South Hills Rehabilitation Center

On 4/9/26 at 1:25 PM, an observation was completed with Staff 1 (Administrator) of the first-floor shower room, which identified the following: -Four broken tiles with missing pieces were noted in the shower floor. On the shower floor were three holes containing a black sludge-like substance and standing water. The fourth hole by the shower entrance contained gravel and/or rocks of various sizes.-á -Four holes in the shower wall near the soap dispenser container. -Black coloring noted in one corner of the shower going up along the caulking measuring approximately four to five inches and from the side to the bottom measuring approximately two inches. Other random areas of caulking around the shower had a black coloring over the caulking.-á -á On 4/9/26 at 1:26 PM, Staff 1 acknowledged the broken/cracked tiles, black sludge in the holes, the holes in the wall, and the random black coloring on the caulking around the shower and would get it fixed right away.-á

Corrective Action 1) The first-floor shower room broken tiles (4) were replaced and the black coloring noted on caulking was addressed/resolved on 4/9/26 Identification of others at risk All residents have the potential to be affected by this practice. A facility wide environmental audit of all resident showers will be inspected; any damages noted will be repaired. Systemic Changes All staff will receive education regarding the policy on “Safe and Homelike Environment”. All staff will receive instructions on how to enter environmental concerns into the maintenance log, TELS, in order for maintenance/designee to be able to follow up and address the identified concern(s). QR codes to be given to staff and posted in common areas that link directly into TELS. Admin to give education to maintenance staff regarding frequent rounding in common areas to identify hazards, as well as how to manage maintenance log in TELS, address, and resolve identified areas of concern. Barriers will be discussed with Admin to seek resolution. Monitoring Maintenance/Designee will perform environmental inspections in common areas to identify hazards, such as but not limited to: broken/missing tiles, floor hazards, wall damage, water damage, and general safety concerns. Admin/Designee will monitor facility TELS system Audits will be performed weekly x4 weeks, then monthly x2 months. Audit trends will be reported to facility QAPI for 3 months for review and further recommendations or until substantial compliance has been met.

3. Resident 4 was admitted to the facility in 1/2023 with diagnoses including bilateral knee osteoarthritis and anxiety disorder. -á Resident 4GÇÖs Physician Order dated 5/20/25 revealed an order for methadone HCI 10 mg tablet (an opioid used for pain reduction) 1.5 tablets (15 mg) every morning and noon, and 1 tablet (10 mg) every evening. -á Resident 4GÇÖs Physician Order dated 11/7/25 revealed an order for clonazepam 0.5 mg tablet (an anti-anxiety medication) 1 tablet PRN for anxiety and not to exceed three tablets in a 24-hour period.-á -á Resident 4GÇÖs Medication Error forms dated 11/17/25 and 11/22/25 revealed Resident 4 was administered 15 mg of methadone at the evening dose instead of the ordered 10 mg dose.-á -á Resident 4GÇÖs Medication Error forms dated 11/20/25 and 11/23/25 revealed Resident 4 was administered four tablets of clonazepam on 11/20/25 and on 11/22/25.-á -á On 4/13/26 at 3:45 PM, Staff 2 (DNS) acknowledged the clonazepam and methadone medication errors. Staff 2 stated Resident 4GÇÖs MAR was updated to require nursing staff to document the total number of tablets administered within a 24-hour period. Additionally, Resident 4GÇÖs methadone cards were clearly labeled to specify which card was to be used for the morning and noon doses and which card was to be used for the evening dose. , 2. Resident 25 admitted to the facility in 12/2025 with diagnoses including diabetes. -á Resident 25GÇÖs 3/31/26 Care Plan indicated Resident 25 had diabetes and was insulin dependent. -á On 3/3/26 at 3:44 PM, the State Agency received a public complaint regarding a concern related to insulin.-á -á The facility's 2/27/26 Medication Error form indicated Staff 17 (RN) administered an extra dose of insulin to Resident 25.-á -á On 4/9/26 at 10:10 AM, Staff 18 (LPN/Unit Manager) stated Resident 25 received an extra dose of insulin on 2/27/26. Staff 18 stated Staff 4 (LPN) was working on a new admission and did not finish documenting in the DAR for Resident 25. Staff 17 (RN) arrived on shift, saw Resident 25GÇÖs insulin was due and administered her/his insulin.-á -á On 4/9/26 at 10:30 AM, Resident 25 stated she/he had received a second dose of insulin on 2/27/26. -á On 4/10/26 at 12:48 PM, Staff 2 (DNS) stated Resident 25 was monitored and she/he had no outcome from the additional administration of insulin.-á -á On 4/13/26 at 9:42 AM, Staff 17 (RN) stated on 2/27/26 Staff 4 (LPN) asked her to chart on Resident 25. Staff 17 stated she thought Staff 4 wanted her to administer insulin to Resident 25. Staff 17 stated she administered a second dose of insulin to Resident 25. -á Attempts to contact Staff 4 were made on 4/12/26 at 10:10 AM and 4/13/26 at 9:43 AM and were unsuccessful.-á -á On 4/13/26 at 3:00 PM, Staff 1 (Administration) and Staff 2 (DNS) acknowledged physician orders were not followed for Resident 25GÇÖs insulin administration.-á -á , 1. Resident 1 admitted to the facility in 6/2024 with diagnoses including malnutrition. -á Resident 1's 6/4/24 Care Plan indicated Resident 1 had the potential for skin integrity impairment and had a history of skin tears.-á -á Resident 1's 5/25/25 Progress Note revealed a left elbow skin tear. -á Resident 1's 11/24/25 Progress Note revealed a skin tear to her/his right hand. -á Review of Resident 1's clinical record found no documented evidence a skin assessment or evaluation had been completed for the resident's skin tears on 5/25/25 or 11/24/25. -á On 4/10/26 at 11:10 AM, Staff 2 (DNS) verified comprehensive skin assessments were not completed for the 5/25/25 and 11/24/25 skin tears.-á -á -á -á

Corrective Action Resident #1 no longer resides in this facility. Resident #25 has not had any medication errors related to double dose of insulin since incident originally occurred. Resident #4 no longer resides in the facility Identification of others at risk DON/Designee will complete baseline audit of current residents to ensure total body skin assessments have been completed within the last 7 days. Those identified without a skin assessment within the last 7 days, will have one completed. Any areas of impaired skin integrity identified will have risk management completed, resident/resident representative notified, and provider notification with any correlating treatment orders in place. The following identified skin impaired areas will be assessed, measured, photograph (per resident preference), and documented weekly in the skin and wound module: All pressure related injuries; Non-healing skin tears or skin tears of suspicious origin; Any skin tear that is infected, regardless of size; All vascular related wounds, venous or arterial; MASD Any neuropathic ulcer (diabetes); Non-healing bruises or bruises of suspicious origin; Scabs which have not healed for 4 weeks; Surgical Incisions; Any lesion/injury requiring sutures DON/Designee will perform baseline audit of all current residents who receive insulin to confirm DAR is being signed off subsequently after administration of insulin. Any identified areas of concern/deficiency will be addressed immediately. DON/Designee will perform baseline audit of all current residents who receive two different doses of opioids at different times of the day to ensure order and pharmacy card delivered have the instructions clearly labeled and medication is administered per orders. Issues identified will be corrected immediately. DON/Designee will perform baseline audit of all current residents with medications that currently have a “not to exceed in 24 hours order” to ensure supplementation documentation captures how many doses have already been administered within the 24 hour period to prevent medication errors, as well as medication has been administered per orders. Issues identified will be corrected immediately. Systemic Changes DON/Designee will provide skin and wound policy to Licensed Nurses. Further education to Licensed Nurses related to following facility policy regarding weekly head to toe skin assessments in order to identify potential skin breakdown early. Areas of impaired skin integrity identified during weekly skin assessments will have a risk management completed, resident/resident representative notified, and provider notified with correlating treatment orders in place. Identified skin impaired areas that qualify per policy to be followed in skin and wound module will have wounds assessed weekly per policy. DON/Designee to educate CNA staff regarding inspection of skin during bath/shower and report any concerns to the nurse immediately. CNA’s shall also report changes in skin condition that are noted during any care services provided. DON/Designee to provide medication error policy to Licensed Nurses with focused education related to 6 rights of medication administration. Focused education regarding right dose, right time, and right documentation. Further education will be provided regarding following provider orders related to “not to exceed in 24 hours” and adding supplementation documentation to capture total doses given within the 24 hour period. Monitoring DON/Designee will continue ongoing monitoring of 10 residents to ensure total head to toe skin assessments are completed weekly. DON/Designee will continue ongoing monitoring of 10 residents who have wounds per policy will be followed weekly in skin and wound module. DON/Designee will observe 8 insulin administrations following subsequent documentation. DON/Designee will continue ongoing monitoring of newly admitted residents and current residents who have two different doses of opioids at different times of the day to ensure order and pharmacy card delivered have the instructions clearly labeled and medication is administered per orders. DON/Designee will continue ongoing audits of newly admitted residents and 5 current residents to ensure orders with “not to exceed in 24 hours” have supplementation documentation attached to order to capture how many doses have already been administered within the 24 hour period, as well as ensure medication was administered per order. Audits will be conducted weekly by DON/Designee for 4 weeks, then monthly for two months. Audit trends will be reported to facility QAPI for 3 months for review and further recommendations or until substantial compliance has been met.

On 4/9/26 at 9:50 AM, Resident 4 stated the food was GÇ£horribleGÇ¥ and GÇ£a lot of us will refuse our trays because we canGÇÖt stand to eat it.GÇ¥ -á On 4/9/26 at 10:01 AM, Resident 26 stated the food was ""pretty terrible.GÇ¥ -á On 4/9/26 at 4:10 PM, Resident 27 stated the food was GÇ£awful.GÇ¥ -á On 4/9/26 at 10:19 AM, Staff 9 (CNA) stated residents had complained about the taste of the food. -á On 4/9/26 at 1:32 PM, Staff 20 (Kitchen Manager) stated she occasionally received complaints regarding the palatability of the food and reported increased complaints related to meals prepared by the cook for that dayGÇÖs lunch. -á On 4/10/26 at 9:36 AM, Staff 22 (CNA) stated the food was GÇ£horrible, it is rottenGÇ¥ and usually too tough for residents to cut. -á On 4/10/26 at 11:27 AM, Staff 23 (CNA) stated residents had complained about the taste of the food. -á On 4/9/26 at 11:53 AM, a sample meal tray was tested and found the lunch meal of pork sausage, noodles with butter, cooked spinach and spiced peaches were bland and unpalatable.-á -á On 4/9/26 at 12:15 PM, Staff 1 (Administrator) acknowledged the noodles and spinach were bland.-á

Corrective Action Resident #4 no longer resides at the facility Resident #26 and #27 food will be served that is of good presentation and palatable. Residents will be interviewed to verify preferences and update them within the meal tray card system. Identification others at risk Current residents who eat meals at the facility DM/Designee completed a baseline audit of current residents with Bims score of 9 or higher to verify residents are receiving palatable food. Systemic Change VP Nutrition/Designee re-educated Dietary Manager and kitchen staff related to service staff food tasting/serving expectations. DM/Designee will provide training to all dietary personnel and will conduct ongoing training for staff as needed to verify proper training of proper use of recipes, garnishes, and tasting of food. Monitoring DM/Designee will audit 5 trays weekly to verify items are appropriate and meet menu guidelines. DM/Designee will audit trayline to verify textures prior to service and sample trays. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

