed some redness to her knee and lower extremity was painful to touch, resident was put in bed and the Nurse Practitioner was notified with no new orders and family was notified. RN H stated that resident did not appear to be in pain when in bed. RN H stated on 05/10/2024, Resident #36 did not appear to be in pain when she was in bed or when asked but there were some signs of pain during activities of daily living care and the Nurse Practitioner was notified with no new orders. RN H stated the x-ray was ordered on 05/15/2024 because the resident was observed screaming and yelling out and grimacing during activity of daily living care. RN H stated it was appropriate to contact the Nurse Practitioner instead of Physician.
Interview on 05/16/2024 at 2:04 PM with DON revealed Resident #36 had a fall on 05/09/2024 and staff had told her that resident had some redness to her knee but was not complaining of pain and had good range of motion and thought she was fine, she was walking in the hall. DON stated that it was not uncommon for Resident #36 to complain of generalized pain and was not aware that staff and therapy were documenting that Resident #39 was showing symptoms of right hip pain after 05/09/2024 and that it would have been a change in condition for the resident. DON stated she had not read therapy's notes that noted resident was immobile and she did not have access to those notes. DON stated the Nurse Practitioner was notified of Resident #36's fall on 05/09/2024, were provided no new orders. DON stated that she was aware on 05/15/2024 that resident had hip pain so Dr. K was notified and ordered an x-ray. DON stated that the result of the x-ray was that resident had a hairline fracture and the plan was to not do surgery and to try to keep resident immobile as much as possible and manage pain. DON stated that staff are supposed to notify the physician but physicians direct staff to contact Nurse Practitioner if he was not available. DON stated that she had seen Resident #36 out of bed since her fall on 05/09/2024 and was not told of the symptoms of hip pain by staff. DON stated that Resident #36 was provided Tylenol for breakthrough pain. DON stated that nursing staff were responsible for monitoring, and notifying physician of resident pain if uncontrolled, and to document and provide pain medication given to residents and their pain levels. DON stated that not providing pain management for residents would impact their quality of life if their pain was not managed. DON stated that they always contacted NP EE for changes in condition.
Interview on 05/16/2024 at 2:50 PM with Power of Attorney (POA) for Resident #36 revealed she was notified on 05/09/2024 that resident had fallen and did not have any pain. POA stated she was not notified about any symptoms or signs of pain for Resident #36 until 05/15/2024 when she was contacted by facility stating Resident #36 displayed signs of pain and an x-ray had been ordered.
Interview on 05/16/2024 at 3:46 PM with Physician K revealed he was an attending physician at the facility and was notified that Resident #36 had a fall and was told she did not have pain. Physician K stated that he was at the facility on 05/14/2024 and a nurse practitioner informed him that the resident had pain, an x-ray was ordered, and resident had a nondisplaced fracture or a hairline fracture of her hip. Physician K stated he ordered a second x-ray to confirm the original findings because it would impact the treatment plan. Physician K stated that he expected if a resident had significant pain they would be sent to the Emergency Room. Physician K stated it was important for any new or different pain symptoms to be reported to the physician so he was aware of the resident's condition and able to make necessary orders. Physician K stated that staff not reporting resident with pain symptoms could result in a resident experiencing pain for extended periods of time or not receiving proper treatment.
Interview on 05/17/2024 at 2:50 PM with Physician L revealed he was a pain management physician at facility and if a resident had a pain management concern physician facility staff might call them if resident was having pain but he was not aware that Resident #36 was experiencing pain after 05/09/2024 until 05/14/2024. Physician L stated that if he knew resident was experiencing pain after her fall on 05/09/2024 he would have ordered an x-ray sooner. Physician L stated he would expect staff to check for resident pain post fall by flexion and adduction and look for visual or verbal indications of pain such as grimacing or crying out. Physician L stated the risk to a resident by not notifying the physician about a change of condition of resident could result in a resident to not be provided care they needed or remain in pain.
Observation on 05/19/2024 at 11:30 AM of Resident #36 revealed she was lying in bed sleeping, wearing hospital gown, covered with a blanket with call light within reach and water cup at bedside table.
Interview on 05/20/2024 at 1:00 PM with Nurse Practitioner (NP) EE revealed if a resident was already on pain management and they were experiencing pain, the staff would reach out to her. NP EE stated she was not aware that resident was having pain until 05/15/2024 when the nurses told her that the resident was in a lot of pain when she moved. NP EE stated that she doesn't like to give stronger medications than Tylenol 3 or Tramadol and was able to write prescriptions for those medications without asking the Physician AA. NP EE stated Resident #36 was on already on Tramadol 50 mg two times a day for generalized pain and increased frequency to 3 times a day and added Tylenol 650 mg three times a day starting 05/15/2024. NP EE stated she did not know who ordered the x-ray and did not remember asking Physician AA about Resident #36. NP EE stated that the risk to a resident when they do not receive proper pain management was that they could have decreased movement, increase of pain, and decrease in quality of life.
2. Review of Resident #4's Comprehensive MDS dated [DATE] revealed resident was an [AGE] year-old male, admitted on [DATE], with diagnoses of postlaminectomy syndrome (a condition that causes pain or other sensations in the body after spinal surgery), muscle weakness, unspecified abnormalities of gait and mobility, chronic pain syndrome (pain that can be continuous or may come and go and persists for weeks or years), anemia (low iron), hyponatremia (low salt levels), hyperlipidemia (elevated levels of fat in blood), arthritis (inflammation of the joints causing pain and stiffness), stroke (loss of blood flow to the brain), dementia (loss of cognition), depression (persistent low moods), asthma, macular degeneration (eye disease causing vision loss), and a BIMS score of 15 (intact cognition). Review of Comprehensive MDS revealed the care area of pain was triggered for pain.
Review of Resident #4's Care Plan with problem start date of 03/25/2024 revealed Resident is at risk complaints of chronic pain, use routine pain meds and Narcotic PRN [as needed] R/T [due to] chronic pain syndrome, disease process.
Review of Resident #4's face sheet dated 05/14/2024 revealed Resident #4 had a Resident Representative, and he was his own representative.
Observation and interview on 05/14/2024 at 1:46 PM with Resident #4 revealed he was lying in bed with a slightly curled position and with a blanket wrapped over his neck and appeared stiff. He stated he does not get his oxycodone every 4 hours even though the Physician prescribed it. He stated the staff taunt him by saying he has 1 minute until he can have his next dose or 6 minutes and it made him feel really bad and he felt that he was having more breakthrough pain due to the delays. Resident #4 stated he had chronic pain due to previous surgeries, cervical (neck) fusion and lumbar (back) fusion. He stated some of the hardware caused him pain and that he took the same dosage for years with his orthopedic Physician and his pain was usually controlled enough at a level 2 or 4 when he took his medication regularly. Resident #4 stated that he was involved in his care planning and stated that the facility was aware that he had chronic pain syndrome and needed oxycodone every 4 hours. The facility said they can accommodate his need, but the order would have to be PRN. This means when needed, so you would need to ask for it every 4 hours if you needed the pain medication. Resident #4 stated that he understood that to mean he needs to ask every 4 hours, so he did. He stated it seemed like they did not understand his pain, that his pain will flare up if he misses the dose of oxycodone every 4 hours.
Review Resident #4 orders revealed following orders:
-Oxycodone, Schedule II, 15 mg, one tablet, by mouth, every 4 hours with a start date of 04/29/2024 and end date of 05/01/2024.
-Oxycodone, Schedule II, 15 mg, one tablet, by mouth, every 4 hours PRN (as needed) with a start date of 05/01/2024 and end date of 05/02/2024.
-Oxycodone, Schedule II, 10 mg, one tablet, by mouth, every 4 hours PRN (as needed) with a start date of 05/02/2024 and end date of 05/02/2024.
-Oxycodone, Schedule II, 15 mg, one tablet, by mouth, every 4 hours PRN (as needed) with a start date of 05/18/2024.
-Buprenorphine Schedule III patch, 10mcg/hour one transdermal film every 7 days for chronic pain with a start date of 04/30/2024 and end date of 05/03/2024 and another start date of 05/03/2024 with end date of 05/17/2024.
Review of Resident orders with a start date of 05/18/2024 for Resident #4 for psychology evaluation for possible drug seeking behavior and decreased perception of pain.
Review of Resident #4 orders Medication Administration History for 05/01/2024 through 05/18/2024 revealed resident received Oxycodone, 10 mg for pain on:
05/01/2024: none
05/02/2024 at:
-6:18 PM by LVN M
05/03/2024 at:
-6:41 PM by LVN M
05/04/2024 at :
-12:17 PM by LVN T
-4:15 PM by LVN M
05/05/2024 at:
-6:52 AM by LVN P
-11:23 AM by LVN P
-4:07 PM by LVN P
-8:17 PM by LVN P
05/06/2024:
-7:23 AM by LVN G
-11:37 AM by LVN G
-3:41 PM by RN I
-7:40 PM by RN I
05/07/2024:
-5:59 AM by LVN O
-10:05 AM LVN G
-7:32 PM by RN I
05/08/2024:
-5:06 AM by LVN T
-9:10 AM by LVN G
-4:16 PM by RN I
-8:18 by RN I
05/09/2024:
-9:13 AM by LVN G
-3:15 PM by RN I
-7:15 PM by RN I
05/10/2024:
-8:47 AM by LVN G
-5:02 PM by LVN V
05/11/2024:
-1:56 PM by LVN V
05/12/2024:
-7:00 AM by LVN P
-11:54 AM by LVN V
-3:55 PM by LVN P
-8:04 PM by LVN P
05/13/2024:
-4:30 AM by LVN X
-8:37 AM by LVN G
-4:38 PM by RN I
-9:05 PM by RN I
05/14/2024:
-5:05 AM by LVN T
-5:06 PM by RN I
-9:09 PM by RN I
05/15/2024:
-5:02 AM by LVN T
-11:55 AM by LVN G
-4:20 PM by RN I
-8:21 PM by RN I
05/16/2024:
-2:50 AM by LVN O
-8:04 by LVN G
-3:41 PM by RN I
-7:50 PM by RN I
05/17/2024:
-8:40 AM by LVN G
-12:34 PM by LVN G
-5:43 PM by LVN V
-9:35 PM by LVN V
05/18/2024:
-4:39 AM by LVN O
-8:46 AM by LVN P
Review of Resident #4 orders Medication Administration History for 05/01/2024 through 05/18/2024 revealed resident received Oxycodone, 15 mg for pain on:
05/18/2024 at 9:09 PM by LVN P
05/19/2024 at 10:11 AM by LVN P
Review of Resident #4's nurse's progress notes revealed note dated 04/27/204 by LVN N at 11:56 PM .resident continue on excessive amount of pain med gets it every 4 hours around clock prn [as needed] will contact pain doctor to reevaluate him.
Review of Resident #4's nurse's progress notes revealed note dated 04/28/204 by LVN N at 5:50 AM Resident continues on skill charting appears obsessed [sic] with pain med demanding it every 4hr around the clock does not seem to be in pain when checking [sic] on resident always sleeping.
Review of Resident #4's nurse's progress notes revealed note dated 04/29/204 at 1:26 AM by LVN N .Appears to be taking to [sic] many pain pills will have day shift get in touch with dr.
Review of Resident #4's progress notes revealed note dated 04/29/2024 at 12:20 PM by LVN M As per DON, Oxycodone 15mg changed to schedule Q4hr as Pt continues to request for Pain medication every 4 hrs.
Review of Resident #4's progress notes revealed note dated 05/02/2024 at 1:01 AM by LVN N Residents oxycodone 15 changed to 10mg q 4hr prn but was put on pain patch 10mg.
Review of Resident #4's progress notes revealed note dated 05/03/2024 at 8:29 AM by LVN M Resident continues on pain mgt with oxycodone 10mg PRN Q4hrs, no discomfort reported at this time, plan of care on-going.
Review of Resident #4's progress notes revealed note dated 05/07/2024 at 8:35 AM by LVN G Resident refused to take morning medication when he was offered. Resident wants CMA to wait until later. Medication will be offered in a later time.
Review of Resident #4's progress notes revealed note dated 05/08/2024 at 2:16 PM by LVN G Resident refused patches to be placed.
Review of Resident #4's progress notes revealed note dated 05/10/2024 at 1:32 PM by LVN G: Resident continues to refuse pain patches. Resident also using Icy Hot cream topically for pain. No order in place. Notified pain NP to obtain order, no order needed for the icy hot, per NP. NP wants resident to be encouraged to use pain patches. NP will be in the facility and will see resident.
Review of Resident #4's progress notes revealed note dated 05/15/2024 at 10:43 AM by LVN G: Resident refused pain patches and buprenorphine patch. Resident states I don't want them. I have to talk to my Dr. That is too much chemicals for my heart. This nurse explained to the resident that buprenorphine patch is for pain and he gets it once a week but resident refused stating that he gets oxycodone and does not need that patch. Pain management NP notified. WCTM.
Review of Resident #4's progress notes revealed note dated 05/15/2024 at 1:14 PM by LVN G NP called back about resident's refusal of pain patches. Will talk to resident when in facility.
Interview on 05/15/2024 at 2:06 PM with Resident #4 revealed he was told by a nurse that he had been prescribed a patch for pain and was concerned about the interactions between that patch and his current pain medication since he had heart problems in the past and bad experiences with patches. Resident #4 stated that he said he told the nurse that he wanted to talk to his Physician about the concern. He stated his previous Physician, he was with for 10 years, and felt that he had figured out a pain management schedule that already had been working for him. Resident #4 stated that the staff told him that this was how it was, you talk with the nurse practitioner, he told them he was not going to use the patch, and he did not want any of his pain medications changed.[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (Resident #16, 42, and 50) of six residents observed for infection control.
1.
The facility failed to ensure that CNA B performed hand hygiene while providing incontinence care to Resident #16.
2.
The facility failed to ensure that CNA E changed her gloves and performed hand hygiene while providing incontinence care to Resident #42.
3.
The facility failed to ensure that CNA D performed hand hygiene while providing incontinence care to Resident #50.
These failures could place the residents at risk of cross-contamination and development of infection.
Findings included:
1.
Review of Resident #16's Face Sheet dated 05/14/2024 reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included chronic kidney disease and pneumonitis.
Review of Resident #16's Comprehensive MDS assessment dated [DATE] reflected Resident #16 was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated Resident #16 required extensive assistance for toilet use.
Review of Resident #16's Care Plan dated 05/09/2024 reflected resident was at risk of for deterioration in ADL and one of the interventions was provide assistance for ADL.
Observation and interview on 05/14/2024 at 1:56 PM revealed CNA C was about to do incontinent care for Resident #16.
CNA C prepared the things needed for incontinent care. CNA C washed her hands and put on gloves. CNA C then unfastened the tape on both sides of the brief, rolled the front half of the brief down, and then pushed it between the resident's thighs. CNA C cleaned the front part of the resident using the front to back technique. CNA C instructed the resident to roll to the right. CNA C changed her gloves but did not sanitize before putting on the new pair of gloves. CNA C then proceeded to clean the bottom of the residents. After wiping down the resident, CNA C rolled the rest of the brief, pulled it, and threw it in the trash can. CNA C took off the soiled gloves and proceeded to change her gloves. She did not do hand hygiene in between gloves change. CNA C then proceeded to get the new brief, opened it, and placed it at the bottom of the resident. The resident was instructed to roll back. CNA C fixed the brief and fastened the tape on both sides, pulled the blanket up, and gave the call light to the resident. CNA C took off her gloves, threw them in the trash can, and washed her hands. CNA C said she washed her hands before and after doing incontinent care but acknowledged she did sanitize her hands when she changed her gloves. She said she should have taken off her gloves, washed her hands or sanitized her hands, and then put on new gloves after cleaning the resident. She added this could result to cross contamination and infection because the microorganisms from the soiled gloves could transfer to the things touched after incontinent care.
2.
Review of Resident #42's Face Sheet dated 05/15/2024 reflected resident was a [AGE] year-old male admitted on [DATE].
Review of Resident #42's Comprehensive MDS assessment dated [DATE] reflected Resident #42 had a severe impairment in cognition was cognitively with a BIMS score of 03. The Comprehensive MDS Assessment indicated Resident #42 required extensive assistance for toilet use.
Review of Resident #42's Care Plan dated 02/16/2024 reflected resident required assistance with ADL's related to impaired mobility, weakness, cognitive impairment.
Observation and interview on 05/15/2024 starting at 11:14 AM revealed CNA E was about to transfer Resident #42 to her wheelchair to prepare for lunch. CNA E told the resident that she would change her first before transferring her to the wheelchair. CNA E washed her hands and put on gloves. CNA E prepared the things needed for incontinent care. CNA E then removed the resident's pants. CNA E took off her gloves and put on new gloves. CNA E then tore the sides of the pull-up, rolled the front half of the pull-up, and then pushed it between the resident's thighs. CNA E cleaned the front part of the resident using the front to back technique. CNA E instructed and assisted the resident to turn to the right and proceeded to clean the resident's bottom. After cleaning the resident's bottom, CNA E pulled the rest of the pull-up and threw it in the trash can. CNA E then proceeded to get the new pull-up and put it on the resident. CNA E did not change her gloves nor wash/sanitize her hands before getting the pull-up. CNA E then put on the resident's pants and proceeded to transfer the resident to the wheelchair. CNA E took off her gloves and threw them in the trash can. CNA E acknowledged she did not sanitize her hands when she changed her gloves and did not change her gloves before touching the new pull-up. She said she should had sanitized in between changing gloves and changed her gloves before getting the new pull-up. She said this could result to cross contamination and infection. She said they had an in-service two weeks prior about hand hygiene.
3.
Review of Resident #50's Face Sheet dated 05/15/2024 reflected resident was a [AGE] year-old female admitted on [DATE]. One of the relevant diagnoses was diarrhea.
Review of Resident #50's Comprehensive MDS assessment dated [DATE] reflected Resident #50 was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated Resident #16 required extensive assistance for toilet use.
Review of Resident #50's Care Plan dated 04/19/2024 reflected resident required assistance with ADL's related to impaired mobility and one of the interventions assist in toileting.
Observation and interview on 05/15/2024 starting at 10:18 AM revealed CNA D was about to do incontinent care to Resident #50. CNA D told Resident #50 that she would be changing him. CNA D prepared the things needed for incontinent care and then put on a pair of gloves. She did not wash her hands. CNA D then unfastened the tape on both sides of the brief, rolled the front half of the brief down, and then pushed it between the resident's thighs. CNA D cleaned the front part of the resident. CNA D instructed the resident to turn to the left. When the resident was on the side lying position, the resident begun to have a bowel movement. CNA D waited for the resident to finish. When the resident was done with the bowel movement, CNA D cleaned the resident's bottom. After cleaning the resident, CNA D rolled the rest of the brief, pulled it, threw it in the trash can, and then changed her gloves. She did not do any hand hygiene. CNA D then proceeded to get the new brief, opened it, and placed it at the bottom of the resident. The resident rolled back and CNA D fixed the brief. CNA D took off her gloves and threw them in the trash can. CNA D then washed her hands. CNA D acknowledged she did not wash her hands before doing incontinent care and did not sanitize her hands when she changed her gloves after cleaning the bottom of the resident. CNA D then pulled a container from her pocket and said she had the sanitizer but forgot to use it. She said it was important to do hand washing before giving care to ensure there was no transfer of any microorganism. She said the same thing was true sanitizing the hands after taking the gloves off.