2. Resident 3 was admitted to the facility in 1/2026 with diagnoses including sepsis (a life-threatening reaction to infection). A 1/23/26 physician order indicated Resident 3 received Cefazolin (antibiotic) every eight hours. The 1/2026 MAR indicated Resident 3 received ceftriaxone (antibiotic) every eight hours. A 1/28/26 FRI indicated Resident 3 was admitted with orders for Cefazolin, but the orders were transcribed as ceftriaxone. Resident 3 was administered the wrong antibiotic 11 times. On 2/9/26 at 12:42 PM, Staff 2 (DNS) acknowledged the errors regarding Resident 3's medication administration. 3. Resident 5 was readmitted to the facility in 1/2026 with a diagnosis including PTSD (Post-Traumatic Stress Disorder). A 12/9/25 physician order indicated Resident 5 received quetiapine (antipsychotic) 100mg in the morning and at bedtime. A 1/5/26 FRI indicated during a care conference meeting for a GDR (Gradual Dose Reduction), it was noted Resident 5 was administered more quetiapine than ordered. Orders changed on 11/21/25 to receive 300 mg at bedtime and to discontinue the 100mg morning administration. The morning medication was not discontinued. On 2/9/26 at 12:42 PM, Staff 2 (DNS) acknowledged the errors regarding Resident 3's medication administration. -á -á , 1. Resident 1 admitted to the facility in 1/2026 with diagnoses including multiple fractures of the spine and kidney disease. A 1/23/26 Admission MDS indicated Resident 1 was cognitively intact. Review of Resident 1's medical record indicated a critical lab value for low red blood cell count was called in to the facility on 1/27/26 at 12:35 PM.-á A hospital communication note written by Staff 3 (On Call Physician) on 1/27/26 at 1:48 PM indicated Staff 3 was aware of the critical lab value for Resident 1, Staff 3 completed a virtual assessment of Resident 1 and ordered Resident 1 to be sent to the Emergency Department (ED) for a possible blood transfusion.-á During an interview on 2/9/26 at 12:17 PM, Staff 5 (LPN) stated when she arrived for her shift (2-10 PM) on 1/27/26 the morning nurse, Staff 4 (Agency LPN), was speaking with Staff 3 about Resident 1 on an iPad. Staff 5 heard Staff 3 tell Staff 4 to send the resident to the ED, and to call her/his family. Staff 5 stated she heard Staff 3 ask to speak with the resident and Staff 4 took the iPad to the resident's room.-á Staff 5 stated when Staff 4 returned from the resident's room, she began gathering the necessary paperwork to send Resident 1 to the ED. Staff 5 stated Staff 4 did not inform her of the critical lab value or the need to complete Resident 1's transfer to the ED. Staff 5 stated during her shift she noticed Resident 1 was still in her/his room and assumed she/he had refused the transfer to the ED but did not ask Resident 1. Staff 5 stated Staff 7 (Certified Occupational Therapy Assistant) told her of Resident 1's low blood pressure the evening of 1/27/26 and she told Staff 7 to give the resident a drink of water. Staff 5 stated she gave Resident 1 medication for nausea twice throughout the evening of 1/27/26. Staff 5 stated when she left her shift on 1/27/26 Resident 1 was communicative and responsive.-á During an interview on 2/9/26 at 12:55 PM, Staff 4 stated on 1/27/26 at 1:50 PM she received a call from the lab regarding a critical value for a low red blood cell count for Resident 1 and she called Staff 3 for further guidance. She stated Staff 3 spoke with Resident 1 via an iPad and completed a virtual assessment. Staff 4 stated Staff 3 told her to send Resident 1 to the ED via non-emergent transport, and Staff 3 would call the hospital to inform them Resident 1 would be coming into the ED.-á Staff 4 stated when she asked Staff 6 (LPN), what it meant to be non-emergent for a transport, she was told it meant the resident could be sent to the ED at any time. Staff 4 stated she wrote a nurses note and left the transfer for Staff 5 to complete on the next shift.-á No order for sending Resident 1 to the ED was found in Resident 1's medical chart.-á A nursing note was found to have been written on 1/28/26 at 1:28 PM (the next day) by Staff 4. The note indicated a critical lab value was called in to the facility on 1/27/26, she called Staff 3, Staff 3 assessed the resident, and ordered Staff 4 to send Resident 1 to the ED. During an interview on 2/9/26 at 2:17 PM, Staff 6 stated on 1/27/26 Staff 4 asked her about sending residents out via non-emergent transport. She stated she assisted Staff 4 by defining the term and finding the phone number of who to call for the transport. Staff 6 stated when she came in for her shift at about 5:45 AM on 1/28/26 the night shift nurse informed her Resident 1 had just died. Staff 6 stated she was not aware Resident 1 was who Staff 4 was asking about on 1/27/26. A progress note dated 1/28/26 at 5:50 AM indicated Resident 1 died.-á During an interview on 2/9/26 at 4:37 PM, Staff 7 stated on 1/27/26 she informed Staff 5 of a low blood pressure reading for Resident 1 as well as changes in cognition, increased fatigue, nausea, and pale skin. She stated the nurse told her to have the resident drink water and retake the blood pressure. Staff 7 stated when Staff 5 heard the new blood pressure reading, Staff 5 stated she was no longer concerned. Staff 7 stated she did not see Staff 5 assess Resident 1 after hearing Resident 1's symptoms. During an interview on 2/9/26 at 1:43 PM, Staff 3 stated she was called by Staff 4 on 1/27/26 at 1:48 PM regarding a critical lab value for Resident 1. Staff 3 stated she completed a virtual assessment and spoke with Resident 1 who told her she/he wanted to go to the ED. Staff 3 stated she told the resident she would be sending her/him to the ED that day (1/27/26) for assessment and a possible blood transfusion. Staff 3 stated she told Staff 4 to have Resident 1 sent to the ED via non-emergent transport and called the ED to inform them about Resident 1's upcoming arrival and plan of care. Staff 3 stated her order was very clear to send Resident 1 to the ED, she expected Resident 1 to go to the ED for a transfusion, and she did not know Resident 1 was not sent to the ED as ordered.-á During an interview on 2/9/26 at 2:12 PM, Staff 2 (DNS) acknowledged at the time of the incident on 1/27/26,-á Staff 4 did not write a progress note regarding the critical lab value notification, did not put in Staff 3's verbal order to transport Resident 1 to the ED, did not act on the transport to ED order, and did not put in a progress note regarding Staff 3's verbal order to send Resident 1 to the ED. She stated her expectation for all nursing staff was for them to report all critical labs to the provider, receive guidance from the provider, inform the resident, act on the guidance from the provider, and then write a progress note. She stated her expectation for nurses was for them to put all verbal orders into the computer, follow the order as given by the provider, and then write a progress note.-á

Corrective Action Resident #1 is no longer in facility Medications for resident #3 will be transcribed accurately and given per orders. Resident #3’s Medication administration record will be reviewed to address any discrepancies. Areas identified will be corrected immediately, provider and resident representative will be notified as indicated, resident will be assessed for adverse effects, and medication error report will be initiated as indicated. Resident #5 is no longer in the facility Identification of others at risk All residents have the potential to be affected. DON/Designee will complete baseline audit of all current residents to ensure any change in condition, including critical lab results, are reported to the provider, and any orders given by the provider are followed and completed. DON/designee will complete baseline audit of current residents’ medication orders in the last 30 days compared to MAR/TARs for all residents to ensure accuracy of transcription. Any discrepancies identified will be corrected immediately, provider and resident representative will be notified as indicated, and medication error report will be completed per policy. Systemic Changes DON/Designee will provide further education to all staff regarding policy on notification of changes in condition and who to escalate/report those changes to. DON/Designee will provide further education to Licensed Nurses regarding reporting changes in condition to provider and following provider orders. DON/Designee will provide education to licensed nurses on proper transcription of medication orders following the six rights of medication administration. DON/Designee to provide education to licensed nurses and medication aides on verification of orders against MAR/TAR before administration. DON/Designee to provide medication administration policy and medication error policy to licensed nurses and certified medication aides. The facility will implement a second-nurse or supervisor verification process for new or changed medication orders prior to the first dose when applicable. Monitoring DON/Designee will continue ongoing monitoring of changes in condition daily five days/week x4 weeks, then monthly x2 months, or until substantial compliance is achieved. DON/designee will complete audits on newly ordered medications to ensure accuracy of transcription weekly x4 weeks, then monthly x2 months, or until substantial compliance is achieved. Audit trends will be reported to facility QAPI Committee. The QAPI committee will determine when compliance is achieved or if further monitoring is required.

Resident 208 was admitted to the facility in 7/2025 with diagnoses including diabetes and diabetic kidney complications.-á The 9/2025 DAR instructed staff to administer insulin glargine twice a day for diabetes management. During the 8:00 AM administration, Staff 5 (LPN) documented Resident 208 was absent from the facility without her/his medications on five occasions. On 11/21/25 at 1:05 PM, Staff 5 (LPN) stated Resident 208 left the facility before her shift began and returned in the afternoon following dialysis. Staff 5 reported she did not know what the night nurse had completed or whether insulin was sent with the resident to the dialysis appointment.-á -á On 11/24/25 at 10:18 AM, Staff 28 (Regional Nurse) stated she would expect the physician to be involved in developing a clinical plan for insulin administration while the resident was out of the facility.-á

Corrective Action 1) Resident #208 will have complete review of medications with provider to discuss medication administration times, including insulin, to ensure when resident is out of facility at dialysis that medications are not missed. Provider will be given MAR/DAR records to show all missed medications for the month of November. Issues identified will be addressed with provider and resident representative. Identification of others at risk DON/Designee will complete baseline audit of current dialysis residents to ensure medications are discussed with provider and medication administration times are changed to avoid missed medications while out of the facility at dialysis. DON/Designee will complete baseline audit of all dialysis residents’ medication administration records, and notify provider of any missed medications in the month of November. Issues identified will be addressed with provider and family representative. Systemic Changes DON/Designee will provide further education to Licensed Nurses related to following physician orders, and proper notification to provider if medications are unable to be administered per orders. DON/Designee to educate staff on dialysis residents and discussing adjusting medication administration times with provider on dialysis days to avoid missed medications. Monitoring 1) DON/Designee will continue ongoing monitoring of current and new dialysis residents and ensure medication times are discussed with provider to avoid missed medications while out of facility at dialysis. Audits will be conducted weekly by DON/Designee for 4 weeks, then monthly for two months. 2) Audit trends will be reported to facility QAPI for 3 months for review and further recommendations.

Resident 201 was admitted to the facility in 12/2024 with diagnoses including chronic respiratory failure. -á A physician order dated 12/22/24 instructed staff to administer oxygen at three liters per minute continuously, every shift. -á A Physical Therapy Treatment Encounter Note dated 12/31/24 indicated Staff 20 (Former Physical Therapist Assistant) entered Resident 201's room and found the oxygen concentrator was not on. Resident 201GÇÖs oxygen level was at 88 percent. After oxygen was administered, the level increased to 93 percent. -á A public complaint was received on 2/25/25, which alleged when Resident 201 was returned to her/his room, staff did not turn on her/his oxygen concentrator. Several hours later, Staff 20 came into the room and found the concentrator off. -á On 11/21/25 at 10:02 AM, Staff 20 confirmed the note was accurate and the oxygen concentrator was off when entering Resident 201's room on 12/31/24. -á On 11/24/25 at 10:17 AM, Staff 1 (Administrator) confirmed staff were expected to follow physician orders for Resident 201's oxygen use.-á

Corrective Action 1) Resident #201 is no longer at the facility Identification of others at risk The facility has determined that all residents who currently utilize oxygen have the potential to be affected. DON/Designee to perform baseline audit of all residents who require oxygen to ensure oxygen is applied per orders and is properly functioning. Systemic Changes 1) DON/Designee will provide further education to nursing staff related to following physician orders related to oxygen use and verifying that oxygen is in place per orders, as well as ensuring oxygen is in place after activities which may require temporary removal of oxygen, such as when changing from concentrator to oxygen tank and vice versa. 2) DOR/Designee will provide education to therapy staff regarding any observation of a resident that generally wears oxygen and it’s noted that oxygen is not in place or concentrator is not turned on, therapy staff is to then notify the charge nurse immediately and follow up with the UM/DON. The UM/DON will ensure charge nurse is reviewing orders for oxygen and ensuring oxygen is applied per orders and is properly functioning, as well as ensuring charge nurse is performing an immediate assessment of resident and noting any changes in condition, and notifying provider and family representative as indicated. Monitoring 1) DON/Designee will conduct random observations of 10 residents who utilize oxygen to verify it is being provided per orders and properly functioning. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. 2) Audit trends will be reported to facility QAPI for 3 months for review and further recommendations.

Resident 15 was admitted to the facility in 7/2025 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and muscle weakness. No documentation was found in the clinical record to indicate the resident was assessed to self-administer her/his medication. -á-á On 8/6/25 at 8:17 AM, Resident 15 was observed sitting in her/his room with one inhaler on the bedside table and a second inhaler on the nightstand. Resident 15 stated staff were aware of the inhalers in her/his room. Resident 15 explained she/she uses the inhaler when her/his COPD flares up and expressed concern that if they had to wait 10 minutes for staff during a flareup, GÇ£they would be dead.GÇ¥ On 8/6/25 at 8:18 AM, Staff 27 (CNA) confirmed Resident 15 had an inhaler at her/his bedside and reported this to the charge nurse. Staff 27 stated she was unaware if the resident was authorized to have the inhaler and would need to confirm with the nurse. Staff 27 later confirmed Resident 15 had two inhalers at her/his bedside.-á On 8/6/25 at 8:20 AM, Staff 26 (LPN) stated he was aware residents are required to be assessed prior to keeping medications at the bedside but did not know if Resident 15 had been assessed. Staff 26 checked both inhalers and confirmed one inhaler had two doses remaining and the other had 200 doses remaining. Staff 26 stated he would follow up with administration to determine if the resident had been assessed to self-administer medications. Staff 26 left both inhalers in Resident 15GÇÖs room.-á On 8/6/25 at 8:59 AM, Staff 6 (Corporate DNS) acknowledged resident 15 had two inhalers in her/his room. Staff 6 confirmed Resident 15 did not have an order to self-administer her/his inhalers and had not been assessed to self-administer medications. -á -á -á

1. Corrective Action for Resident Affected Resident #15’s inhalers were immediately removed from the bedside and secured in the medication cart on 8/6/25. The attending physician was notified, and an assessment for self-administration of inhalers was completed by the interdisciplinary team (IDT). Based on assessment results, the IDT determined appropriate medication administration and documented findings in the clinical record. Education was provided to Resident #15 on safe use of inhalers and the facility’s process for self-administration approval. 2. Identification of Other Residents at Risk A facility-wide audit was initiated on 8/6/25 of all residents to identify medications at bedside and confirm physician orders/IDT assessments for self-administration. Any resident found with medications at bedside without proper assessment had medications removed and secured until the IDT completed an evaluation and the physician order was obtained. 3. Systemic Changes to Prevent Recurrence The facility educated all licensed nurses and Certified medication Assistants on the Self-Administration of Medications Policy to include: Nursing assessment using a standardized tool prior to resident self-administration. Physician order required before any medications can be kept at bedside. Ongoing quarterly review of residents with self-administration privileges. Nursing staff were re-educated on the policy and procedures for identifying, reporting, and securing unauthorized bedside medication CNAs were specifically instructed to notify licensed staff immediately if they observe medications in resident rooms. All education will completed by 9/29/2025. Any contract staffing working after 9/29/2025 will be in-serviced on their first scheduled shift. 4. Monitoring to Ensure Sustained Compliance The Director of Nursing (DON) or designee will audit 5 random residents weekly for 4 weeks, then monthly for 3 months, to ensure no medications are kept at bedside without appropriate IDT assessment and physician order. Results of audits will be reviewed during the facility’s QAPI meetings. Any identified issues will result in immediate corrective action, re-education, and follow-up monitoring. Compliance will be sustained when compliance is demonstrated for 3 consecutive months. The Director of Nursing Services (DNS) is responsible for the implementation and oversight of this Plan of Correction.

-áBased on interview and record review the facility failed to notify the physician of a resident's change of condition for 1 of 2 sampled residents (# 72) reviewed for hospitalizations. Findings include:-á -á1. Resident 72 was admitted to the facility in 5/2025 with diagnoses including acute kidney disease. An Admission MDS dated 5/23/2025 revealed Resident 72 had a BIMS score of 14, which indicated the resident was cognitively intact. A review of the nursing notes dated 6/1/24 at 6:44 PM, revealed nursing staff documented Resident 72's blisters forming on her/his chest were draining. The resident also complained of feeling she/he was ""on fire and being stabbed with needles."" Resident 72 was sent to the emergency department.-á A review of Resident 72GÇÖs medical records revealed the physician was not notified of the change of condition the evening of 6/1/24. On 8/08/2025 at 10:58 AM, Staff 6 (Corporate DNS) confirmed the lack of documentation and stated the physician was not notified.-á On 8/08/2025 at 10:58 AM staff 2 (Director of nursing) and staff (Regional nurse) acknowledged physician notification had not occurred.-á -á

Immediate action(s) taken for the resident(s) found to have been affected include: Resident # 72 was not harmed and was transferred to the emergency room on 6/1/2024.  The physician has been notified of the change of condition that occurred on 6/1/2024 without physician notification. Identification of other residents having the potential to be affected was accomplished by: The facility has determined that all residents have the potential to be affected. An audit has been completed by the DON and/or designee for all residents with a change in condition to validate the physician being notified. This audit was/will be completed from 8/1/2025 through 9/29/2025. Any findings have been reported to the physician. Actions taken/systems put into place to reduce the risk of future occurrence include: An in-service education program was conducted by the Director of Nursing Services/Staff Development Coordinator/ designee with all licensed staff addressing circumstances that require notification of the resident’s physician, legal representative or family member. How the corrective action(s) will be monitored to ensure the practice will not recur: •     The Director of Nursing (DON) or designee will audit 5 residents that returned to the hospital weekly for 4 weeks, then monthly for 3 months.  This audit is to ensure that any declines in condition have been identified, properly evaluated and communicated to the appropriate people. Findings of this audit will be discussed with the QAPI committee monthly. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met.