In an interview with RN A on 05/16/2024 at 7:43 AM, RN A stated the right procedure was to wash hands before and after incontinent care, to do hand hygiene in between changing of gloves, to change the gloves after cleaning the bottom of the resident, and before getting the new brief. She said the purpose of the method was to prevent cross contamination and infection. She said microorganisms could easily transfer from soiled hands and gloves.
In an interview with the ADON on 05/16/2024 at 7:21 AM, the ADON stated staff should wash their hands before and after doing any care. He said gloves should be changed after cleaning the buttocks of the resident and staff should do hand hygiene in between changing of gloves. he said the risk from improper hand hygiene would be infection and cross contamination. The ADON said the expectation was the staff would remember to wash their hands and change their gloves when transitioning from a dirty area to a clean area. He added the staff must also use the sanitizer that were provided to them. The ADON concluded he would do an in-service and would continually remind the staff to be diligent in making sure the procedures for infection control were followed.
In an interview with the DON on 05/16/2024 at 7:35 AM, the DON stated not doing hand hygiene before, during, after incontinent care could result to spreading microorganisms and eventually infection of any kind. She said, herself and the ADON were responsible in ensuring proper hand hygiene were done. The DON said the expectation was the staff would remember to wash their hands, change their gloves when transitioning from a dirty area to a clean area, and do hand hygiene when changing the gloves. She concluded that she would do an in-service about hand hygiene and continually remind the staff of the importance of hand hygiene.
In an interview with Administrator on 05/16/2024 at 8:34 AM, the Administrator stated hand hygiene was important to prevent infection. He said this should be done so the clean items would not be soiled. He said the staff should be cognizant about washing their hands and changing their gloves when needed. The Administrator said they would re-educate the staff regarding hand hygiene and would monitor for three weeks if the in-service was effective and would do another one id needed.
Record review of facility's policy, Hand Hygiene/Hand Washing Infection Prevention and Control Policies and Procedures rev. May 15,2023 revealed Procedures: 1. Hand hygiene/hand washing is done . A. Before patient/resident contact . After contact with soiled or contaminated articles . H. After removal of medical/surgical or utility gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect and exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, which included the State Survey Agency, in accordance with State law through established procedures for one of three residents (Resident #1) reviewed for abuse and neglect.
The facility did not report to the State Survey Agency when Resident #1 reported allegations of abuse within 2 hours.
These failures could place residents at risk for injuries, abuse, and/or neglect.
Findings include:
1. Record review of Resident #1's electronic face sheet, dated 02/09/24, reflected an [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1's diagnosis included cerebral infarction (stroke), Alzheimer's disease (most common type of dementia), anxiety, and cognitive communication deficit.
Record review of Resident #1's Quarterly MDS assessment, dated 11/25/23, reflected a BIMS score of 01, which indicated severe cognitive impairment.
Record review of Resident #1's Care Plan, revised 11/28/23, reflected Resident #1 required hospice services and assistance with his ADLs.
Review of the Hospice occurrence form dated 01/24/24 reflected: ADON at facility communicated with [staff] that [Resident #1] had made an accusation that the aid that morning was rough with her and caused her bruising. It was determined that [hospice 2] had never transferred the patient off their service, despite having being notified of the transfer on 1/18/24. The [staff] that saw [Resident #1] that morning was from [hospice 2]. [Hospice 1] sent out an RN that evening to assess the patient regarding the complaint. Please see her attached clinical note, confirming bruising and patient statement
Review of the Hospice complaint form-reporting page dated 01/15/24 revealed 1720- SN arrived to facility to find pt ambulating halls going in and out of different rooms having to be redirected multiple times. Pt able to show SN to her room. Alert to self. Denies any pain or discomfort. When arrived asked pt how was her day. Pt begin to explain that she been working with other residents as if she is part of the staff. Asked if she had a bath today and she states, No, I don't want no one cleaning my behind. I can clean my own behind. Then pt states, Do you know the lady that came to shower me today? You are not her. SN informed pt that it was not her but asked how did that go. Pt states, Well, she beat me up. I have all the bruises from her trying to force me to let her bathe me and I don't even know why she was doing that because, she was no where near the soap or water when she was grabbing on me. Asked if any of the bruises on her arms hurt, and pt states, Yes, my arms (upper arms pointed) were she grabbed me trying to make me do what she wanted me to do, I guess. This one on my bone is sore too but nothing too bad I can handle it. Pt has multiple bruises to to bilateral upper extremities:
Right out upper arm has bruise: 1.7x0.9cm light red Right medial forearm: 1.7x1.4cm light red color Right posterior wrist: 1.6x 1cm deep purple color
Top of right hand: 1x0.7cm and 0.5x1.5cm 1.7x1.1 cm multiple small purple in color Left upper arm outer upper arm:0.5x1cm light red
Posterior left lower arm: 2x1.2cm deep purple Scattered light red discoloration to posterior left forearm
Left anterior wrist: 5.8x3.7 large green and purple discoloration with noted knot. Top of Left hand: 1.1x1cm light purple discoloration
Pt pleasantly confused but continues to recall the events from the morning of someone trying to make her shower. She ask, You not going to try and make me shower are you because I can do my own shower. SN discussed finding with FN who states she was aware of event from early. No other needs or concerns voiced or noted at this time.
Review of the nursing notes dated 01/24/24 authored by LVN A revealed hospice aid in facility to give resident shower. Resident refused, after a few tries resident started to be upset.
Interview on 02/09/24 at 10:41 AM with Resident #1 revealed she was confused about her location and was not able to answer questions directly due to thinking she was in a church and the surveyor was a church worker. The resident was observed well groomed, no bruises were observed.
Interview on 02/9/24 at 12:45 PM with the ADON revealed she had not received any complaints from residents regarding hospice staff being rough toward any resident nor had she received allegation of any resident having bruises caused by hospice staff. The ADON stated she did not recall if she had contacted hospice on 01/24/24 however if there were concerns of abuse, she would have notified the administrator.
In an interview on 02/09/24 at 1:00 PM with the Hospice field staff and Director of Quality revealed the Hospice field staff received a call from the ADON stating Resident #1 had informed her that the hospice aide was rough with her and had caused bruising to her. The Hospice Field staff stated she did send a nurse to assess the resident following the incident. The Hospice Field staff stated she found out that the hospice worker was not from her agency and no longer had contact with Resident #1.
In a follow up interview on 02/09/24 at 1:15 PM with the ADON revealed she = recalled calling the hospice agency to inform them that Resident #1 wanted a new hospice aide because her current aide was getting her up too late. The ADON stated she did not remember stating anything about bruises or the aide being rough. The ADON stated if there were allegation of the hospice aide being rough, she would have had to report it to her administrator who in turn would have completed a self-report. The ADON stated she did not document her conversation with the hospice field staff.
Interview on 02/09/23 at 1:30 PM with the Administrator and DON revealed they were not aware of the ADON being made aware by Resident #1 of abuse by hospice aide nor were they aware that hospice was contacted. The Administrator stated he spoke with the ADON, and she stated she contacted hospice but did not mention any abuse. The Administrator stated the resident had bruises. However, they were not sure if they were new or not. The Administrator stated an investigation was not complete regarding the incident and a self-report was not complete because he nor the DON were made aware of any allegations of abuse. The Administrator revealed he was the abuse coordinator and would have been responsible for completing the self report
Review of the facility's undated policy LEADERSHIP POLICIES AND PROCEDURES ORGANIZATIONAL ETHICS, abuse, neglect, exploitation or mistreatment reflected: .2.The Facility shall report immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. See Also Reporting Reasonable Suspicion of a Crime Policy.The facility's Leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect or exploitation or mistreatment and will implement immediate action to safeguard resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must have evidence that all alleged violations are thoroughly investigated and prevent further abuse, neglect, exploitation, or mistreatment while the investigation is in process for one of three (Resident #1) residents reviewed for abuse and neglect.
The facility did investigate the allegation of abuse made by Resident #1.
These failures could place residents at risk for injuries, abuse, and/or neglect.
Findings include:
1. Record review of Resident #1's electronic face sheet, dated 02/09/24, reflected an [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1's diagnosis included cerebral infarction (stroke), Alzheimer's disease (most common type of dementia), anxiety, and cognitive communication deficit.
Record review of Resident #1's Quarterly MDS assessment, dated 11/25/23, reflected a BIMS score of 01, which indicated severe cognitive impairment.
Record review of Resident #1's Care Plan, revised 11/28/23, reflected Resident #1 required hospice services and assistance with his ADLs
Review of the Hospice occurrence form dated 01/24/24 reflected: ADON at facility communicated with [staff] that [Resident #1] had made an accusation that the aid that morning was rough with her and caused her bruising. It was determined that [hospice 2] had never transferred the patient off their service, despite having being notified of the transfer on 1/18/24. The [staff] that saw [Resident #1] that morning was from [hospice 2]. [Hospice 1] sent out an RN that evening to assess the patient regarding the complaint. Please see her attached clinical note, confirming bruising and patient statement.
Review of the Hospice complaint form-reporting page dated 1/15/24 reflected: 1720- SN arrived to facility to find pt ambulating halls going in and out of different rooms having to be redirected multiple times. Pt able to show SN to her room. Alert to self. Denies any pain or discomfort. When arrived asked pt how was her day. Pt begin to explain that she been working with other residents as if she is part of the staff. Asked if she had a bath today and she states, No, I don't want no one cleaning my behind. I can clean my own behind. Then pt states, Do you know the lady that came to shower me today? You are not her. SN informed pt that it was not her but asked how did that go. Pt states, Well, she beat me up. I have all the bruises from her trying to force me to let her bathe me and I don't even know why she was doing that because, she was no where near the soap or water when she was grabbing on me. Asked if any of the bruises on her arms hurt, and pt states, Yes, my arms (upper arms pointed) were she grabbed me trying to make me do what she wanted me to do, I guess. This one on my bone is sore too but nothing too bad I can handle it. Pt has multiple bruises to to bilateral upper extremities:
Right out upper arm has bruise: 1.7x0.9cm light red Right medial forearm: 1.7x1.4cm light red color Right posterior wrist: 1.6x 1cm deep purple color
Top of right hand: 1x0.7cm and 0.5x1.5cm 1.7x1.1 cm multiple small purple in color Left upper arm outer upper arm:0.5x1cm light red
Posterior left lower arm: 2x1.2cm deep purple Scattered light red discoloration to posterior left forearm
Left anterior wrist: 5.8x3.7 large green and purple discoloration with noted knot. Top of Left hand: 1.1x1cm light purple discoloration
Pt pleasantly confused but continues to recall the events from the morning of someone trying to make her shower. She ask, You not going to try and make me shower are you because I can do my own shower. SN discussed finding with FN who states she was aware of event from early. No other needs or concerns voiced or noted at this time.
Review of the nursing notes dated 01/24/24 authored by LVN A revealed hospice aid in facility to give resident shower. Resident refused, after a few tries resident started to be upset.
Interview on 02/09/24 at 10:41 AM with Resident #1 revealed she was confused about her location and was not able to answer questions directly due to thinking she was in a church and the surveyor was a church worker. The resident was observed well groomed, no bruises were observed.
Interview on 02/9/24 at 12:45 PM with the ADON revealed she had not received any complaints from residents regarding hospice staff being rough toward any resident nor had she received allegation of any resident having bruises caused by hospice staff. The ADON stated she did not recall if she had contacted hospice on 01/24/24 however if there were concerns of abuse, she would have notified the administrator.
In an interview on 02/09/24 at 1:00 PM with the Hospice field staff and Director of Quality revealed the Hospice field staff received a call from the ADON stating Resident #1 had informed her that the hospice aide was rough with her and had caused bruising to her. The Hospice Field staff stated she did send a nurse to assess the resident following the incident. The Hospice Field staff stated she found out that the hospice worker was not from her agency and no longer had contact with Resident #1.
In a follow-up interview on 02/09/24 at 1:15 PM with the ADON revealed she recalled calling the hospice agency to inform them that Resident #1 wanted a new hospice aide because her current aide was getting her up too late. The ADON stated she did not remember stating anything about bruises or the aide being rough. The ADON stated if there were allegation of the hospice aide being rough, she would have had to report it to her administrator who in turn would have completed a self-report. The ADON stated she did not document her conversation with the hospice field staff.
Interview on 02/09/23 at 1:30 PM with the Administrator and DON revealed they were not aware of the ADON being made aware by Resident #1 of abuse by hospice aide nor were they aware that hospice was contacted. The Administrator stated he spoke with the ADON, and she stated she contacted hospice but did not mention any abuse. The Administrator stated the resident had bruises. However, they were not sure if they were new or not. The Administrator stated an investigation was not complete regarding the incident and a self-report was not complete because he nor the DON were made aware of any allegations of abuse. The Administrator revealed he was the abuse coordinator and would have been responsible for completing the self report.
Review of the facility's undated policy LEADERSHIP POLICIES AND PROCEDURES ORGANIZATIONAL ETHICS, abuse, neglect, exploitation or mistreatment reflected: .2.The Facility shall report immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. See Also Reporting Reasonable Suspicion of a Crime Policy.The facility's Leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect or exploitation or mistreatment and will implement immediate action to safeguard resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #1) of 4 residents reviewed for bladder incontinence.
The facility failed to ensure Resident #1's catheter bag was not on the floor.
This failure could place residents at risk for UTI's and other infections.
Findings included:
Review of Resident #1's electronic face sheet, printed 01/10/24, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Osteomyelitis (serious infection of the bone that can be either acute or chronic), bipolar (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and diabetes type 2.
Review of Resident #1s admission MDS, dated [DATE], reflected she had a BIMS score of 11 indicating the resident had mild cognitive impairment.
Review of Resident #1's care plan, dated 12/08/23, reflected the use of a urinary catheter.
Review of Resident #1s Consolidated Order dated 12/11/23 reflected foley catheter care every shift.
In an observation and interview on 01/10/24 at 11:45 AM with Resident #1 revealed she was lying in her bed with the catheter bag hanging on the floor beside her bed. Resident #1 denied that she was in any pain and stated she was not aware of the catheter bag sitting on the floor.
Interview on 01/10/24 at 1:35 PM with LVN #A revealed foley catheter bag should not be on the floor and the bag should have a cover. She stated the nurses should be making sure the bags were not on the floor and are covered. She stated the bags were checked every hour or every two hours.
Interview on 01/10/23 at 2:15PM with the ADON revealed foley catheter bags should be positioned below the bladder and firmly attached to the bed. The ADON stated the catheter bag should not have been on the floor and the nurses were responsible for ensuring catheter bags were firmly secured. The ADON stated the risk of the catheter bags being on the floor would be the possible infection to the resident. The ADON stated the catheter bags should have been emptied every shift and checked by aides when they were completing rounds. The ADON stated facility followed [NAME] nursing procedures regarding Foley care and did not have a separate policy
Review of Lippincott Nursing Procedures, undated section titled Indwelling urinary catheter care and removal revealed, Don't place drainage on floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity for two (Resident #1 and Resident #2) of 6 residents reviewed for dignity.
The facility failed to ensure Resident # 1'surinary catheter drainage bag had a dignity/privacy cover.
The facility failed to maintain resident dignity by labeling Resident #2's door as COVID.
These failures placed residents at risk of not having their right to a dignified existence maintained and a decline in their quality of life.
The findings include:
Review of Resident #1's electronic face sheet, printed 01/10/24, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Osteomyelitis (serious infection of the bone that can be either acute or chronic), bipolar (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and diabetes type 2.
Review of Resident #1s admission MDS, dated [DATE], reflected she had a BIMS score of 11 indicating the resident had mild cognitive impairment.
Review of Resident #1's care plan, dated 12/08/23, reflected the use of a urinary catheter however did not address use of privacy bag.
Review of Resident #1s Consolidated Order dated 12/11/23 reflected foley catheter care every shift.
Review of Resident #2's electronic face sheet printed 01/10/24 revealed she was a [AGE] year-old- female admitted to the facility on [DATE] with diagnosis that included metabolic encephalopathy (brain problem caused by chemical imbalance of blood), major depressive disorder (persistent feeling of sadness)
Review of Resident #2's care plan revised 01/03/24 revealed Resident #2 was at risk psychosocial wellbeing.
Review of Resident #2's admission MDS completed 12/27/23 revealed a BIMS score of 15 which indicate the resident was not cognitively impaired.
Review of the nursing note dated 01/10/24 authored by LVN #B revealed Resident #2 tested positive for covid on 1/6/24.
Observation on 01/10/24 at 11:00AM of a handwritten note on Resident #2's door that stated covid please mask and gown.
In an observation and interview on 01/10/24 at 11:45 AM with Resident #1 revealed she was lying in her bed with the catheter bag hanging on the floor beside her bed toward her roommate. Resident #1 denied that she was in any pain and stated she was not aware of the catheter bag sitting on the floor.
Resident #2 was not able to be interviewed due to being on isolation precautions.
Interview on 01/10/23 at 2:15PM with the ADON revealed foley catheter bags should be positioned below the bladder and firmly attached to the bed and should have been covered with a privacy bag. The ADON stated the facility followed [NAME] nursing procedures regarding Foley care and did not have a separate policy. The ADON stated the resident's door should not indicate the reason for isolation and that would be a violation of resident rights. The ADON stated she was not sure who put the sign up on the Resident#2's door stating it could have been family, but she would have it removed.
Review of the facility policy Resident rights revised 11/01/17 revealed The Facility staff will promote a quality of life for patients/residents that support independent expression, choice, and decision-making, consistent with applicable law and regulation. The Facility staff will provide the patient/resident with considerate care that respects his/her personal values, beliefs, cultural and spiritual preferences, and life-long patterns of living.
The Facility staff will allow and promote the right of personal freedom and dignity for the patient/resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards of practice to promote the prevention of pressure ulcer/injury development; promote the healing of existing pressure ulcers/injuries (including prevention of infection to the extent possible); and prevent development of additional pressure ulcer/injury for one (Resident #1) of four residents reviewed for wounds.
1.
The facility failed to perform weekly skin assessments for Resident #1. The facility failed to identify early signs of skin breakdown and implement interventions to prevent the re-opening of a Stage 3 Sacral pressure ulcer (PU) {Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and rolled wound edges are often present}. The wound deteriorated into a Stage 4 PU {Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer}.
2.