The Abuse Policy revised 5/14/23 stated abuse included verbal abuse. The policy applies to any person who is GÇ£an owner, operator, employee, manager, agent or contractor of the facility.-á -á It further states it is not necessary for the reporter to categorize the event as abuse for the facility to consider the potential for abuse and act accordingly. 1. -á-á-á-á-á Resident 43 was admitted to the facility in 6/2025 with diagnoses including respiratory failure. Resident 43GÇÖs admission MDS from 6/2025 revealed a BIMS score of 14, indicating the resident was cognitively intact. A progress note on 7/23/25 revealed a resident verbally abused a Spanish-speaking resident who was visiting with her/his family by making comments including, ""these people need to go back to where they belong, they are taking over. I thought these was the United States (sic).""-á A progress note dated 7/30/25 revealed the resident again yelled at the Spanish-speaking resident, who was speaking on the telephone at the time.-á On 8/7/25 at 4:50 PM, Witness 1 (family) stated another resident at the facility had ""rude"" outbursts demanding, ""why don't you speak English this is America speak English (sic),"" and on ""8 different occasions"" multiple family members, as well as staff and residents, witnessed these verbal outbursts. Witness 1 stated the staff apologized to Resident 43 and made her stay away instead of dealing with the resident who was having outbursts.-á Witness 1 stated Resident 43 was sitting in the dining area on a phone call, and the other resident was watching TV. She/he told Resident 43, ""shut up. Why can't you speak English? You are in America (sic),"" and continued being ""rude, obnoxious and disrespectful."" Witness 1 stated the facility staff told the family to ignore the other resident. -á On 8/8/25 at 10:06 AM, Witness 2 (Community Partner) stated Resident 43's family called her and wanted to file a complaint about the facility's failure to intervene because another resident was making racial slurs toward the resident and her/his family. Witness 2 stated the family member told her the statements were making the resident uncomfortable, and even though Resident 43 was not sure what was being said, GÇ£(Resident 43) knows it is bad."" Witness 2 also stated the family member told her the resident no longer wanted to go into the communal areas of the facility because of the hostile behavior of the other resident.-á On 8/8/25 at 11:30 AM, Staff 26 (LPN) stated if there were verbal confrontations between residents, he was trained to speak with the residents then talk to the unit manager, and, if necessary, follow up with the DNS. He stated he was not sure why Resident 43 was moved to another room and stated he was not aware of verbal aggression toward Resident 43. Staff 26 stated most of the time Resident 43 would go outside when she/he was out of her/his room and had not been sitting in the dining room recently. On 8/11/25 at 8:00 AM, Staff 20 (Nursing Assistant) stated Resident 43 did not want to come into the second-floor dining area when the other resident was there because the other resident said ""racist things"" to Resident 43. Staff 20 stated Resident 43 would go outside instead of being in the second-floor common area to avoid the resident. -á Staff 20 stated she was not aware of facility staff doing anything to stop the verbal abuse by the resident. She stated Resident 43 talked to her about it because she speaks Spanish and took the time to listen to Resident 43GÇÖs concerns. Staff 20 stated she recognized the other residentGÇÖs behavior as verbal abuse. On 8/11/25 at 12:45 PM Resident 43 stated she/he was talking with her/his grandson and his girlfriend in the common area and another resident turned and stared at them and said, ""Why are you guys speaking in Spanish donGÇÖt you know you are in America (sic)?GÇ¥ Resident 43 stated the other resident kept talking but the staff ignored it. Resident 43 stated there were other times the same resident made racial comments to her/him and her/his family. When her/his grandson came back the next time, staff took him aside and told him ""not to take it personal and just ignore"" the residentGÇÖs comments. Her/his grandson was ""very upset"" by the staffGÇÖs comments. Resident 43 stated she/he was on phone with her/his granddaughter and the other resident started making racial comments again so Resident 43 ended her/his phone call. A CNA asked Resident 43 if she/he wanted to go to another room or table and the other resident just kept saying things.-á Resident 43 confirmed she/he would not go out in the common areas if the other resident was there, so she/he goes outside or stays away from the common area. Resident 43 stated she/he feels targeted because she/he is from a different race and stands out from the rest of the residents. -áResident 43 stated she/he was moved to another hall to be further away from the other resident. On 8/11/25 at 3:30 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated they learned of the verbal abuse to Resident 43 on 8/8/25. Staff 3 (Vice President of Operations) entered the room and much of the conversation was repeated.-á 2. Resident 49 was admitted to the facility in 3/2025 with diagnoses including dementia and anxiety. Resident 49's Saint Louis Mental Status Exam (SLUMS) was 2/30 indicating mild cognitive impairment.-á On 8/4/25 at 10:35 AM, Resident 49 stated her/his former roommate and Resident 49 had been arguing about the volume of the televisions in the room. Resident 49 stated a staff person came into the room and talked with them and when the staff person left the roommate made ""a racial slur.""-á Resident 49 stated she/he was moved to her/his current room after the argument. Resident 49 stated as a result of the comment she/he no longer wants to go out into the facility because she/he does not want to interact with the other resident. On 8/8/25 at 12:08 PM, Staff 21 (CNA) stated since the incident, Resident 49 prefers to stay in her/his room. Staff 21 stated before the incident Resident 49 used to come out and sit in the common area on the second floor. On 8/11/25 at 3:30 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated Resident 49 suffered from a urinary tract infection at the time of the argument with her/his roommate which caused her/him to be confused. During the interview with Staff 1 and Staff 2, Staff 3 (Vice President of Operations) entered the room and much of the conversation was repeated.-á -á -á -á -á -á -á -á -á -á -á -á -á

1. Corrective Action for Residents Affected On 8/8/25, the Administrator and Director of Nursing (DNS) met with Resident #43 and family to acknowledge concerns, offer emotional support, and reinforce the resident’s right to be free from abuse. On 8/12/2025 Resident #43 was evaluated by Psych NP Treatment Plan: Supportive psychotherapy and emotional reassurance. Monitor for recurrence of interpersonal conflicts. Social work follow-up for advocacy and culturally sensitive care. Resident #43 was relocated to another hall to avoid further interactions with the abusive roommate on 5/16/2025. Resident #49 was provided with a room change on 5/16/2025 to minimize further contact with the resident involved in verbal abuse. 2. Identification of Other Residents at Risk A facility-wide resident interview and observation audit was initiated on 8/8/25 to determine if any other residents had experienced or witnessed verbal abuse. No other residents were identified as experiencing unaddressed verbal abuse at the time of the audit. 3. Systemic Changes to Prevent Recurrence The facility re-educated all staff in all departments on the Abuse Prohibition Policy, emphasizing that: All staff are mandated to immediately intervene, report, and protect residents from verbal, emotional, physical, or racial abuse. Residents and families must never be told to “ignore” abusive behavior. All allegations must be immediately reported to the Administrator, DNS, and Abuse Coordinator, investigated, and documented per federal requirements. The facility added mandatory training on prevention of abuse during orientation and annually for all staff. Resident Council were informed of the reinforced abuse prevention process and avenues for safe reporting. 4. Monitoring to Ensure Sustained Compliance The Administrator or DNS will conduct weekly rounds for 4 weeks to interview at least 5 residents and/or family members regarding any concerns of abuse, disrespect, or intimidation. Thereafter, random interviews will be completed monthly for 3 months. The Administrator and DON will review all grievances and incident reports weekly to ensure timely follow-up and resolution. All findings will be presented and reviewed at monthly QAPI meetings, with corrective action taken immediately if lapses are identified. Sustained compliance will be demonstrated when 100% of residents interviewed for 3 consecutive months report feeling safe and free from abuse. The Administrator and Director of Nursing Services (DNS) are responsible for implementing, monitoring, and sustaining this Plan of Correction.

The Abuse Policy revised 5/14/23 states abuse included verbal abuse. The policy applies to any person who is GÇ£an owner, operator, employee, manager, agent or contractor of the facility. -á It further states it is not necessary for the reporter to categorize the event as abuse for the facility to consider the potential for abuse and act accordingly and it remains the responsibility of the covered individual to verify the report (to appropriate entity) timely. 1. -á-á-á-á-á Resident 43 was admitted to the facility in 6/2025 with diagnoses including respiratory failure. Resident 43GÇÖs admission MDS completed in 6/2025 revealed a BIMS score of 14, indicating the resident was cognitively intact.-á -á -á-á A progress note on 7/23/25 revealed a resident verbally abused a Spanish-speaking resident who was visiting with her/his family by making comments including, ""these people need to go back to where they belong, they are taking over. I thought these was the United States (sic).""-á A progress note dated 7/30/25 revealed the resident again yelled at the Spanish-speaking resident, who was speaking on the telephone at the time.-á On 8/7/25 at 4:50 PM, Witness 1 (family) stated another resident at the facility made ""rude"" outbursts demanding, ""why don't you speak English? This is America, speak English (sic)."" On ""8 different occasions"" multiple family members, as well as staff and residents, witnessed these verbal outbursts. Witness 1 stated the staff apologized to Resident 43 and made her stay away instead of dealing with the resident who was having outbursts.-á Witness 1 stated Resident 43 was in the facility sitting in the dining area on a phone call and the other resident was watching TV and told Resident 43, ""Shut up. Why can't you speak English? You are in America (sic),"" and continued being ""rude, obnoxious and disrespectful."" Witness 1 stated the facility staff told them to ignore the other resident. -á On 8/8/25 at 10:06 AM, Witness 2 (Community Partner) stated Resident 43's family called her and wanted to file a complaint about the facility's failure to intervene because another resident was making racial slurs toward the resident and her/his family.-á Witness 2 stated the family member told her the statements were making the resident uncomfortable, and even though Resident 43 was not sure what was being said, GÇ£(Resident 43) knows it is bad."" Witness 2 also stated the family member told her the resident no longer wanted to go into the communal areas of the facility because of the hostile behavior of the other resident.-á On 8/11/25 at 12:45 PM Resident 43 stated she/he was talking with her/his grandson and his girlfriend in the common area and another resident turned and stared at them and then said, ""Why are you guys speaking in Spanish? DonGÇÖt you know you are in America (sic)?GÇ¥ Resident 43 stated the staff ignored it. Resident 43 stated there were other times the same resident made racial comments to her/him and her/his family. When her/his grandson came back the next time, staff took him aside and told him ""not to take it personal and just ignore"" the residentGÇÖs comments. Her/his grandson was ""very upset"" by the staffGÇÖs comments. Resident 43 stated she/he was on phone with her/his granddaughter and the other resident started making racial comments again so Resident 43 ended her/his phone call. A CNA asked Resident 43 if she/he wanted to go to another room or table while the other resident just kept saying things.-á On 8/5/25 Staff 1 (Administrator) was asked to provide copies of all internal and facility-reported incidents (FRI) involving alleged abuse. Staff 1 did not provide any documentation of an investigation or FRI for the events related to verbal abuse of Resident 43.-á On 8/11/25 at 3:30 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated they learned of the verbal abuse to Resident 43 on 8/8/25. During the interview with Staff 1 and Staff 2, Staff 3 (Vice President of Operations) entered the room and much of the conversation was repeated.-á 2. Resident 49 was admitted to the facility in 3/2025 with diagnoses including dementia and anxiety. Resident 49's Saint Louis Mental Status Exam (SLUMS) was 2/30 indicating mild cognitive impairment.-á On 8/4/25 at 10:35 AM, Resident 49 stated her/his former roommate and Resident 49 had been arguing about the volume of the televisions in the room. Resident 49 stated a staff person came into the room and talked with them and when the staff person left the roommate made ""a racial slur."" Resident 49 stated she/he was moved to her/his current room after the argument. Resident 49 stated as a result of the comment, she/he no longer wants to go out into the facility because she/he does not want to interact with the other resident. On 8/5/25 Staff 1 (Administrator) was asked to provide copies of all internal and facility-reported incidents (FRI) involving alleged abuse. Staff 1 did not provide any documentation of an investigation or FRI for the events related to verbal abuse of Resident 49.-á On 8/11/25 at 3:30 PM, Staff 1 and Staff 2 (DNS) stated Resident 49 suffered from a urinary tract infection at the time of the argument with her/his roommate which caused her/him to be confused. During the interview with Staff 1 and Staff 2, Staff 3 (Vice President of Operations) entered the room and much of the conversation was repeated. -á -á -á -á -á -á -á -á -á -á -á -á -á

Immediate action(s) taken for the resident(s) found to have been affected include: On 8/8/25, the Administrator and Director of Nursing (DNS) met with Resident #43 and family to acknowledge concerns, offer emotional support, and reinforce the resident’s right to be free from abuse. On 8/12/2025 Resident #43 was evaluated by Psych NP Treatment Plan: Supportive psychotherapy and emotional reassurance. Monitor for recurrence of interpersonal conflicts. Social work follow-up for advocacy and culturally sensitive care. Resident #49 was relocated to another hall to avoid further interactions with the abusive roommate on 5/16/2025. Resident #49 was provided with a room change on 5/16/2025 to minimize further contact with the resident involved in verbal abuse. The Administrator and Director of Nursing are no longer employed with Volare Health as of 8/22/2025. Identification of other residents having the potential to be affected was accomplished by: The facility has determined that all residents have the potential to be affected. A facility-wide resident interview and observation audit was initiated on 8/8/25 to determine if any other residents had experienced or witnessed abuse.  No concerns of abuse were identified. Any additional reports identified as unaddressed abuse at the time of the audit have been reported to all regulatory reporting entities. Actions taken/systems put into place to reduce the risk of future occurrence include: An in-service education program was conducted by the Regional Director of Clinical (RDC) with the Director of Nursing Services and the Administrator and then all staff and all departments addressing circumstances that require reporting including appropriate timeframes. How the corrective action(s) will be monitored to ensure the practice will not reoccur: The Director of Nursing Services, or designee, will conduct a random audit of five (5) residents weekly for (4) weeks then monthly for 3 months.  These residents will be assessed and interviewed to ensure that any injuries are identified, properly investigated and reported to the appropriate regulatory agencies. Findings of this audit will be discussed with the QAPI committee. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met.