Resident #1 did not receive scheduled daily wound care on 04/07/23, 04/10/23, 04/23/23, 04/29/23, 05/07/23, 05/11/23, 05/13/23, & 05/14/23.
3.
The facility failed to offer relevant alternatives when Resident #1 declined the specific intervention to remain in bed throughout the day to offload pressure from Stage 3 Sacral PU. Staff did not assist with repositioning to relieve pressure when Resident #1 sat up in wheelchair for more than 4 hours at a time during the day.
4.
The facility failed to provide appropriate pressure-relieving device(s), LAL mattress, identified in Resident #1's care plan on 10/13/22 until 04/17/23.
5.
The facility failed to provide treatment and services to heal and to prevent infection to Resident #1's sacral PU. Resident #1's sacral wound developed an MRSA infection (a staph (group of bacteria) infection that is difficult to treat because of resistance to some antibiotics) that required IV antibiotic therapy. The resident was admitted to the hospital on [DATE] after RP request.
On 05/19/23 at 5:17 PM an Immediate Jeopardy (IJ) was identified. The IJ template was provided to the NFA. While the IJ was removed on 05/22/23, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.
These failures could place residents with wounds at an increased and unnecessary risk of complications such as pain, acquiring new wounds, worsening of existing wounds, and infection.
Findings included:
Record review of Resident #1's MDS quarterly review assessment dated [DATE] revealed a [AGE] year-old female admitted on [DATE]. Resident #1 had medically complex conditions that included HF (when the heart cannot pump enough blood and oxygen to support other organs in your body); DM (chronic condition that affects the way the body processes blood sugar (glucose), the body either doesn't produce enough insulin, or it resists insulin); Non-Alzheimer's Dementia (a decline in mental ability severe enough to interfere with daily life - Alzheimer's is a specific disease); Depression; and stiffness of right hand. Resident #1's BIMS score was 11, which suggested moderately impaired cognition. Resident #1 had no behavioral symptoms or exhibited rejection of care behavior during the MDS review period. Resident #1's functional status reflected one-person limited assistance with eating and required one-person extensive assistance for dressing, toilet use and personal hygiene. Resident #1 was always incontinent of bladder and always continent of bowel. The MDS Quarterly review indicated Resident #1 was at risk of pressure ulcer/injury (PU/PI). Resident #1 did not have one or more unhealed PU/PI, venous or arterial ulcers. Skin and Ulcer/Injury treatments included Q2 turn and reposition.
A record review of Resident #1's MDS Annual assessment dated [DATE] revealed the following:
Section M Skin Conditions. Unhealed PU/PI:
The MDS Annual assessment reflected one Stage 3 and one Stage 4 unhealed pressure ulcers/injuries.
Skin and Ulcer/Injury treatments included in the MDS Annual assessment: Pressure reducing device for bed, turning/repositioning program, PU/PI care, and applications of ointments/medications.
A review of Resident #1's comprehensive care plan, last care conference dated 05/10/23, indicated:
Category: Indwelling Catheter [Start: 04/28/23]
Problem: Resident requires an indwelling urinary catheter r/t wound Stage 3 and 4 [Edit: 05/04/23]
Goal: Resident will have catheter care managed appropriately AEB not exhibiting signs of infection or urethral trauma through the next review date. [Target: 08/04/23; Edit: 05/04/23]
Approach: [Start: 04/28/23]
-Assess drainage. Record the amount, type, color, odor. Observe for leakage
-Change catheter per MD order
-Provide assistance for catheter care
-Provide catheter care as scheduled and as needed
-Report s/sx of UTI
Category: Baseline Care Plan [Start: 04/28/23]
Problem: Resident is prescribed Antibiotic therapy [Edit: 05/04/23]
Goal: Resident will take antibiotic as ordered without serious complications through the next review date. [Target: 08/04/23; Edit: 05/04/23]
Approach: [Start: 04/28/23]
-Administer antibiotic as order. Evaluate/record effectiveness. Evaluate/report adverse side effects.
-Monitor lab work: as order. Notify MD of results.
Category: Baseline Care Plan [Start: 03/28/23]
Problem: Resident non-compliant laying bed for release pressure to bottom, likes stay up in w/c all day [Edit: 05/04/23]
Goal: Resident will be compliant to laying bed for release pressure to bottom through the next review date. [Target: 08/04/23; Edit: 05/04/23]
Approach: [Start: 03/28/23]
-Assist resident transfer bed after meals
-Explain procedure, encourage resident laying bed after meals for release pressure to bottom
-Maintain a calm environment and approach to the resident
-Observe resident right
Category: Continence Status (Bowel/Bladder) [Start: 10/03/21]
Problem: [Resident #1] experiences bladder incontinence r/t impaired mobility, weakness. [Edit: 05/04/23]
Goal: Will have a decrease in incontinence episodes through review date [Target: 08/04/23; Edit: 05/04/23]
Approach: [Start: 10/03/21]
-Adapt environment to maximize independence (e.g., path free of obstacles, grab bars, elevated toilet seat, bedside commode, etc.)
-Ensure adequate bowel elimination
-Keep call light in reach
-Obtain therapy consult as needed
-Provide incontinence care after each incontinent episode
-Report s/sx of UTI
Category: Pressure Ulcer/Injury [Start: 07/19/2022]
Problem: Resident has a pressure ulcer stage 4 to sacrum AND Stage 3 left heel. [Edit: 05/04/23]
Goal: Resident will respond to ulcer treatment AEB improved wound healing with less pain and drainage or positive lab results. [Target: 08/09/22; Created: 07/19/22]
Approach: [Start: 07/19/22]
-Reposition while in bed [Start: 05/04/23]
-Sugar free liquid protein supplement for promoting wound healing [Start: 03/23/23]
-LAL mattress as needed [Start 10/13/2022]
-Assess condition of surrounding skin. Report emergence of skin excoriation (repetitive picking of skin that leads to skin lesions)
-Keep resident and RP aware of wound healing progress and any MD order changes
-Observe and report signs of localized infection
-Record the amount, type, and odor of drainage from the wound
-Record the color, consistency, and location of exudate (fluid that leaks out of blood vessels into nearby tissues)
-Use aseptic (to maintain sterility and free of contamination) techniques when performing dressing changes
Review of Resident #1's physician orders indicated:
-
Start Date 09/21/21: Weekly Skin Check by Licensed Nurse. Once A Day on Tuesday. 2 PM - 10 PM.
-
Start Date 08/08/22: Reposition Q2H. Every 2 hours. {Times entered from midnight, 2:00 AM, 4:00 AM, 6:00 AM . to 10:00 PM every two hours on TAR} [D/C Date: 01/19/23]
-
Start Date 01/17/23: Boots on at night. At bedtime. 7:00 PM [D/C Date 04/19/23]
-
Start Date 01/19/23: Reposition Q2 hours. Every Shift. First, Second, Third.
-
Start Date 03/28/23: Other Test: UA with C&S (Urinalysis with Culture and Sensitivity)
-
Start Date 03/31/23: Daily Wound Treatment: Stage 3 Pressure wound to the Sacrum. Cleanse wound and apply calcium alginate and dry dressing. Once A Day. [D/C Date: 04/06/23]
-
Start Date 04/02/23: Daily Wound Treatment: Unstageable DTI of the left heel. Apply skin prep daily. Once a Day. [D/C Date 04/27/23]
-
Start Date 04/03/23: Other Test: Arterial doppler study LLE. Once between the 3rd - 5th of the Month. [D/C Date: 04/26/23]
-
Start Date 04/06/23: Indwelling FC 16 Fr/10 mL d/t sacral wound. Continuous Second, Third.
-
Start Date 04/06/23: Daily Wound Treatment: Stage 3 Pressure wound to the Sacrum. Cleanse wound and apply silver alginate and dry dressing. Once A Day. [D/C Date 04/14/23]
-
Start Date 04/14/23: Daily Wound Treatment: Stage 3 Pressure wound to the Sacrum. Cleanse wound and apply Calcium Alginate, Santyl and cover with dry dressing. Once A Day. [D/C Date 04/27/23]
-
Start Date 04/19/23: Boots on while in bed. At bedtime 7:00 PM
-
Start Date 04/19/23: Air Loss Mattress. Every Shift. First, Second, Third.
-
Start Date 04/26/23: Other Test: CBC with differential (measures the number of each type of these white blood cells), CMP (a test that measures chemical balance and metabolism in the blood), TSH (blood test that measures the thyroid stimulating hormone), A1C (a blood test that measures average blood sugar levels over the past 3 months), and prealbumin level (a protein that is made mainly by the liver).
-
Start Date 04/27/23: Daily Wound Treatment: Stage 4 Pressure wound to the Sacrum. Cleanse wound and apply Calcium Alginate with Silver, Metronidazole, and cover with dry dressing. Once A Day and PRN.
-
Start Date 04/27/23: Daily Wound Treatment: Stage 3 Pressure wound to the left heel. Cleanse wound, apply Xeroform and dry dressing. Once A Day. [D/C Date: 05/04/23]
-
Start Date 05/01/23: doxycycline Hyclate 100 mg capsule, 1 capsule, oral, twice a day [End Date: 05/06/23]
-
Start Date 05/11/23: Midline Catheter Intermittent Use: Flush 10 ML NS before and after medication administration. Every Shift. First, Second, Third.
-
Start Date 05/11/23: Zosyn in dextrose piggyback; 3.375 gram/50 mL Intravenous. Every 8 hours. [D/C Date: 05/11/23]
-
Start Date 05/12/23: doxycycline Hyclate 100 mg capsule, 1 capsule, oral, twice a day [End Date: 05/26/23]
-
Start Date 05/12/23: Ertapenem Solution, Reconstituted (Recon Soln), 1 gram, intravenous once a day [D/C Date 05/12/23]
-
Start Date 05/15/23: May send to hospital for evaluation of Stage 4 sacral wound per family request. Once A Day. 06:00 (6 AM) - 14:00 (2 PM) [End Date: 05/15/23]
Review of Resident #1's April 2023 TAR reflected blank spaces in the columns that represented the day(s)/date(s) in April and treatment time, 6 AM - 2 PM. There were no nurse initials or a chart code with reason/comment that the treatment was or was not provided for the following order(s):
-
Friday 7th and Monday 10th: Daily Wound Treatment: Stage 3 Pressure wound to the Sacrum. Cleanse wound and apply silver alginate and dry dressing. Special Instructions to identify drainage, general appearance, and surrounding skin
-
Sunday 23rd: Daily Wound Treatment: Stage 3 Pressure wound to the Sacrum. Cleanse wound and apply Calcium Alginate, Santyl and cover with dry dressing
-
Friday 7th, Monday 10th, and Sunday 23rd: Daily Wound Treatment: Unstageable DTI of the left heel. Apply skin prep daily
-
Saturday 29th: Daily Wound Treatment: Stage 4 Pressure wound to the Sacrum. Cleanse wound and apply Calcium Alginate with Silver, Metronidazole, and cover with dry dressing
-
Saturday 29th: Daily Wound Treatment: Stage 3 Pressure wound to the left heel. Cleanse wound, apply Xeroform and dry dressing was blank, did not reflect the initials of a person providing treatment, under the column, that represented the day/date in April.
Review of Resident #1's May 2023 TAR reflected blank spaces in the columns that represented the day(s)/date(s) in May and treatment time, 6 AM - 2 PM. There were no nurse initials or a chart code with reason/comment that the treatment was or was not provided for the following order(s):
-
Friday 7th, Thursday 11th, Saturday 13th, and Sunday 14th: Daily Wound Treatment: Stage 4 Pressure wound to the Sacrum. Cleanse wound and apply Calcium Alginate with Silver, Metronidazole, and cover with dry dressing
Review of Resident #1's April 2023 TAR reflected initials in the columns that represented the day(s)/date(s) in April and scheduled time, 2 PM - 10 PM, Weekly Skin Check by Licensed Nurse. Once A Day on Tuesday. [Start 09/21/21 - Open Ended] was performed as ordered. The nurse must also complete a Focused Observation Weekly Skin Assessment to include HTT skin assessment, new or existing skin issues, interventions if applicable, if WCN, PCP, RP were notified, and document in the EMR (Electronic Medical Record). The April weekly skin assessments revealed:
-
04/04/23: LVN A initialed the TAR. A Focused Observation Weekly Skin Assessment was not completed.
-
04/11/23: LVN A initialed the TAR. A Focused Observation Weekly Skin Assessment was not completed.
-
04/18/23: LVN A initialed the TAR. A Focused Observation Weekly Skin Assessment was not completed.
-
04/25/23: LVN A initialed the TAR. LVN A completed a Focused Observation Comprehensive Assessment. LVN A answered No to the question Alterations in skin?
Review of Resident #1's May 2023 TAR reflected initials in the columns that represented the day(s)/date(s) in May and scheduled time, 2 PM - 10 PM, Weekly Skin Check by Licensed Nurse. Once A Day on Tuesday. [Start 09/21/21 - Open Ended] was performed as ordered. The nurse must also complete a Focused Observation Weekly Skin Assessment to include HTT skin assessment, new or existing skin issues, interventions if applicable, if WCN, PCP, RP were notified, and document in the EMR. The weekly skin assessments revealed:
-
05/02/23: LVN A initialed the TAR. A Focused Observation Weekly Skin Assessment was not completed. LVN A completed a Daily Skilled Focused Observation Comprehensive Assessment on 05/03/23. LVN A answered No to the question Alterations in skin? in the skin section
-
05/09/23: LVN A initialed the TAR. A Focused Observation Weekly Skin Assessment was not completed.
Resident #1 transferred to the hospital on [DATE] per RP request.
Review of ADL documentation/flow sheets, the POC (Point of Care) responses in PCC indicated Resident #1 had moisture associated skin damage:
-
On 03/12/23, charted by CNA C
-
On 3/14/23, charted by CNA C
-
On 3/15/23, charted by CNA C
Review of a nurse progress note dated 03/16/23 entered by the WCN, stated Resident #1 was seen by the WMD for assessment and evaluation of a reopened stage 3 pressure wound to the sacrum. The nurse also documented Resident #1 was advised to stay up less sitting on the wheelchair, to allow wound to heal.
A review of the WMD Wound Evaluation and Management Summary dated 03/16/23 reflected, At the request of the referring provider, [PCP], a thorough wound care assessment and evaluation was performed. [Resident #1] has a stage 3 pressure wound, sacrum, for at least 1 day duration. There is light serous exudate. The wound measured (L x W x D): 0.7 x 0.6 x 0.2 cm. Additional wound detail indicated reopened stage 3 pressure wound. Recommendations: Off-load wound; reposition per facility protocol.
A review of the WMD Wound Evaluation and Management Summary dated 03/30/23 reflected, the stage 3 sacrum pressure wound measured (L x W x D): 1.2 x 0.7 x 0.2 cm. There was moderate serous exudate. The stage 3 pressure wound sacrum improved evidenced by decreased surface area. Additionally, the WMD documentation revealed an Unstageable DTI (Deep Tissue Injury) of the left heel, a blood-filled blister, >1 day. The wound measured (L x W x D) 6.5 x 7.5 x Not Measurable cm. There was no exudate. Recommendations: Off-load wound; Reposition per facility protocol; Float heels in bed; Pressure off-loading boot. The WMD recommended a lower extremity arterial doppler (an ultrasound exam of the arteries in the legs that can help evaluate whether there are blockages) on 03/30/23.
A review of the WMD Wound Evaluation and Management Summary dated 04/06/23 reflected, the stage 3 sacrum pressure wound increased in size (L x W x D): 2.2 x 1.7 x 0.2 cm. There was moderate serous exudate. The stage 3 pressure wound sacrum deteriorated. The WMD documentation indicated no change in the Unstageable DTI (Deep Tissue Injury) of the left heel.
A review of the April 24-hour reports for Resident #1, dated 04/06/23, 04/11/23, and 04/14/23 in the Day Shift (6A - 2P) column entered by LVN B revealed communication between the health care team and provided information about multiple requests for LAL mattress and heel boots for off-loading wound(s) to sacrum and left heel.
A review of the WMD Wound Evaluation and Management Summary dated 04/13/23 reflected, the stage 3 sacrum pressure wound increased in size (L x W x D): 4 x 2.5 x 0.2 cm. There was moderate serous exudate, 20% slough, and 80% granulation. A surgical excisional debridement procedure performed to remove necrotic tissue and establish the margins of viable tissue. The WMD indicated a generalized decline of Resident #1. The documentation indicated the Unstageable DTI of the left heel deteriorated. The wound measured (L x W x D): 10 x 9 x Not Measurable cm. Additional details reflected the WMD suggested [Resident #1] to see a vascular physician.
A review of the WMD Wound Evaluation and Management Summary dated 04/27/23 reflected, the stage 3 sacrum pressure wound deteriorated into a stage 4 pressure wound. The wound measured (L x W x D): 5 x 4 x 2 cm. There was moderate serous exudate, undermining (when significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface) 2 cm at 9 o'clock, 50% necrotic tissue, and 20% granulation tissue. Other viable tissue: 30% (muscle, fascia). A surgical excisional debridement procedure performed to remove necrotic tissue and establish the margins of viable tissue. The WMD documentation indicated the Unstageable DTI of the left heel deteriorated into a stage 3 pressure wound. The wound measured (L x W x D): 2 x 1 x 0.3 with improvement. The WMD recommended a WBC lab draw - the WBC collected on 04/27/23 resulted 30.7 CRITICAL HIGH [Range: 3.8 - 10.1]. The WMD Wound Evaluation and Management Summary dated 04/27/23 stated the WMD performed a wound culture on stage 4 pressure wound, sacrum. The WMD discussed the size increase and deterioration of the sacral wound and heel wound improvement with the RP via phone. The WMD put off consulting a vascular physician and recommended focus on the sacral wound. The WMD started oral antibiotic therapy.
A review of the WMD Wound Evaluation and Management Summary dated 05/04/23 reflected, the stage 4 sacrum pressure wound measured (L x W x D): 5 x 5 x 2.5 cm. There was moderate serous exudate, undermining 6 cm at 9 o'clock, 20% necrotic tissue, and 50% granulation tissue. Other viable tissue: 30% (muscle, fascia). Additional wound detail indicated the sacral wound had less necrotic tissue and WBC trended down. (The WBC collected on 04/28/23 resulted 23.9 CRITICAL HIGH; and on 05/04/23 resulted 12.0 HIGH). A surgical excisional debridement procedure performed to remove necrotic tissue and establish the margins of viable tissue. The WMD documentation indicated the stage 3 pressure wound of the left heel was resolved.
A review of the WMD Wound Evaluation and Management Summary dated 05/11/23 indicated, the stage 4 sacrum pressure wound measured (L x W x D): 6 x 5 x 3 cm. There was moderate serous exudate, undermining 6 cm at 9 o'clock, 10% slough, and 60% granulation tissue. Other viable tissue: 30% (muscle, fascia). Wound progress indicated improvement. A surgical excisional debridement procedure performed to remove necrotic tissue and establish the margins of viable tissue.