The Abuse Policy revised 5/14/23 states abuse included verbal abuse. The policy applies to any who is GÇ£an owner, operator, employee, manager, agent or contractor of the facility.-á -á It further states it is not necessary for the reporter to categorize the event as abuse for the facility to consider the potential for abuse and act accordingly and it remains the responsibility of the covered individual to verify the report (to appropriate entity) timely. 1. -á-á-á-á-á Resident 43 was admitted in 6/2025 with diagnoses including respiratory failure. Resident 43GÇÖs admission MDS completed in 6/2025 revealed a BIMS score of 14, indicating the resident was cognitively intact. 1.-á-á-á-á-á Resident 43 was admitted in 6/2025 with diagnoses including respiratory failure. Resident 43GÇÖs admission MDS completed in 6/2025 revealed a BIMS score of 14, indicating the resident was cognitively intact. A progress note on 7/23/25 revealed a resident verbally abused a Spanish-speaking resident who was visiting with her/his family by making comments including, ""these people need to go back to where they belong they are taking over. I thought these was the United States (sic).""-á A note dated 7/30/25 revealed the resident again yelled at the Spanish-speaking resident, who was speaking on the telephone at the time.-á On 8/7/25 at 4:50 PM, Witness 1 (family) stated another resident at the facility had ""rude"" outbursts demanding, ""why don't you speak English this is America speak English (sic),"" and on ""8 different occasions"" multiple family members, as well as staff and residents, witnessed these verbal outbursts. Witness 1 stated the staff would apologize to Resident 43 and make her stay away instead of dealing with the resident who was having outbursts.-á Witness 1 stated Resident 43 was in the facility sitting in the dining area on a phone call and the other resident was watching TV and told telling Resident 43, ""Shut up why can't you speak English you are in America (sic),"" and continued being ""rude, obnoxious and disrespectful."" Witness 1 stated the facility staff had not discussed the outbursts with the family other than to tell them to ignore the other resident. -á On 8/8/25 at 10:06 AM, Witness 2 (Community Partner) stated the Resident 43's family called her and wanted her to file a complaint about the facility's failure to intervene because another resident was making racial slurs toward the resident and her/his family.-á Witness 2 stated the family member told her the statements were making the resident uncomfortable, and even though Resident 43 was not sure what is being said, GÇ£(Resident 43) knows it is bad."" Witness 2 also stated the family member told her the resident no longer wanted to go into the communal areas of the facility because of the hostile behavior of the other resident.-á On 8/11/25 at 12:45 PM Resident 43 stated she/he was talking with her/his grandson and his girlfriend in the common area and another resident turned and stared at them and then said, ""Why are you guys speaking in Spanish donGÇÖt you know you are in America (sic)?GÇ¥ Resident 43 stated the other resident kept talking and saying other things but the staff ignored it. Resident 43 stated there were other times the same resident made racial comments to her/him and her/his family. When her/his grandson came back the next time staff took him aside and told him ""not to take it personal and just ignore"" the residentGÇÖs comments and her/his grandson was ""very upset"" by the staffGÇÖs comments. Resident 43 stated she/he was on phone with her/his granddaughter and the other resident started making racial comments again so Resident 43 ended her/his phone call. A CNA asked Resident 43 if she/he wanted to go to another room or table and the other resident just kept saying things.-á On 8/5/25 Staff 1 (Administrator) was asked to provide copies of all internal and facility-reported incidents (FRI) involving alleged abuse. Staff 1 did not provide any documentation of an investigation or FRI for the events related to verbal abuse of Resident 43.-á On 8/11/25 at 3:30 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated they learned of the verbal abuse to Resident 43 on 8/8/25, implying they had not had time to initiate an investigation. During the interview with Staff 1 and Staff 2, Staff 3 (Vice President of Operations) entered the room and much of the conversation was repeated. Staff 3 stated, ""Thank you, we will look into this."" 2. Resident 49 was admitted to the facility in 3/2025 with diagnoses including dementia and anxiety. A Psychiatric Evaluation conducted 5/13/25 indicated Resident 43 had a SLUMS-á On 8/4/25 at 10:35 AM, Resident 49 stated her/his former roommate and Resident 49 had been arguing about the volume of televisions in the room. Resident 49 stated a staff person came into the room and talked with them and when the staff person left the roommate made ""a racial slur.""-á Resident 49 stated the slur was not made directly at her/him but was stated at a volume Resident 49 would not be able to avoid hearing. Resident 49 was very reserved in his language and bearing and would not repeat the exact language her/his former resident used.-á Resident 49 stated she/he was moved to her/his current room after the argument. Resident 49 stated as a result of the comment she/he no longer wants to go out into the facility because she/he does not want to interact with the other resident. Resident 49's Saint Louis Mental Status Exam (SLUMS) was 2/30 indicating mild cognitive impairment.-á A review of the residentGÇÖs clinical record revealed a Psych Note dated 5/19/25 stating the resident was irritable and expressed persecutory beliefs after an incident involving a racial slur, which resulted in Resident 49 being moved to another unit. -á On 8/5/25 Staff 1 (Administrator) was asked to provide copies of all internal and facility-reported incidents (FRI) involving alleged abuse. Staff 1 did not provide any documentation of an investigation or FRI for the events related to verbal abuse of Resident 49.-á On 8/11/25 at 3:30 PM, Staff 1 and Staff 2 (DNS) stated Resident 49 had suffered from a urinary tract infection at the time of the argument with her/his roommate which caused her/him to be confused. Staff 1 and Staff 2 did not comment on the lack of investigation of verbal abuse of Resident 43. During the interview with Staff 1 and Staff 2, Staff 3 (Vice President of Operations) entered the room and much of the conversation was repeated. Staff 3 stated, ""Thank you, we will look into this.""

Immediate action(s) taken for the resident(s) found to have been affected include: On 8/8/25, the Administrator and Director of Nursing (DNS) met with Resident #43 and family to acknowledge concerns, offer emotional support, and reinforce the resident’s right to be free from abuse. On 8/12/2025 Resident #43 was evaluated by Psych NP Treatment Plan: Supportive psychotherapy and emotional reassurance. Monitor for recurrence of interpersonal conflicts. Social work follow-up for advocacy and culturally sensitive care. Resident #49 was relocated to another hall to avoid further interactions with the abusive roommate on 5/16/2025. Resident #49 was provided with a room change on 5/16/2025 to minimize further contact with the resident involved in verbal abuse. The Administrator and Director of Nursing are no longer employed with Volare Health as of 8/22/2025. Identification of other residents having the potential to be affected was accomplished by: The facility has determined that all residents have the potential to be affected. The facility has determined that all residents have the potential to be affected. A facility-wide resident interview and observation audit was initiated on 8/8/25 to determine if any other residents had experienced or witnessed abuse.  No concerns of abuse were identified. Any additional reports identified as unaddressed abuse at the time of the audit have been reported to all regulatory reporting entities. Actions taken/systems put into place to reduce the risk of future occurrence include: An in-service education program was conducted by the Regional Director of Clinical (RDC) with the Director of Nursing Services and the Administrator with addressing circumstances that require reporting including appropriate timeframes. How the corrective action(s) will be monitored to ensure the practice will not reoccur: The Director of Nursing Services, or designee, will conduct a random audit of five (5) residents weekly for four (4) consecutive weeks and monthly for 3 months. These residents will be assessed and interviewed to ensure that any injuries are identified, properly investigated, and reported to the appropriate people. Findings of this audit will be discussed with the Resident Council. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met.

2. Resident 72 was admitted to the facility in 5/2025 with diagnoses including acute kidney disease. An Admission MDS dated 5/23/2025 revealed Resident 72 had a BIMS score of 14, which indicated the resident was cognitively intact. A review of the nursing notes dated 6/1/24 at 6:44 PM revealed the nurse documented Resident #72 developed blisters forming on her chest that are draining. The resident also complained of feeling she is on fire and being stabbed with needles. Resident was sent to emergency department. No documentation was found in clinical record informing resident 72 of Bed Hold Policy or written notice of transfer to the hospital. On 8/07/2025 5:32 PM Staff 2 (DNS) stated she could not find notice in clinical record for resident 72. On 8/07/2025 at 5:27 PM Staff 1 (Administrator) and Staff 2 (DNS) confirmed there was no bed hold notice given for resident 72. On 8/07/2025 5:39 PM, Staff 3 (VP of Operations) Staff 16 (SSD) did not give discharge and treatment notice, ""we dropped the ball.""-á , Resident 40 was admitted to the facility in 1/2023 with diagnoses including Type 2 diabetes mellitus.-á Resident 40 has a BIMS of 15 (cognitively intact).-á The undated Bed Hold Policy stated before the facility transferred a resident to a hospital the facility shall provide the resident a copy of the Bed Hold Policy and document in the resident's record whether the resident or resident's representative declined or agreed to pay to hold the bed. According to the policy, if a resident was unable to make a decision due to physical or mental incapacity and there was no legal representative to make a decision, the information would be documented in the resident's clinical record.-á A 3/4/25 Progress Note indicated Resident 40's roommate informed staff Resident 40 had fallen. Resident 40 was falling asleep as staff attempted to assess her/his condition and her CBG (blood glucose) was 63. The resident began exhibiting agonal breathing (an abnormal, gasping pattern of respiration that often indicates a medical emergency) and EMS was called. Resident 40 was transported to the hospital by EMS.-á On 8/7/24 at 4:28 PM, Staff 23 (LPN) stated the process when a resident needs to be sent to the hospital was to notify the doctor and unit manager and if it was a crisis, to call 911 and request an ambulance. Staff 23 stated if the resident was coherent, they would offer them a bed hold verbally but not provide a written notice.-á On 8/7/25 at 4:35 PM, Staff 8 (LPN/Unit Manager) stated staff were to call the family and inform them of the bed hold.-á On 8/7/25 at 4:53 PM, Resident 40 stated she/he was unconscious and not in any condition to get information when she/he was sent out the hospital on 3/4/25. Resident 40 stated she/he did not receive any paperwork from the facility when she/he was taken to the hospital.-á On 8/7/25 at 4:55 PM, Staff 3 stated the Discharge Transfer Notice was to be handed to the resident by nursing staff as they were wheeled out of the facility. On 8/7/25 at 5:05 PM, Staff 1 stated residents were supposed to get the pre-printed brochure and a copy of the Bed Hold Policy when they discharged to the hospital.-á -á -á

Immediate action(s) taken for the resident(s) found to have been affected include: Resident #40 and Resident #72 record was reviewed for notification of Bed Hold.  The resident and/or legal representative will be notified of the facility’s bed hold policy by 09/29/2025. Identification of other residents having the potential to be affected was accomplished by: The facility has determined that all residents transferred to the hospital have the potential to be affected. An audit was/will be completed by the Director of Nursing and / or designee from 08/30/2025 to 09/29/2025 validating any transfer to the hospital having received a Bed Hold Notice.  Any findings will be addressed with those residents or legal representatives. Actions taken/systems put into place to reduce the risk of future occurrence include: An in-service education program was conducted by the Director of Nursing Services and/ or designee with all licensed nursing staff and IDT addressing the facilities’ notification of bed hold policy. This will be completed by 09/29/2025. How the corrective action(s) will be monitored to ensure the practice will not reoccur: The Director of Nursing (DON) or designee will audit 5 random residents weekly for 4 weeks, then monthly for 3 months, These residents’ charts will be audited to ensure proper notification of bed hold was provided to the resident and/or legal representative and documented as such. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met.

Resident 62 was admitted to the facility on 6/30/25 with diagnoses including a stroke with fluency disorder (disrupts the natural flow of speech) and depression.-á The 7/28/25 psychiatric admission progress note indicated a new order for CBC (Complete Blood Count) lab. A review of Resident 62GÇÖs medical record revealed no indication a CBC lab draw was obtained. On 8/11/25 at 2:22 PM Staff 2 (DNS) stated she was not aware of the laboratory order for Resident 62, and it was not completed.

Immediate action(s) taken for the resident(s) found to have been affected include: A request for laboratory tests (BMP) ordered by the physician for resident(s) #62 were submitted to the lab o n 08/05/2025 .  Lab work was drawn at 0644 on 08/05/2025.  Test results were received at 0551 on 08/06/2025 and promptly reported to the ordering physician. Identification of other residents having the potential to be affected was accomplished by: The facility has determined that all residents with lab orders in a progress note have the potential to be affected . The Director of Nursing and / or designee completed an audit of all providers’ progress notes for labs ordered and not having a corresponding order entered I PCC and the lab test obtained. Any findings will be reported to the provider for follow up.  This audit will be completed by 9/29/2025. Actions taken/systems put into place to reduce the risk of future occurrence include: By 09/29/2025, the Director of Nursing Services and/or designee will provide Inservice education programs for all licensed staff and providers regarding the transcription and submission of physician orders from progress notes. How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing (DON) or designee will audit 5 random residents weekly for 4 weeks, then monthly for 3 months, to monitor the provision of s ervices ordered and provided for residents . Discrepancies will be promptly reported to the MD and the Administrator. Findings of this audit will be discussed with the QAPI Committee. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met.

Resident 10 was admitted to the facility in 7/2025 with diagnoses including stroke. A Fall Investigation Report indicated that on 6/12/25 at 4:10 AM, Staff 24 (Former LPN) responded to Resident 10GÇÖs call light and found her/him on the floor next to her/his bed. It was determined Resident 10 fell out of bed and her/his roommate activated the call light. Resident 10 was unable to recall how she/he ended up on the floor and did not know if she/he struck her/his head. On 6/12/25 at 4:10 AM, neurological checks were initiated. The Neurological Check Assessment form directed staff to complete neurological checks every 15 minutes for one hour, every 30 minutes for one hour, and every hour for four hours. Resident 10GÇÖs clinical record contained documentation of only one neurological assessment. On 8/11/25 at 11:00 AM, Staff 23 (LPN) stated that when a resident experienced an unwitnessed fall, staff were expected to complete and document neurological assessments. On 8/11/25 at 11:32 AM, Staff 2 (DNS) stated nurses were expected to complete and document neurological checks following an unwitnessed fall. Staff 2 acknowledged neurological assessments were not completed for Resident 10.