Review of Resident #1's wound culture of the stage 4 pressure wound sacrum results presented E. coli (Escherichia coli) and Proteus microorganisms (resistant bacteria methicillin-resistant Staphylococcus aureus) on 05/11/23.
Review of a nurse progress note dated 05/10/23 entered by LVN A, stated she was informed by NP of wound to [Resident #1] right 3rd/4th toe. LVN A documented that she cleaned wound with normal saline and patted dry.
An interview and observation on 05/18/23 at 9:12 AM at the hospital revealed Resident #1 in an upright position, the HOB elevated between 60 - 90 degrees, bi-lateral offloading boots. Hips offloaded with wedges. Resident #1 appeared groomed and in a clean gown; single lumen midline catheter to right arm. FC draining yellow urine by gravity to drainage bag. NPWT unit (Wound vac) noted at bedside, continuous suction set at 125 mm/hg to sacrum pressure wound site, foam bridged to left hip. Scant dark red drainage noted in tubing and approximately 150 cc dark red solidified drainage in the wound vac canister. Resident #1 was awake, alert and oriented to self and surroundings. Flat affect congruent with mood. Resident #1 spoke in a soft, low-pitched tone and at a slow pace. During the interview, Resident #1 acknowledged understanding of the RN Investigator presence and purpose of visit. Resident #1 denied staff behavior/interaction, infection control, Abuse/Neglect, or quality of care or ADL concerns. Some responses indicated understanding of questions but was unable to describe specific instances about accommodation of needs and care provided at the SNF.
A review of the ED to Hospital admission provider note dated 05/15/23 showed Resident #1 presented to the ED from SNF via EMS c/o wound check. Per EMS, [Resident #1] had a large sacral wound that recently cultured and grew MRSA. [Resident #1] was placed on doxycycline 100 mg BID on 05/12/23. Admit diagnosis: Decubitus ulcer of back.
A review of in-patient admission hospital medical records dated 05/15/23 through 05/18/23 indicated Resident #1 had wound healing issues of a non-healing stage 4 sacral ulcer despite antibiotics and wound care. A CT (Computed Tomography - a diagnostic imaging test) of Pelvis with Contrast resulted a large sacral decubitus ulcer measured 10.6 x 5 x 3.8 cm extended directly next to the sacrum and coccyx. Assessment and plan revealed IV antibiotic therapy, resident is not a surgical candidate, no benefit from extended IV course, and recommended palliative care consult.
A review of in-patient admission hospital medical records dated 05/15/23 revealed skin assessments and wound images:
-
Sacrum pressure wound, 6.5 x 3.5 x 1.4 cm, small serous drainage, no odor
-
Right lateral third toe abrasion, scant serous drainage, no odor. From what appeared to possibly be from 4th toenail
-
Left lateral fifth metatarsal head with appearance of maroon/purple intact skin consistent with DTPI
-
Left medial first metatarsal head with appearance of maroon/purple intact skin consistent with DTPI
-
Left medial knee intact blister - unclear cause
-
Heels with evidence of old healed wounds, no skin currently open and no appearance of wounds on heels
During an interview on 05/17/23 at 10:57 AM, the WCN stated responsibilities were daily wound care, Monday - Friday (the nurses provided wound care on Saturday and Sunday), review shower sheets and followed up on any noted skin issues; followed up labs and notified the MD of lab results. The WCN said that the nurses completed weekly skin assessments, documented in the EMR and informed [WCN] of any new skin issues or changes. The WCN said that she audited new admission charts to ensure HTT skin assessment was done, weekly, and quarterly. The WCN said that she would complete a HTT assessment if notified by the admitting nurse of any identified skin issues to confirm the findings and documented in the EMR. The WCN stated recalled Resident #1 had a stage 3 PU to the sacrum that reopened. The WCN said that the CNAs look at the skin during baths/showers for skin issues. The WCN stated she stays informed of the treatment and care needs of residents with wounds because she must be notified by nurses of any new skin issues, and she rounds with the WMD every Thursday morning. The WCN said that she was informed one morning that Resident #1 had an open area to her lower back. The WCN stated the WMD was notified assessed, evaluated, and treated the pressure wound area. The WCN said that the WMD recommended Q2 turn and reposition, LAL mattress, and heel boots when a DTI on the left heel was discovered. The WCN stated blood labs were drawn that resulted a high WBC count, the WMD was notified, and Resident #1 was started on an oral antibiotic for 10 days. The WCN said that a culture was done of the sacral wound that resulted with MRSA. The WCN stated the RP inquired about IV antibiotic therapy, the WCN contacted the PCP and received a new order for a midline insertion and start IV Zosyn. The WCN said that the pharmacy informed Resident #1 had an allergy to active ingredients in Zosyn and would call back with an alternate antibiotic. The WCN stated a new order received from the NP the next day to start Ertapenem (Brand name: Invanz, an antibiotic that treats serious bacterial infections) IV (Intravenously) but the pharmacy notified [Resident #1] is also allergic to that medicine.
During an interview on 05/17/23 at 2:39 PM, CNA C indicated he was familiar with Resident #1. CNA C stated Resident #1 liked to sit up in wheelchair for activities and for meals in the dining room. CNA C said that Resident #1 was a two-person assist with a mechanical lift. CNA C said that he would transfer Resident #1 to bed to provide incontinence care after meals and assist Resident #1 back to wheelchair. CNA C stated he first noticed redness, like a rash, and a small open area on Resident #1's lower back, the tailbone area when provided a shower. CNA C said he notified the nurse and documented in the POC. CNA C stated that he did not apply barrier cream because of the open area. CNA C said he provided care to Resident #1 in the past and recalled the open area had healed before. CNA C stated that the nurses provided wound care but did not know what treatment was done to the wound. CNA C said that Resident #1 did not like to lay in the bed, but the nurses said that [Resident #1] should stay in bed all day to keep pressure off the wound. CNA C said that he was unaware of interventions to reposition or offload pressure when a resident was up to the wheelchair.
During an interview on 05/18/23 at 2:21 PM, the ADON stated her responsibility was to oversee staff and follow up on dietary recommendation, attend clinical meetings and review documentation for Medicare part A/managed care residents. The ADON said that she is responsible for Angel Rounds to ensure safety and address resident concerns not necessarily done daily but she performed observations throughout the day. The ADON stated that she attended morning meetings when the 24-hour reports are reviewed and residents' needs are discussed to determine interventions needed to be implemented. The ADON said that she was familiar with Resident #1 that she was able to make her wants and needs known. The ADON said that she spoke with the RP that [Resident #1] was hospice appropriate, the wound culture results, allergies to ordered IV medications, and that Resident #1 was getting older. The ADON said she explained to the RP that the disease process with aging was the reason Resident #1 is unable to metabolize food, wound takes longer to heal, but refused to stay in bed throughout the day to allow staff to turn and reposition every two hours. The ADON stated that Resident #1 did not want to stay in bed because it prevented her from playing BINGO, eat in the dining room and socialize. The ADON said that it was necessary for Resident #1 to stay in bed to relieve pressure on the sacrum wound and [Resident #1] had the right to choose when wanted to get in/out of bed and the staff are required to honor resident rights. The ADON replied when asked about pressure relieving devices and offloading when resident is up to wheelchair that the resident was too weak to reposition in the wheelchair. The ADON said that the staff that ordered central supplies was responsible for ordering the LAL mattresses for Resident #1 as indicated on care plan. The ADON stated that Resident #1 had a LAL mattress before, but it was returned when the wound healed.
During an interview on 05/18/2023 at 4:08 PM, CNA D said he worked with Resident #1. CNA D stated Resident #1 required two-persons assist with ADLs, mechanical lift for transfers, and he provided bed baths T/Th/S on the 2P - 10P shift. CNA D said that he reviewed the POC to determine the resident's level of functioning and care needs. CNA D said Resident #1 was up to the wheelchair when he came on shift and would transfer to bed after dinner. CNA D said that he noticed a very small area on Resident #1's back side where a wound had healed reopened during a bed bath and now its really big. CNA D stated he documented the open area on the shower sheet and notified the nurse.
During an interview on 05/18/2023 at 4:32 PM, LVN A stated that she was the primary nurse for Resident #1, Monday - Friday on the 2P - 10P shift. LVN A said that she did the HTT skin assessments on Tuesdays. LVN A stated that she answered no

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care was provided with such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 2 residents (Resident #25 and Resident #34) reviewed for respiratory care.
The facility failed to ensure Resident #25 and Resident #34 oxygen concentrators and oxygen concentrator filters remained free of sediment and debris.
These failures could place residents at risk of not receiving proper delivery of oxygen, cross contamination, respiratory compromise and/or infection and residents not having their respiratory needs met.
Findings Included:
1. Review of Resident #25's Face Sheet, dated 03/28/23, revealed she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included dementia (loss of memory, language, or problem-solving skills) and chronic obstructive pulmonary disease (disease of the lung which may lead to respiratory failure.)
Review of Resident #25's Quarterly MDS, dated [DATE] stated she was unable to complete the BIMS assessment, but she was marked as having both long and short-term memory problems. Additionally, she was severely impaired with the ability to make decisions for daily life tasks. She required extensive assistance of two staff with bed mobility and toileting, and extensive assistance of one staff with personal hygiene.
Record review of Resident #25's physician orders revealed the following:
O2 at 2-4 liters per minute via nasal cannula or mask, every shift with a start date of 08/27/2021.