Immediate action(s) taken for the resident(s) found to have been affected include: Resident # 10 was reassessed September 5th by a licensed nurse. there were no abnormal neurological effects from the fall, or the missed documentation were noted. Patients attending notified no new orders. Patient is his own responsible party for contact. Identification of other residents having the potential to be affected was accomplished by: The facility has determined that all residents have the potential to be affected. An audit has been completed by the DON and/or designee for all residents Requiring neurological assessments from a fall. This audit was/will completed from 9/1/2025 through 9/29/2025. Any findings have been reported to the physician. Actions taken/systems put into place to reduce the risk of future occurrence include: An in-service education program was conducted by the Director of Nursing Services/Staff Development Coordinator/ designee with all licensed staff addressing circumstances that require tiered neurological assessments due to fall and possible head injury. Will be completed by 9/29/25 How the corrective action(s) will be monitored to ensure the practice will not recur: •     The Director of Nursing (DON) or designee will audit all residents required tiered neurological assessments due to fall and possible head injury weekly for 4 weeks, then monthly for 3 months.  This audit is to ensure that Neurological assessments are completed timely and documentation is complete. Findings of this audit will be discussed with the QAPI committee monthly. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met.

The Direct Care Staffing Daily Report forms 7/1/25 through 8/3/25 revealed the facility did not have sufficient CNA staffing for six out of 33 days reviewed.-á -7/3/25, (day shift). -7/4/25, (evening shift). -7/22/25, 7/5/25, 7/8/25, 7/19/25, (night shift).-á On 5/9/25 at 9:09 AM, Staff 25 (Regional Staffing Coordinator) confirmed the facility did not have sufficient staffing on the above dates.-á -á

The facility will maintain appropriate staffing numbers to adequately provide resident care and meet resident needs. The facility will staff at or above the minimum staffing requirement for daily census to meet resident needs per 19 CSR 30-85.022(41a) and determined by facility assessment. The facility will identify other situations having the potential to be affected by the same deficient practices as follows: All residents have the potential to be affected. The facility has implemented a recruiting initiative for licensed nurses, CMTs, and C.N.A.s. The facility is employing agency staff to maintain appropriate staffing numbers. The measures that will be put into place or systematic changes made to ensure that the deficient practice will not recur are as follows: The staffing schedule will be reviewed daily with the Administrator, DON, and staffing coordinator to validate appropriate staffing numbers and identify the distribution of staff based on resident needs. Unit Managers and Charge Nurses will be educated to ensure care is provided to residents, such as showers, wound care, call lights being answered in a timely manner, and residents care based on the residents plan of care, how to appropriately delegate tasks, monitor for assigned tasks completion, and who to contact if additional help or resources are needed. Outside consultant has been engaged to assist with staffing. The facility will monitor the corrective actions to ensure the deficient practice will not recur as follows: The DON/Designee will monitor staffing sheets and assignments daily to ensure appropriate staff are available and assignments are appropriately delegated 5 X a week for 4 weeks, then weekly thereafter for 3 months which will be an ongoing practice of this facility until substantial compliance is met. The DON/Designee will report all findings to the monthly QAPI committee.  The QAPI committee will determine when compliance is achieved or if further monitoring is required.

On 8/4/25 at 12:12 PM, Staff 30 (Dietary Aide) grabbed a plate cover from other staff that had left kitchen and placed it on the dirty dish counter and went back to plating lunches without washing his hands.-á On 8/4/25 at 12:20 PM, Staff 30 washed his hands, shut off the water with a paper towel and then dried his hands with the same paper towel.-á On 8/4/2025 12:23 PM, Staff 31 (Prep Cook/Dietary Aide) opened the refrigerator to remove items.-á After completing her task she washed hands, turned off the faucet with wet hands then dried her hands with a towel.-á On 8/4/25 a 12:25 PM, Staff 30 washed his hands, turned off the faucet with wet hands and dried his hands with a paper towel before returning to plating food.-á On 8/4/2025 at 12:36 PM Staff 30 stated he was trained to turn off the faucet with a paper towel then dry his hands with it and had not been aware the towel he used to turn off the faucet was contaminated.-á On 8/4/25 at 12:41 PM, Staff 19 (Corporate Dietary Manager) was present in the kitchen during lunch preparation and stated Staff 30 and Staff 31 did not follow the correct hand washing procedure.-á

Corrective action for affected residents No direct resident care was identified by this defective practice. The dietary aide who was observed failing to perform hand hygiene immediately received one-on-one re-education regarding the facility's infection control and hand hygiene policies, as well as the Centers for Disease Control and Prevention (CDC) guidelines. Identification of other residents with potential to be affected All residents have the potential to be affected by this defective practice. 3. Systemic changes to prevent recurrence Staff Education Program: A mandatory, comprehensive hand hygiene in-service training program will be developed and implemented for all dietary staff. This program will include: Demonstration of proper handwashing with soap and water and proper drying steps to verify staff are drying hands before turning off the faucet with a fresh paper towel. Emphasis on specific situations, such as before and after contact with surfaces that are not sanitary, before and after cleaning dishes, and after contact with soiled materials or touching hair, face, or clothing. Responsible Party: DM, ICP and Administrator 4. Monitoring to ensure solutions are sustained Hand Hygiene Audits: The Dietary manager or designee will conduct 3 random daily observations times 5 days a week for 4 weeks, then 3 daily random observations 5 times a week times for 4 weeks and then random daily observations twice a week for 3 months. Real-time Feedback: Staff will receive immediate, supportive, and constructive feedback when an observation occurs. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met.

On 8/4/25 at 9:45 AM, the outdoor refuse container for the facility was observed during a walk through with Staff 9 (Dietary Manager) of the outdoor trash and recycling area for the facility. The lid to the dumpster was open with a gap of about twelve to fifteen inches between the lid and body of the dumpster at the front of the unit. Staff 9 stated the staff did not always close the dumpster because it was difficult to close. When Staff 9 attempted to close the lid of the dumpster, he was unable to do so and stated the cranking mechanism used to close the dumpster appeared to be broken.-á -á

1. Immediate action(s) taken for the resident(s) found to have been affected include: No noted affected individuals. 2. Identification of other residents having the potential to be affected was accomplished by: The facility has determined that no residents were affected in the lack of lid on dumpster. An audit was completed by the Admin and / or designee 08/30/2025 confirming dumpster lid was closed. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: An in-service education program was/will be conducted by the Admin and/ or designee with all facility staff regarding the importance of opening and closing the lid on the dumpster to ensure proper sanitation. This will be completed by 09/29/2025. 4. How the corrective action(s) will be monitored to ensure the practice will not reoccur: The Admin. and/or designee will do 3 daily audits at random throughout the day x4 weeks. Then 3 daily random audits 5 times a week x4 weeks. Then random daily audits twice a week monthly. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met.

The online reference ""CDC Preventing C-Diff."" revealed the best way to prevent the spread of C-Diff from person to person-áwas for all healthcare workers to wash their hands with soap and water before and after touching contaminated surfaces and for proper disinfection of bleaching surfaces. The online reference GÇ£CDC How C-Diff. spreadsGÇ¥ revealed any surface, device or material that becomes contaminated with feces could serve as a reservoir for C- Diff spores. C- Diff spores can transfer to patients by the hands of healthcare personnel who have touched a contaminated surface or item. C-Diff can live on inanimate surfaces for up to five months. A contaminated wheelchair becomes a vector for transmission to other residents, staff, and visitors. The online reference GÇ£CDC The Progression of C-Diff. InfectionGÇ¥ revealed C-Diff can be colonized, but the bacteria itself can be spread through spores even in the absence of detectable toxin levels. Resident 78 admitted to the facility on 7/29/25 with diagnoses including C-Diff, weakness, and nicotine dependence. A review of the 7/29/25 Hospital Discharge Summary revealed Resident 78 had a diagnosis of C-Diff. The C-Diff DNA revealed it was positive, and the toxin was negative (can indicate colonization rather than active infection). The resident was to continue with oral antibiotics through 8/5/25 and was to be on isolation enteric precautions (including PPE gloves and a gown, disinfect all equipment used before it left the room and hand washing with soap and water prior to exit of the room).-á A review of the 7/30/25 Smoking Safety Assessment revealed the resident was assessed for smoking safety and was deemed independent, able to smoke in the designated smoking area at the facility.-á A review of the facility floor plan revealed the designated smoking area for the residents was located on the second floor of the facility. The 7/30/25 care plan for C-Diff indicated Resident 78 was on contact isolation precautions and all equipment used was to be disinfected before it left the room. A review of the August 2025 MAR revealed Resident 78 completed a course of antibiotics on 8/3/25. Bowel records from 8/2/25 through 8/7/25 indicated Resident 78 had 13 bowel movements; nine were loose/diarrhea; bowel movements each day. The last loose stool was on 8/7/25 at 1:00 PM. On 8/4/25 at 1:53 PM Resident 78 was observed to exit her/his room independently on the first floor and self-propel the wheelchair down the hallway to the elevator. The resident did not disinfect her/his wheelchair before it left the room, and no staff members were observed to exit the residentGÇÖs room after the resident. On 8/7/25 at 1:50 PM Resident 78 was observed to exit her/his room independently on the first floor and self-propelled the wheelchair down the hallway to the elevator. The resident did not disinfect her/his wheelchair before it left the room, and no staff members were observed to exit the residentGÇÖs room after the resident. On 8/7/25 at 4:13 PM Resident 78 was observed to exit the elevator independently on the second floor and self-propel towards the back exit that led to the dedicated smoking area for residents. Staff 4 (CNA) greeted Resident 78 and asked if she/he wanted assistance outside; Resident 78 accepted. Staff 4 was observed to wheel Resident 78 to the back door, open the locked back door using a key card that was on her person with non-gloved hands and assist the resident by pushing the wheelchair outside to the smoking area. Staff 4 was observed to have re-entered the facility using her key card with a non-gloved hand and proceeded to her job duties without washing her hands with soap and water after assisting Resident 78. On 8/7/25 at 4:16 PM and at 6:21 PM Staff 4 stated she was unaware Resident 78 was on contact precautions. Staff 4 stated it was not communicated to staff who worked on the second floor any resident who was on transmission-based precautions from the first floor. Staff 4 confirmed she did not wash her hands with soap and water after contact with Resident 78GÇÖs wheelchair.-á On 8/7/25 at 4:41 PM Staff 10 (CNA) and at 4:46 PM Staff 11 (CNA) both stated they worked on the second floor and were unaware of any resident who was on contact precautions from the first floor as that was not communicated to them. On 8/7/25 at 5:09 PM Staff 12 (CNA) stated he worked on the first and second floors and was aware of Resident 78GÇÖs contact precautions; however, he was unsure how that was communicated to the staff on the second floor. -á On 8/7/25 at 5:15 PM Staff 13 (CNA) stated she worked on the second floor only and it was not communicated to her if any residents from the first floor were on contact precautions. -á On 8/7/25 at 6:16 PM Staff 14 (CNA) stated she assisted any resident who was an independent smoker to the smoking area by using her key card to unlock the door. She stated she was unaware of residents on precautions from the first floor. On 8/7/25 at 7:00 PM Staff 5 (CNA) stated he worked on the first floor, worked with Resident 78, and was aware of the contact precautions in place. Staff 5 stated Resident 78GÇÖs wheelchair was on a cleaning schedule for night shift to complete but was not disinfected with bleach each time the resident left her/his room. Staff 5 stated Resident 78 was an independent smoker and left her/his room often to go the smoking area on the second floor.-á On 8/7/25 at 8:10 PM Staff 1 (Administrator), Staff 3 (Vice President of Operations), and Staff 6 (Regional RN) were informed the facilityGÇÖs failure to implement appropriate precautions to prevent the spread of C-Diff constituted an Immediate Jeopardy situation. An IJ start date was determined as 7/29/25. An IJ removal plan was requested.-á On 8/7/25 at 10:32 PM an acceptable facility IJ removal plan was submitted by the facility. The plan indicated the facility would implement the following actions: -Resident 78 requested to stay in her/his room except for medically necessary transport. Smoking privileges with one-on-one escort until transmission-based precautions were discontinued per Infection Preventionist (IP) order. -Resident 78 identified as having or being at risk for C-Diff was reviewed by the Director of Nursing (DON) and with the Medical Director on 8/7/25. -Contact Precautions Re-Education: All staff were reminded verbally and in writing that Resident 78 was on Contact Precautions- including gown and gloves upon room entry, hand hygiene with soap and water upon exit of room or after disinfection or contact with contaminated equipment, and disinfection of all equipment after use. -Wheelchair Disinfection: Resident 78GÇÖs wheelchair was sanitized with bleach wipes prior to exit and re-entry to her/his room and after any use. A dedicated wheelchair was labeled and restricted to Resident 78 only. - Hand Hygiene Enforcement: Staff member involved in breach (Staff 4) was re-educated immediately on proper C-Diff protocol, specifically that alcohol-based sanitizer is ineffective against spores; soap and water are required. Staff 4 was removed from direct resident care until re-education was completed, and competency was validated. -Environmental Cleaning: Housekeeping performed immediate bleach-based cleaning of all surfaces touched by Resident 78 and/or the residentGÇÖs wheelchair (elevator buttons, back door, and smoking area entrance).-á -Resident 78 was placed on one-on-one to ensure compliance with C-Diff precautions. The immediacy was removed on 8/11/25 after onsite verification of the IJ removal plan.