Equipment Oxygen: Change O2 tubing/nasal cannula/mask/humidification system weekly, every 1 week(s) on Sunday, with a start date of 08/27/2021.
Record review of Resident #25's Comprehensive Care Plan, dated 01/26/2023 revealed Resident #25 .requires oxygen therapy r/t disease process, with a goal to not exhibit signs of hypoxia (cyanosis, tachypnea, dyspnea, confusion, restlessness, nasal flaring, elevated blood pressure, increased respirations, increased pulse) for the next 90 days.
During observation and an attempted interview on 03/28/2023 at 11:28am Resident #25 was resting in her bed with her oxygen concentrator turned on and the end of the nasal cannula positioned appropriately in her nares. The oxygen concentrator machine was observed to be dirty, with multiple brown, yellow, and white stains in a linear drip-like pattern with several droplets at the base. The filter located on the back of the machine had a thick layer of dust, sediment, and debris present. Resident #25 was non-verbal and not able to articulate any information about her oxygen concentrator.
During observation and an attempted interview on 03/29/2023 at 9:53am, Resident #25 was resting in her bed with her oxygen concentrator turned on and the end of the nasal cannula positioned appropriately in her nares. The oxygen concentrator was observed to be dirty, with multiple brown, yellow, and white stains in a linear drip-like pattern with several droplets at the base. The filter located on the back of the machine had a thick layer of dust, sediment, and debris present. Resident #25 was non-verbal and not able to articulate any information about her oxygen concentrator.
During observation and interview with Resident #25's nurse, LVN A, on 03/29/2023 at 9:53am she stated Resident #25 was non-verbal and at her cognitive baseline at this time. LVN A then observed Resident #25's oxygen concentrator and stated the front was dirty, but stated it arrived at the resident's room in that condition. She inspected the back of the concentrator and stated the filter was dirty as well. She was observed removing large clumps of dust, debris, and sediment off the filter. She stated it was respiratory therapy's responsibility to ensure the concentrator was maintained, and that they would come around once in a while to evaluate the residents. She stated it was the weekend night shift nurses to replace the tubing and humidification routinely and the shift nurses to change that equipment as needed. She stated she had not been educated or instructed to clean the oxygen concentrator and ensure the filter was clean. She stated the oxygen concentrator and filter being dirty would be an infection control risk.
2. Review of Resident #34's Face Sheet, dated 03/29/23, revealed she was an [AGE] year-old female admitted on [DATE]. Relevant diagnosis was chronic obstructive pulmonary disease (disease of the lung which may lead to respiratory failure).
Review of Resident #34's Quarterly MDS, dated [DATE] stated she was moderately cognitively impaired with a BIMS score of 11. She required extensive assistance of one staff with bed mobility, toileting, and personal hygiene.
Record review of Resident #34's physician orders revealed the following:
O2 at 2-4 liters per minute via nasal cannula or mask, every 8 hours PRN with a start date of 08/27/2021.
Equipment Oxygen: Change O2 tubing/nasal cannula/mask/humidification system weekly, once a day on Sunday, with a start date of 08/27/2021.
Record review of Resident #34's Comprehensive Care Plan, dated 03/30/2023 revealed Resident #34 had a problem that Resident requires oxygen therapy r/t COPD disease process, with a goal to not exhibit signs of hypoxia (cyanosis, tachypnea, dyspnea, confusion, restlessness, nasal flaring, elevated blood pressure, increased respirations, increased pulse) for the next 90 days.
During observation on 03/28/2023 at 11:14am Resident #34 was resting in her recliner with her oxygen concentrator turned on and the end of the nasal cannula positioned appropriately in her nares. The oxygen concentrator machine was observed to be dirty with multiple brown and yellow textured stains in a linear drip-like pattern with accumulation of sediment at the base. The filters located on each side of the machine had a thick layer of dust, sediment, and debris present.
During observation on 03/29/2023 at 11:12am Resident #34 was resting in her recliner with her oxygen concentrator turned on and the end of the nasal cannula positioned appropriately in her nares. The oxygen concentrator machine was observed to be dirty with multiple brown and yellow textured stains in a linear drip-like pattern with accumulation of sediment at the base. The right filter located the side of the machine still the had a thick layer of dust, sediment, and debris present.
During interview with Resident #34's nurse, LVN B, on 03/29/2023 at 12:57pm he stated the oxygen concentrator, and the filters were dirty. He stated nurses responsible for ensuring resident oxygen concentrators were clean. He stated the filters were cleaned every Saturday by the nurses. He stated if the concentrator filters were dirty, it could restrict airflow circulation of the machine. He stated this would not cause harm to the resident.
During interview on 03/30/2023 at 10:14am the ADON stated she expected the nurses to ensure oxygen concentrators were maintained and clean. She stated that if oxygen concentrators were dirty, it would be an infection control issue and would look bad to the families. She stated if oxygen concentrator filters were dirty, it could cause the concentrator to quit working properly, as well as be an infection control risk. She stated currently no one in leadership audited this but stated she had plans to begin performing audits moving forward.
During interview on 03/30/2023 at 12:51pm DON stated she expected the nurses to ensure oxygen concentrators were maintained and clean. She stated if oxygen concentrators were dirty, it could be an infection control issue and/or an environmental concern. She stated if oxygen concentrators were dirty, it could lead to malfunctions and possibly an infection for the resident. She stated that it was not previously on the list for audits but moving forward she will ensure it will be audited.
During interview on 03/30/2023 at 1:40pm with Administrator he stated he expected nurses to ensure oxygen concentrators were maintained and clean. He stated if oxygen concentrators were dirty it could be an infection control issue or cause the equipment to malfunction. He stated if the filters were dirty, it could lead to compromised air flow into the concentrator.
Review of the facility's policy, Respiratory Policies and Procedures, rev. 02/01/2020, stated Procedures: 1 . Inlet filters on oxygen concentrators shall be visually inspected and cleaned/replaced as necessary. 2 personnel staff shall visually inspect . treatment compressors for inlet filter status, operational verification, and general cleanliness. Inlet filters, suction canisters, and suction tubing will be cleaned/replaced in soiled. External surfaces will be wiped down with a facility and manufacturer approved solution.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #53) of six residents observed for infection control.
The facility failed to ensure Medication Technician G (Med Aide G) donned gloves and gown prior to providing care for Resident #53, who was in contact Isolation for Extended Spectrum Beta - lactamase (ESBL) in urine. ESBL is a bacterial infection.
This failure placed residents at risk of cross-contamination and infections.
Findings included:
Review of Resident #53's Face Sheet, dated 03/29/23, revealed he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included Urinary Tract infection (Bladder infection), Acute Renal failure (Kidney damage), and retention of urine.
Review of Resident #53''s Physician orders on 03/29/23 revealed orders for contact isolation effective 03/27/23 due to ESBL.
Record review of resident's progress notes dated 03/21/23 written by ADON revealed Resident #53 was moved to a room for contact Isolation for Extended Spectrum Beta - lactamase (ESBL) in urine.
Observation on 03/29/23 at 10:00 AM revealed Med Aide G entered Resident #53's room with a blood pressure monitor in her hand, without donning the appropriate PPE( gown and gloves). Resident #53 had an Isolation sign on the room door and hanging on the door were boxes of Gowns and Gloves. Med Aide G was in the room for approximately 5 minutes with the door closed, before re-opening the door and exiting the room without any gown or gloves on.
Interview with Med Aide G on 03/29/23 at 10:05 AM revealed she was in the room assisting Resident #53. She stated she had donned gloves and gown prior to entering the room. Med Aide G was advised that she was observed entering the room without gloves and gown, and she denied it. She stated she had re-entered the room only to go into the resident's bathroom to wash her hands. She stated the resident was in isolation and staff were required to put on gloves and a gown when assisting the resident anytime they enter Resident #53's room if he was in isolation.
Interview with LPN H on 03/29/23 at 10:15 AM revealed Resident #53 was in isolation because of a urinary tract Infection and staff were required to wear a gown and gloves when assisting the resident. He advised staff should sanitize their hands and don gown and gloves prior to entering the resident's room and they were required to doff the gown and gloves prior to exiting the resident's room and sanitize their hands again. He stated the risk to Med Aide not donning PPE appropriately could result in the Med Aide possibly contaminating other residents she may assist.
Interview with ADON on 03/30/2 at 12:30 PM revealed she was made aware Med Aide G was not donning the appropriate gown and gloves before entering Resident #53's room. She advised she and the DON were completing in-services with all staff for proper donning and doffing of PPE. She stated the risk of staff not donning and doffing PPE properly before entering a contact isolation room, could result in staff spreading an infection to other residents they may encounter.
Interview with DON on 03/30/23 at 12:50 PM revealed she was made aware Med-aide not wearing the appropriate PPE when entering the resident's room. She stated the Med Aide should have donned the appropriate gown and gloves when entering the room to aid the resident because he was in isolation. She stated the risk of her not properly donning and doffing PPE could result in transfer of a communicable disease. She stated she completed in-service on 03/30/23 with 100% of her staff on appropriate donning and doffing of PPE when entering a resident's room in isolation for a contagious infection.
Interview with Administrator on 03/30/23 at 2:00 PM revealed he was made aware of the Med Aide G entering the resident's room without donning the appropriate PPE. He stated he expects his staff to follow the proper donning and doffing process when assisting residents that are in isolation for a transferable infection.
Review of facility policy on Infection Prevention and Control Policies and Procedures, rev. 06/29/2021. Appropriate precautions will be instituted when caring for patients with known ESBL. The following precautions are utilized in the care of these individuals . gloves, fluid resistant gown, and mask/goggle.