1. Immediate Actions Taken (Within Hours of IJ Notification) •             Resident #78 requested  to stay room except for medically necessary transport. Smoking privileges with 1 on 1 escort until transmission-based precautions discontinued per Infection Preventionist (IP) order. •             Resident #78 identified as having or being at risk for Clostridium Difficile (C. Diff.) was reviewed by the Director of Nursing (DON) and with the  Medical Director on 8/7/25. •             Contact Precautions Re-Education: All staff reminded verbally and in writing that Resident #78 is on Contact Precautions—including gown and gloves upon room entry, hand hygiene with soap and water upon exit of room or after disinfection or contact with contaminated equipment , and disinfection of all equipment after use. •             Wheelchair Disinfection: Resident #78’s wheelchair sanitized with bleach wipes prior to exit and re-entry to room and after any use. Dedicated wheelchair labeled and restricted to Resident #78 only. •             Hand Hygiene Enforcement: Staff members involved in breach (Staff #4) re-educated immediately on proper C. diff protocol, specifically that alcohol-based sanitizer is ineffective against spores; soap and water required. Staff removed from direct resident care until re-education completed, and competency validated. •             Environmental Cleaning: Housekeeping performed immediate bleach-based cleaning of all surfaces touched by Resident #78’s and/or wheelchair (elevator buttons, back door handle, smoking area entrance). •             Resident placed on 1 on 1 to ensure residents compliance with C-diff precautions. ________________________________________ 2. Staff Re-Education and Competency Validation (Within 24 Hours) •             Infection Control In-Service: All facility staff (nursing, housekeeping, dietary, therapy, administrative) received mandatory training on C. diff transmission, proper PPE use, contact precaution protocols, and cleaning requirements. •             Competency Checks for all staff: Return demonstrations on Donning/doffing PPE, •             Hand hygiene using soap and water •             Disinfecting wheelchairs and high-touch surfaces with bleach solution. •             Signage: Clear transmission-based precaution signage posted at Resident #78’s door and nursing stations. ________________________________________ 3. Ongoing Monitoring and Sustainability Measures •             PCC communication posting of C-Diff resident in the building for all staff to see.  The daily room roster handed out to staff without PCC access will be updated with resident on C-Diff precautions. •             While resident is out of room the 1 on 1 escort will ensure transmission-based precautions are maintained until discontinued per Infection Preventionist (IP) order •             Infection Preventionist Rounds: IP to audit: PPE and C-diff precaution compliance. •             Resident #78’s isolation compliance every shift •             PPE adherence at point of care •             Handwashing technique •             Wheelchair disinfection logs •             Environmental Services Logs: All high-touch surfaces in common areas to be cleaned with bleach daily. •             Staff Awareness: Daily huddles for 7 days to reinforce protocols and address any gaps. ________________________________________ 4. How the nursing home plans to monitor its performance to make sure that solutions are sustained The Director of Nursing or designee with the oversight of the Administrator will conduct 3 times a week infection control audits weekly for four weeks, monthly for three months, and periodically thereafter to ensure compliance with Infection Prevention Control Standards. These will begin 9/8/2025. Weekly reporting to QAPI Committee (Beginning 9/15/25) and Monthly Governing Body review (Beginning 9/8/25). The Director of Nursing and or designee will promptly address identified concerns, and the results of the audits will be brought to the monthly Quality Assurance and Performance Improvement.

The facility had four residents approved for the bariatric rate.-á A review of the Direct Care Staff Daily Reports form7/1/25 through 8/3/25 revealed the following days when the State minimum bariatric CNA staffing ratios were not met for one or more shifts: 7/16/25, 7/11/25, 7/10/25, 7/9/25, 7/7/25, 7/6/25, 7/4/25, 7/3/25, and 7/2/25, (day shift). -7/21/25, 7/16/25, 7/15/25, 7/14/25, 7/8/25, 7/4/25, and 7/2/25 (evening shift). -7/22/25, 7/19/25, 7/18/25, 7/14/25, 7/12/25, 7/8/25, and 7/5/25 (night shift).-á On 8/9/25 at 9:09 AM, Staff 25 (Regional Staffing Coordinator) confirmed the above dates the facility was short staffed for CNAs at the State minimum bariatric rate.-á

1.           Immediate action(s) taken for the residents found to have been affected include: Staffing schedules have been reviewed to ensure minimum state staffing levels for bariatric care are met. 2.           Identification of other residents having the potential to be affected was accomplished by: All bariatric residents have the potential to be affected. All staffing schedules have been reviewed to ensure minimum staffing levels for bariatric residents are met. 3.           Actions taken/systems put into place to reduce the risk of future occurrence include: The facility will utilize staffing-agency to ensure minimum staffing levels are achieved. Facility has implemented a mentor program with weekly meetings.  Facility has a weekly recruiting call.  Weekly staffing meetings are held to ensure staffing schedules achieve minimum staffing levels for bariatric residents and any open shifts will be filled by bonusing facility level care staff or agency staffing. Staffing coordinator and DON have been educated on minimum staffing levels for bariatric patients and to ensure staffing schedules meet the minimum staffing guidelines and utilization of facility level bonus program and agency use. 4.           How the corrective action(s) will be monitored to ensure the practice will not reoccur: Administrator, or designee, will audit staffing schedules weekly x1 month, bimonthly x1 month, and monthly thereafter until IDT determines sustainable compliance has been achieved. Administrator, Staffing Coordinator, DON, or designees, will attend weekly staffing meetings until IDT determines sustainable compliance has been achieved.

Based on interview and record review it was determined the facility failed to protect residents' right to be free from verbal abuse by staff for 1 of 3 residents (#10) reviewed for abuse and neglect. This placed residents at risk for abuse. Findings include: Resident 10 admitted to the facility in 9/2024 with diagnoses including chronic ulcer to left lower leg, and fracture to the sacrum. An Investigation Report, with an investigation date from 10/3/24 through 10/8/24, revealed on 10/3/24 at approximately 11:00 AM Resident 10 asked Staff 17 (Admissions Coordinator) to assist with filling out a grievance form. Resident 10 stated she/he was asleep and Staff 4 (CNA) came into the room and, with a loud voice, stated "I need your vitals." Staff 4 was loud enough to wake Resident 10 from a deep sleep. Resident 10 stated she/he did not know why Staff 4 was yelling. Staff 4 continued to yell and his voice got louder. Resident 10 stated she/he raised her/his voice to match Staff 4's voice. Staff 4 informed Resident 10 he was at the facility for three years and stated he was "going to do what he does." Staff 4 left the room, and then came back and told Resident 10 to turn the TV down because it was too loud, and then he left. Staff 4 came back a third time and yelled "I'm going to do what I have to do." Resident 4 stopped talking and listening to Staff 4 because his voice was too loud. Staff 4 came back into the room again and stated, "It does not matter what you say to anyone, I'm going to do what I want to do." Resident 10 repeated what Staff 4 said, and Staff 4 started calling Resident 10 a "lair." Staff 4 called Resident 10 a liar multiple times with each time getting louder. Resident 10 asked Staff 4 to leave the room multiple times, but he continued to stay and call Resident 10 a liar. A 10/7/24 MDS indicated Resident 10's BIMS score was 15 indicating she/he was cognitively intact. Resident 10 exhibited no physical, verbal, or other behavioral symptoms during the seven days look back period. On 10/8/24 at 10:56 AM Resident 10 stated Staff 4 called her/him a "damn liar" six to eight times. Resident 10 stated Staff 4's voice was "strong" and when Staff 4 came into the room he just "slapped" the blood pressure cuff on her/him while she/he was still in a daze from waking up. Staff 4 told Resident 10 he needed to get the vitals checks completed. Staff 4 told Resident 10 he was so loud because his roommate was hard of hearing. Staff 4 came back into the room later and told Resident 10 to turn down her/his TV. Resident 10 stated she/he felt like Staff 4 verbally abused her/him. Resident 10 stated she/he told Staff 4 to leave her/his room six to eight times. Resident 10 stated Staff 32 could also hear what occurred. On 10/14/24 at 10:58 AM Staff 17 stated on 10/3/24 she went into Resident 10's room and she/he reported Staff 4 verbally abused her/him. Resident 10 requested to speak to the Staff 1 (Administrator) or Staff 2 (DNS) and if they were not available to fill out a grievance. Staff 17 did not find Staff 1 or Staff 2 so as she brought back a grievance form to Resident 10's room, she could hear yelling down the hallway coming from Resident 10's area. When Staff 17 arrived at Resident 10's door Staff 4 was at the foot of Resident 10's bed, and Staff 32 (LPN) was standing by the closets in the room. Staff 4 was apologizing to Resident 10, Resident 10 interrupted Staff 4 and asked him to get out of her/his room. As Staff 4 walked out of the room he stopped three different times and yelled at Resident 10 she/he was a "lair." After Staff 4 left the room Staff 32 informed Resident 10 she would replace Staff 4 with another CNA. Attempts to contact Staff 32 on 10/11/24, 10/14/24 and 10/15/24 by phone were unsuccessful. On 10/15/24 at 8:43 AM Staff 4 stated he went into Resident 10's room, obtained her/his vital signs, and she/he was upset about Staff 4 waking her/him up. Staff 4 then went to obtain Resident 10's roommate's vital signs, it was bothering Resident 10, and she/he asked "Do you have to be so fucking loud?" Staff 4 brought Resident 10 breakfast and later she/he stated Staff 4 did not bring her/his breakfast. Staff 4 came back to the room to apologize and stated to Resident 10 they did not have a good start to the day, but Resident 10 was still upset. Staff 4 stated he did call Resident 10 a liar but did not yell at her/him. On 10/16/24 at 10:30 AM Staff 1, Staff 2 and Staff 37 (Regional Nurse Consultant) stated during their investigation Staff 17 did not say Staff 4 was yelling at Resident 10. Staff 2 confirmed their investigation was found to be unsubstantiated. Staff 2 stated Staff 4 should have left Resident 10's room and reported Resident 10's behavior to a charge nurse when Resident 10's behavior escalated and she/he told Staff 4 to leave the room.

Resident # 10 is no longer a resident at the facility. Staff Member was terminated 10/18/24 and OSBN notified 11/4/24 of the determination of substantiated Abuse by DHS. Residents who reside in the facility have the potential to be affected. The DON/Designee will complete a baseline interview of current residents with BIMs 9 or higher to verify if they have received verbal abuse from staff. Identified issues will be addressed. The DON/Designee will provide further education to staff related to abuse with specific focus on verbal abuse. The DON/Designee will complete audit of reports of verbal abuse to verify FRI was submitted timely and final investigation was thorough and submitted to DHS timely. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to report investigations timely to the State Survey Agency for 3 of 6 sampled residents (#s 12, 19, and 20) reviewed for medications, abuse, and neglect. This placed residents at risk for abuse and neglect. Findings include: 1. Resident 12 admitted to the facility in 9/2024 with diagnoses including anxiety and a leg fracture. A FRI form dated 9/22/24 indicated an incident was reported to the State Agency on 9/22/24 for an unknown incident date. A related Investigation Report with an investigation date of 9/22/24 through 9/27/24 was received by the State Agency on 10/2/24. On 10/16/24 at 10:49 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 37 (Regional Nurse Consultant) stated Staff 2 thought she emailed the investigation timely, but she did not, and confirmed the investigation was sent late to State Agency. 2. Resident 19 admitted to the facility in 5/2024 with diagnoses including pain and surgical aftercare. A FRI form dated 6/24/24 indicated an incident was reported to the State Agency on 6/24/24 for a 6/19/24 incident. The facility was made aware of the incident on 6/24/24. An Investigation Report with an investigation date of 6/19/24 through 7/1/24 was received by the State Agency on 7/4/24. On 10/16/24 at 10:58 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 37 (Regional Nurse Consultant) stated the facility had issues contacting one of the witnesses and confirmed the investigation was sent late to the State Agency. 3. Resident 20 admitted to the facility in 5/2024 with diagnoses including a leg fracture. A FRI form dated 9/27/24 indicated an incident was reported to the State Agency on 9/27/24 for a 9/27/24 incident. The facility was made aware of the incident on 9/27/24. An Investigation Report with an investigation date of 9/27/24 through 10/10/24 was received by the State Agency on 10/10/24. On 10/16/24 at 11:27 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 37 (Regional Nurse Consultant) confirmed the 9/27/24 investigation was sent late to the State Agency.

Resident #12 investigation for facility FRI submitted on 9/22/24 was completed and submitted 10/2/24. Resident #19 investigation for facility FRI submitted on 6/24/24 was completed and submitted 7/4/24. Resident #20 investigation for facility FRI submitted on 9/27/24 was completed and submitted 10/10/24. The DON/Designee will complete a baseline audit for the last 14 days to verify Facility Reported Incidents (FRI) were completed and submitted to DHS within the required time frame. The DON/Designee will provide further education to IDT staff related to the time frame in which FRI investigations are to be completed and submitted to DHS. The DON/Designee will complete an ongoing weekly audit of FRI to validate investigation was completed and submitted timely to DHS. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to conduct timely or thorough investigations for 3 of 6 sampled residents (#s 11, 19, and 20) reviewed for medications and accidents. This placed residents at risk for falls, uncontrolled pain, and overdose. Findings include: 1. Resident 11 admitted to the facility in 3/2023 with diagnoses including arthritis. Review of a Progress Note dated 6/3/24 revealed Resident 11 was found on the floor next to her/his bed laying on her/his left side. A review of an Un-witnessed Fall investigation dated 6/3/24 revealed Resident 11 was found on the floor next to her/his bed laying on her/his left side. The investigation was completed on 6/26/24. On 10/16/24 at 10:39 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 37 (Regional Nurse Consultant) confirmed Resident 11's fall investigation for her/his 6/3/24 fall was completed late. 2. Resident 19 admitted to the facility in 5/2024 with diagnoses including pain and surgical aftercare. A review of the TAR dated 6/2024 instructed staff to change Resident 19's right lower leg dressing daily with a start date of 5/28/24. On 6/19/24 and 6/21/24 Staff 18 (Agency LPN) completed Resident 19's wound treatment. An Investigation Report with an investigation date of 6/24/24 through 7/1/24 indicated Resident 19 submitted a grievance on 6/24/24 alleging Staff 18 (Agency LPN) was rough during care and had "poor bedside manner" during wound care treatment on 6/19/24. Resident 19 indicated the application of skin prep was more sensitive and "caught [her/him] off guard." Staff 18 was taken off the facility's schedule and would not be rescheduled. Allegations of mistreatment and abuse were unsubstantiated. The investigation did not include witness statements of other residents, staff, or Staff 18. Attempts to reach Resident 19 on 10/8/24 and 10/9/24 were unsuccessful. On 10/14/24 at 10:21 AM Staff 18 stated the facility did not contact her regarding the concern about Resident 19's wound care and she was unaware there was a concern. On 10/16/24 at 11:03 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 37 (Regional Nurse Consultant) confirmed the investigation should have included information about Resident 19's pain medication. Staff 2 stated they were unable to contact Staff 18 for a witness statement. Staff 2 stated she was out of the facility and may not have followed up after her return. 3. Resident 20 admitted to the facility in 5/2024 with diagnoses including a leg fracture. A review of a Nursing Note dated 9/27/24 indicated Resident 20 was unresponsive roughly an hour after a medication administration. An Investigation Report with an investigation date of 9/27/24 through 10/10/24 revealed Resident 20's family member reported the facility was "sedating" and "abusing" Resident 20. On 9/22/24 a floor nurse reported altered mentation of the resident, Resident 20 was examined at a hospital emergency department (ED), and then returned to the facility. Resident 20 complained of inadequate pain control and repeatedly requested more narcotic pain and sedating medications. There was discussion of narcotic influence as the longer she/he was in the ED the "normal" she/he presented. The physician indicated it was suspected Resident 20 had altered mentation due to sedation from pain medications. The conclusion of the investigation revealed abuse and neglect were ruled out, Resident 20 had altered mentation on 9/27/24 and the facility responded timely. Per provider and family direction the facility was to assist the resident to balance and manage pain with pain medications, but not over-sedate the resident. The investigation included a paragraph regarding a different resident and a verbal altercation with another resident unrelated to Resident 20's investigation. The investigation did not include a reconciliation of Resident 20's medications or review of administration of narcotics or sedating medications administered. On 10/14/24 at 9:53 AM Staff 26 (LPN) stated on 9/27/24 Resident 20 was completely cognitively intact and, after medication administration, Resident 20 was unresponsive and she/he was sent to the ED. On 10/16/24 at 11:28 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 37 (Regional Nurse Consultant) stated they were focusing on the general complaint and communication between the facility and the emergency room visits. Staff 37 stated she reviewed medications to ensure administered as ordered but did not include in the investigation. Refer to F842.

Resident #11 no longer resides at the facility. Resident #19 no longer resides at the facility. Resident #20 no longer resides at the facility. The DON/Designee will complete a baseline audit of current residents for the last 14 days to verify residents who had an investigation completed, that the investigation was completed timely, thorough and included witness statements. The DON/Designee will provide further education to nursing staff related to completing timely and thorough investigations to include obtaining witness statements. The DON/Designee will complete weekly audits to investigations completed to verify they are completed timely, thorough and include witness statements. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined facility staff failed to follow professional standards of practice during care and services for 1 of 3 (#12) sampled residents reviewed for abuse and neglect. This placed residents at risk for abuse and neglect. Findings include: Resident 12 admitted to the facility in 9/2024 with diagnoses including a leg fracture. A FRI was received on 9/23/24 which indicated Staff 7 (CNA) was a "little too personal with her." Staff 7 spent too much time with Resident 12, rubbed cream on her/his buttocks and massaged her/his right hip in a way which felt inappropriate, and unlike any other staff. Staff 7 also gave Resident 12 a big hug. Staff 7 provided his personal phone number to Resident 12 and reported to her/him that he could be her/his personal caregiver at her/his home when she/he discharged from the facility. Staff 7 also spent "way too much time" with Resident 12 and came into her/his room and visited with her/him. On 10/8/24 at 12:58 PM Resident 12 stated Staff 7 massaged her/his leg, and no other CNAs were massaging her/him. Staff 7 came and sat in Resident 12's room for a "long time" and when he left, he asked Resident 12 for a hug as he told her/him he was not coming back. Resident 12 stated she/he felt Staff 7 was going "over the line." Staff 7 also provided his name, address, and phone number to be a possible in-home caregiver after she/he discharged from the facility. Resident 12 stated she/he did not feel it was sexual abuse but felt Staff 7's behavior was not professional. On 10/11/24 at 8:17 AM Witness 7 (Family Member) stated Resident 12 reported to her that Staff 7 was overly friendly and wrote his name and phone number on paper to be Resident 12's home caregiver. Witness 7 stated Staff 36 (Speech Therapist) took a photo of the paper. Staff 7 also took a tube of cream out of her/his pocket and told Resident 12 it was a cream he used on her/his bad back, and he applied the cream on Resident 12. Witness 7 stated Resident 12 never complained of any of the other staff members and she/he no longer wanted Staff 7 to provide care to her/him. On 10/11/24 at 9:25 AM Staff 36 stated she saw the paper with Staff 7's contact information he provided to Resident 12, and she photographed the paper and reported the information to Staff 35 (Director of Rehabilitation). On 10/11/24 at 9:41 AM Staff 35 stated he reported the information from Staff 36 regarding Staff 7's contact information to Staff 1 (Administrator) as he was told it was inappropriate. Staff 35 stated it was "in their hands" after he reported it. On 10/11/24 at 11:41 AM Staff 7 stated he provided his phone number to Resident 12's family for possible in-home caregiving. Staff 7 stated he did not sit with Resident 12 and visit with her/him in her/his room. Staff 7 stated he believed Resident 12 gave him a hug once as a friendly "thank you" type hug. Staff 7 denied massaging Resident 12's hip but did provide incontinent care and barrier cream. On 10/16/24 at 10:43 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 37 (Regional Nurse Consultant) confirmed it was against facility policy and a conflict of interest for Staff 7 to provide his phone number and solicit work outside of the facility to Resident 12, and Resident 12 was modest but did not feel inappropriate physical contact occurred. Resident 12 reported that conversations between Staff 7 and Resident 12 were "odd."

Resident #12 no longer resides at the facility Staff member was terminated on 10/18/24 related to conduct unbecoming of a CNA. The DON/Designee will complete a baseline interview with current resident who are in the facility on a short term stay with BIMS 9 or higher to verify if staff are soliciting additional work from them upon discharge or crossing professional boundaries of communication that cause them to be uncomfortable. The DON/Designee will provide further education to nursing staff related to facility handbook policies related to solicitation of services and professional conduct with OSBN licensure. The Don/Designee will complete ongoing interviews with 5 random residents on a temporary stay with BIMs 9 or higher to verify staff are not soliciting additional work from them upon discharge or crossing professional boundaries of communication that cause them to be uncomfortable. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 2 of 3 sampled residents (#s 21 and 22) reviewed for ADLs. This placed residents at risk for unmet needs. Findings include: 1. Resident 21 admitted to the facility in 8/2024 with diagnoses including dementia and anxiety. A review of Resident 21's care plan dated 8/20/24 indicated Resident 21 had an ADL self-care performance deficit and required substantial to maximal assistance from staff with bathing. The admission MDS dated 8/25/24 revealed Resident 21's BIMS score was four, which indicated severe cognitive impairment. A review of the Documentation Survey Report (DSR) for 8/20/24 through 8/31/24 revealed Resident 21's bathing days were Monday and Thursday, and she/he required substantial to maximal assistance from staff for bathing on 8/22/24. On 8/26/24 there was no documentation Resident 21 received bathing. On 8/29/24 documentation indicated Resident 21 refused bathing. The DSR from 9/1/24 through 9/16/24 revealed Resident 21 received bathing on 9/5/24, and refused bathing on 9/2/24 and 9/12/24. On 9/9/24 Staff 19 (CNA) documented bathing was not attempted due to environmental limitations. Resident 21 went 13 days without bathing from 8/23/24 to 9/5/24, and seven days from 9/6/24 through 9/16/24. A review of 8/2024 and 9/2024 Skin and Shower Review sheets revealed on 8/26/24 a sheet was filled out with no resident signature of refusal and was signed by a CNA and nurse. No other information was on the form. On 8/28/24 the sheet was signed by Resident 21 as refused bathing and signed by the CNA and nurse. No other documentation of Skin and Shower Review sheets were found in Resident 21's clinical record. On 10/10/24 at 12:18 PM Staff 19 stated he only worked at the facility for a few weeks and did not know to mark "environmental issues" instead of resident refusal when there was a lack of staff, and he could not complete Resident 21's bathing. On 10/14/24 at 9:20 AM Staff 27 (CNA) stated the process when a resident refused a shower was to reapproach the resident, complete a Skin and Shower Review sheet, have the resident sign the sheet that she/he refused the shower, and then the nurse would also sign the sheet. On 10/16/24 at 11:29 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 37 (Regional Nurse Consultant) stated they were starting a new tracking system for missed showers. 2. Resident 22 admitted to the facility in 7/2024 with diagnoses including history of falling, dementia, and anxiety. On 8/28/24 the State Survey Agency received a public complaint which indicated Resident 22 had an incontinent episode because it took staff longer to assist residents as the facility was short-staffed. A review of Resident 22's care plan dated 7/22/24 indicated she/he had an ADL self-care performance deficit and was totally dependent on one staff for toilet use and transferring. Resident 22 had occasional bladder incontinence and used a bedside commode. The Admission MDS dated 7/28/24 revealed Resident 22 was rarely understood, required substantial to maximal assistance with toilet transfers and was occasionally incontinent of bladder. A Direct Care Staffing Daily Report revealed on 8/2024 during the evening shift Resident 22 was continent 22 times out of 31 opportunities. On 8/13/24 there was no documentation of bladder elimination. There were five instances Resident 22 was documented as wet and one time as soaked. A Direct Care Staff Daily Report dated 8/28/24 revealed on evening shift the facility was not staffed to meet the state minimum staffing requirements. On 10/9/24 at 9:59 AM Witness 4 (Complainant) confirmed Resident 22 had an incontinent episode due to a long wait for staff assistance. On 10/8/24 at 10:36 AM Staff 28 stated there were negative outcomes to the residents because the facility was short-staffed including continent residents experiencing incontinent episodes. On 10/16/24 at 11:32 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 37 (Regional Nurse Consultant) stated staff were supposed to call Staff 2 even if it was the middle of the night if they needed assistance because of low staffing.

Resident #21 no longer resides at the facility. Resident #22 no longer resides at the facility. The DON/Designee will complete a baseline audit of current dependent residents to verify they are being offered bathing opportunities per their bathing schedule. The DON/Designee will complete a baseline interview of current residents with BIMs 9 or higher who require assistance with toileting to verify they are being offered assistance timely. The DON/Designee will provide further education to nursing staff related to completing ADL care with specific focus on bathing. The DON/Designee will provide further education to nursing staff related to providing assistance with toileting timely to prevent incontinence accidents and provide timely assistance. The DON/Designee will complete weekly audits on current residents to verify bathing opportunities and were offered per the resident schedule. The DON/Designee will complete weekly interviews with 10 current residents who require assistance with toileting to verify assistance is provided timely. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview, and record review it was determined the facility failed to provide sufficient staffing to meet the needs of residents for 3 of 5 sampled residents (#14, 17, and 22) and 2 of 2 floors (1st floor and 2nd floor) reviewed for staffing. This placed residents at risk for unmet needs. Findings include: 1. Resident 17 admitted to the facility in 4/2024 with diagnoses including paraplegia and pressure ulcer. A review of Resident 17's care plan dated 4/16/24 indicated Resident 17 was at risk for falls and to ensure the resident's call light was in reach, to encourage the resident to use it for assistance, and she/he needed prompt response to all requests for assistance. A review of Resident 17's admission MDS dated 4/11/24 revealed Resident 17's BIMS score was 15 which indicated she/he was cognitively intact. On 10/8/24 at 10:10 AM Resident 17 stated the facility was short-staffed in 8/2024 and 9/2024 and there were times when here/his call light was activated for multiple hours without response. Weekends were "horrible" with one CNA to 45 residents. On 10/8/24 at 10:36 AM Witness 3 (Complainant) stated she quit working at the facility because the short staffing was unsafe for the residents. Every weekend was short-staffed. One weekend she was assigned 23 residents on day shift. Witness 3 stated residents did not receive showers, and there were incontinent episodes for residents who were continent as well as many falls. On 10/15/24 at 8:41 AM Staff 4 (CNA) stated when he took breaks and lunches the other CNAs did not answer his call lights and, as a result, residents had to wait. Staff 4 stated the short staffing at the facility was "ridiculous." On 10/16/24 at 11:05 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 37 (Regional Nurse Consultant) stated they worked with their corporate office to address the concern of staffing. 2. Resident 22 admitted to the facility in 7/2024 with diagnoses including history of falling, dementia and anxiety. On 8/28/24 the State Survey Agency received a public complaint which indicated Resident 22 had an incontinent episode because it took staff longer to assist residents as the facility was short-staffed. The Admission MDS dated 7/28/24 revealed Resident 22 was rarely understood, required substantial to maximal assistance with toilet transfers and was occasionally incontinent of bladder. A Direct Care Staffing Daily Report for 8/2024 revealed on evening shift Resident 22 was continent 22 times out of 31 opportunities. On 8/13/24 there was no documentation of bladder elimination. There were five instances Resident 22 was documented as wet and one time as soaked. A Direct Care Staff Daily Report dated 8/28/24 revealed on evening shift the facility was not staffed to meet the state minimum CNA staffing requirements. On 10/9/24 at 9:59 AM Witness 4 (Complainant) confirmed Resident 22 had an incontinent episode because she/he had to wait for staff assistance. On 10/16/24 at 11:05 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 37 (Regional Nurse Consultant) stated they worked with their corporate office to address the concern of staffing. 3. On 10/8/24 at 10:36 AM Staff 28 stated there were negative outcomes to the residents because the facility was short-staffed including continent residents experiencing incontinent episodes. On 10/8/24 at 10:36 AM Staff 28 (CNA) stated the short staffing at the facility made it unsafe for the residents in 8/2024 and 9/2024. Every weekend the facility was short-staffed, and one day shift she was assigned 23 residents. Bathing was not completed, residents who were continent had incontinent episodes, and there were many falls. Some residents required one-to-one care and there was not enough staff to do so. On 10/11/24 at 8:54 AM Staff 5 (Agency CNA) stated in 8/2024 low staffing was an issue at the facility. One resident was non-weight-bearing, and she/he positioned her/his commode closer to the bed to try and self-transfer because staff could not get there to assist. Another resident did not receive wound care treatments as ordered and refused showers because she/he was concerned her/his wound would get wet and staff would not have time to change the dressing. Staff 5 stated she did not see the facility administration assist when the facility was short-staffed. On 10/11/24 at 11:26 AM Staff 15 (Former CNA) stated there was always a staffing issue at the facility. Staff 15 stated residents fell because of short staffing as it was difficult to keep eyes on everyone who was a fall risk. Staff 15 stated she did not always have time to complete showers and she quit her job at the facility because of the staffing issues. On 10/11/24 at 11:41 AM Staff 7 (CNA) stated it was very common for the facility to be short-staffed, and when he was not working, he received text messages every day during all shifts to come and assist. During one evening shift in 8/2024 he was assigned 24 residents, and he stated at times he did not have time to complete resident bathing and personal hygiene tasks. On 10/14/24 at 9:07 AM Staff 31 (CNA) stated the facility was short-staffed. Staff 31 stated she assigned to provide care for 22 residents and after working four days in a row had to take two days off because her back hurt so bad. Staff 31 stated the short staffing was causing burnout. When Staff 31 came to work there were instances when residents were soaked with urine as a result of deficits with the previous shift. Staff 31 stated some CNAs did their jobs and others reported to her that a resident was "strange" and those were instances where usually the CNA staff did not provide incontinent care. On 10/14/24 at 9:20 AM Staff 27 (CNA) stated there were staffing concerns "off and on", and on 10/13/24 one staff member worked for 24 hours straight, and then he came in and worked a 12 hour shift. Staff 27 stated it was a "mess" on day shift. Staff 27 stated he usually worked the first floor which was usually not fully staffed. Staff 27 stated, depending on who was working, there were long call light wait times. On 10/14/24 at 11:12 AM Staff 10 (Unit Manager) stated weekend staffing could be a "challenge." During the Summer, short staffing on weekends was common and staff had to work harder than normal to complete needed assignments. On 10/15/24 at 8:13 AM Staff 3 (LPN) stated on 10/14/24 a nurse worked by herself for four hours and had two new resident admissions to the facility. There were assignments which were not completed on the previous shift that were passed on to her, and Staff 3 also had to assist in completing that work. Staff 3 stated the facility was almost always short-staffed of CNAs. On 10/15/24 at 9:06 AM Staff 38 (Agency CNA) stated when she first arrived at the facility, she received no orientation and had to ask many questions to know what to do. Staff 38 stated another agency staff provided her information. Staff 38 stated she attempted to complete charting on residents' care, but could not get into the electronic health record system. Staff 38 stated she could not access residents' care plans to know their care needs, and had to ask another temporary agency staff member to find out the care needs of the residents. On 10/15/24 at 9:11 AM Staff 39 (CNA) stated the facility was short-staffed and CNAs responded to call lights the best they could. Staff 39 stated recently on day shift she was assigned 16 to 17 residents. On 10/16/24 at 7:54 AM Staff 30 (Former LPN) stated she quit working at the facility because of low staffing levels. The facility could not keep staff and most of the CNAs were agency staff. There were concerns of residents falling because of low staffing. The CNAs between the first floor and the second floor were not always assigned residents according to State required minimum stafing levels; one CNA may have less than the maximum number of residents, and another more. On 10/16/24 at 8:18 AM Resident 25 confirmed she/he attended an 8/23/24 resident council meeting. Resident 25 was surprised no mention of staffing concerns were documented on the resident council minutes. Resident 25 stated the facility lost the staffing coordinator and on 10/15/24 during the night there was not enough staff in the facility. On 10/16/24 at 8:22 AM Resident 26 confirmed she/he attended an 8/23/24 resident council meeting and thought the reason staffing was not mentioned during resident council meeting was because there was nothing which could be done to solve it, so it did not do any good to mention the staffing concerns during the meeting. On 10/16/24 at 9:15 AM Staff 41 (Former Unit Manager) stated she worked with residents many times to cover for nurses who did not show up to work or called off of work. Staff 41 stated the facility was consistently short one to two CNAs. Call light wait times for residents were over 30 minutes, and resident had falls because there were not enough staff to supervise residents who were impulsive and were fall risks. On 10/16/24 at 11:05 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 37 (Regional Nurse Consultant) stated they worked with their corporate office to address the concern of staffing.

Resident #14 no longer resides at the facility. Resident #17 no longer resides at the facility. Resident #22 no longer resides at the facility. The NHA/Designee will complete a baseline audit for the last 7 days to validate sufficient staff were scheduled for each shift. The NHA/Designee will complete interviews with current residents with BIMS 9 or higher to validate care needs were met timely. The NHA/Designee will provide further education to nursing staff and staffing coordinator related to scheduling sufficient staff for each shift and process to follow for call in and responding to call lights timely. NHA/Designee will complete weekly audits to validate sufficient staff are working for each shift. NHA/Designee will complete ongoing interviews with 20 random residents with BIMS 9 or higher to verify they receive assistance timely. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview, and record review it was determined the facility failed to post accurate and complete staffing information for 1 of 1 facility reviewed for staffing. This placed residents at risk for incomplete and inaccurate staffing information. Findings include: A review of the Direct Care Staff Daily Reports (DCSDR) from 7/1/24 through 7/30/24, and 8/1/24 through 8/31/24 revealed the following: -7/3/24 no census documented on evening and night shift. -7/7/24 no census documented on night shift. -7/8/24 no DCSDR completed. -7/17/24 no hours worked documented for CNAs on day shift. -7/18/24 no DCSDR completed. -7/21/24 no census documented on night shift -8/10/24 no census documented on night shift -8/23/24 day shift census documented as 27, evening shift documented as 29 and night shift documented as 74. (8/22/24 census was 74 on day shift and 73 on evening and night shift.) A review of Daily Punches (staff time sheet) dated 8/15/24 and 8/28/24 revealed the following: -8/15/24 evening shift: four CNA staff worked a total of 32.5 hours, plus one CNA worked two hours and another CNA worked five hours for a grand total of 39.5 hours worked across six CNA staff. -8/28/24 evening shift: five CNA staff worked a total of 40 hours, plus one CNA worked one hour for a grand total of 41 hours worked across six CNA staff. Review of the DCSDRs for evening shift dated 8/15/24 and 8/28/24 revealed the following: -8/15/24 evening shift: seven CNA staff worked with a total of 56 hours worked. -8/28/24 evening shift: six and a half CNA staff worked with total of 52 hours. On 10/8/24 at 8:37 AM the DCSDR was observed on the wall which all three shifts for 10/7/24 were documented and the 10/8/24 DCSDR was not posted. On 10/9/24 at 10:39 AM and 11:04 AM the DCSDR was observed on the wall which had the day shift staff and hours worked but no census was documented. On 10/16/24 at 11:08 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 37 (Regional Nurse Consultant) stated the facility had new nurses in general and additional education on completion of the DCSDR sheets was needed.

Residents have the potential for misinformation by inaccurate postings of DHS sheets. The Administrator/Designee will complete a baseline audit for the last 7 days to verify Daily DHS posting matches the staff assigned and labor for that day and that the DHS form is fully completed to include census, staff data and signature of the person attesting to the data each shift. The Administrator/Designee will provide further education to Licensed nurses related to accurately completing the DHS form at the start of each shift and to verify matches staff on assignment sheet. The Administrator/Designee will complete weekly audits to verify Daily DHS posting matches the staff assigned and labor for that day and that the DHS form is fully completed to include census, staff data and signature of the person attesting to the data each shift. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to ensure resident records related to controlled medications were complete and accurate for 1 of 3 sampled residents (#20) reviewed for medications. This placed residents at risk for medication errors. Findings include: Resident 20 admitted to the facility in 5/2024 with diagnoses including a leg fracture. Review of the 9/2024 Narcotic Logbook (NLB) revealed the following regarding oxycodone (narcotic pain medication) related to Resident 20: Oxycodone five mg one tablet twice daily PRN start date 9/18/24: -9/20/24 4:30 AM one tablet, 8:13 AM two tablets, and 8:45 PM two tablets. -9/21/24 2:15 AM two tablets, 7:07 AM "one two" tablets, 1:30 PM two tablets, 4:19 PM one tablet, 8:45 PM two tablets. -9/22/24 7:05 AM two tablets "9/27" (under 9/22/24) 8:30 PM two tablets. -9/23/24 7:19 AM one tablet, 1:04 PM one tablet, and 8:35 PM two tablets. -9/24/24 9:34 AM one tablet, 1:19 PM two tablets, and 7:30 PM one tablet. Resident 20 was administered two tablets instead of one on nine occurrences and was administered over the twice a day order on four days. Oxycodone five mg one tablet every four to six hours start date 9/17/24: -9/17/24 7:26 PM two tablets -9/18/24 12:00 AM, one tablet 8:45 AM, 3:02 PM one tablet, 8:00 PM was documented three times on lines 5, 6, and 7 with one tablet documented on each line (one wasted so two total administered). -9/19/24 12:36 AM one tablet, 3:00 PM one tablet, Line 11 time was illegible with one tablet administered and quantity going from two tablets to zero tablets. Resident 20 was administered two tablets instead of one physician ordered tablet two occurrences. Oxycodone one tablet every six hours not to exceed three tablets in a day start date 9/7/24: -9/10/24 2:09 AM one tablet -9/12/24 12:08 AM one tablet -9/14/24 4:16 PM one tablet, 10:25 PM one tablet, "9/14/24" 5:45 AM (next line under the 10:25 PM administration) one tablet. -9/19/24 8:00 PM one tablet -9/25/24 11:41 PM one tablet -9/26/24 3:00 AM one tablet -9/27/24 10:10 PM one tablet, 7:00 PM one tablet -9/29/24 7:37 AM one tablet (next line under was illegible date with no time or signature documented one tablet) -9/30/24 4:50 PM one tablet Review of the 9/2024 MAR instructed staff to administer the following oxycodone medication: Oxycodone 10 mg one tablet three times a day for pain start date 9/18/24. No oxycodone 10 mg was documented on the NLB. Oxycodone five mg one tablet three times a day start date 9/25/24: no oxycodone five mg one tablet scheduled three times a day was documented on the NLB. Oxycodone five mg one tablet every 12 hours PRN start date 9/18/24: -9/19/24 at 12:36 AM date and time matched with oxycodone one tablet every four to six hours. -9/19/24 at 12:38 PM no match found on the NLB. Oxycodone five mg every four hours as needed one to two tablets start date 9/10/24 discontinued 9/17/24. No match found on the NLB. Oxycodone five mg every four hours PRN start date 9/17/24 and discontinued on 9/18/24. No match found on the NLB. On 10/16/24 at 11:28 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 37 (Regional Nurse Consultant) stated she reviewed Resident 20's medications and Resident 20 received medications as physician ordered, but staff used the same page in the NLB after changes in Resident 20's physician orders.

Resident #20 no longer resides in the facility. The DON/Designee will complete a baseline audit of current residents with active orders for controlled medication to verify that controlled medications administered in the last 7 day were signed out on the appropriate card that corresponds to the physician order and matches MAR administration documentation. The DON/Designee will provide further education to Licensed nurse staff and Certified Medication Aides who are responsible for documenting and administering the controlled medication related to completing the information in the controlled record legibly and verifying that they are using the appropriate card that correlates to the resident medication order. The DON/Designee will complete ongoing audit of 10 residents with current orders for controlled medication to verify that the correct card for the physician order was used for the administration, the controlled log record is legible, and the MAR administration record matches the controlled log administration. Audits will be conducted weekly x 4 weeks, then monthly x 2 months. Audit trends will be reported to facility QAPI X 2 quarters for review and further recommendations.

Based on interview and record review it was determined the facility failed to complete reference checks on 1 of 2 sampled staff (#18) reviewed for alleged abuse. This placed residents at risk for abuse. Findings include: On 10/10/24 at 12:05 PM review of Staff 18 (Agency CNA) employee records revealed no evidence reference checks were completed prior to staff working at the facility. On 10/16/24 at 11:37 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 37 (Regional Nurse Consultant) confirmed no reference checks were completed for Staff 18.

Agency nurse is no longer assigned shifts at the facility. The NHA/Designee will complete a baseline audit of current staff to include temporary staff (agency) to verify reference checks have been completed. The NHA/Designee will provide further education to facility HR and staffing representatives and DON related to the requirements for completing reference checks prior to hiring. The NHA/Designee will complete weekly audits of newly hired staff to include temporary staff (agency staff) to verify reference checks were completed prior to employment. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to ensure background checks were completed for staff for 2 of 2 sampled staff (#s 4 and 18) reviewed for alleged abuse. This placed residents at risk for abuse. Findings include: 1. A FRI form dated 10/3/24 indicated Staff 4 (CNA) was alleged to have verbally abused Resident 10. On 10/10/24 a review of Staff 4's personnel file revealed no evidence a background check was conducted. Staff 4's hire date was 7/23/21. On 10/16/24 at 10:40 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 37 (Regional Nurse Consultant) confirmed Staff 4's background check should have been completed before Staff 4 worked with the residents. 2. A review of an Investigation Report dated 6/19/24 alleged Staff 18 (Agency LPN) was rough with cares and had poor bedside manner during wound care treatment. On 10/10/24 a review of Staff 18's personnel file revealed no evidence a background check was conducted on Staff 18 before she worked with residents. On 10/16/24 at 11:03 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 37 (Regional Nurse Consultant) stated the facility needed to check with agency partners about background checks before staff worked at the facility.

Staff members #4 and #18 no longer work at the facility. The Administrator/Designee will complete a baseline audit of current staff to include temporary staff (agency) to verify background check has been completed within the required timeframe. The Administrator/Designee will provide further education to HR and staffing representative and DON related to the requirements for background checks on current staff per OAR. The Administrator/Designee will complete weekly audit of newly hired staff or staff that had a position change to verify an updated background check was completed. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to ensure state minimum CNA staffing requirements were maintained on 44 of 186 shifts reviewed for staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include: A review of the Direct Care Staff Daily Reports from 7/1/24 through 8/31/24 revealed the facility did not have sufficient CNA staff to meet the minimum CNA staffing requirements for 44 of 186 shifts on the following days: -7/2/24 evening and night shift -7/4/24, 7/12/24, 7/15/24, 7/19/24, 7/22/24, 7/23/24, 7/26/24, 8/12/24, 8/15/24, 8/22/24, and 8/28/24 evening shift -7/5/24, 7/30/24, 8/1/24, 8/2/24, 8/16/24, 8/20/24, 8/23/24, and 8/30/24 night shift -7/6/24, 7/7/24, 7/14/24, 7/20/24, 7/28/24, 8/10/24, 8/17/24, 8/24/24, 8/25/24 and 8/31/24 day shift -7/13/24, 8/3/24, and 8/9/24 day and night shift -7/24/24 and 8/11/24 day and evening shift -8/21/24 day, evening, and night shift On 10/16/24 at 11:07 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 37 (Regional Nurse Consultant) confirmed the facility did not meet the minimum CNA staffing requirements on the above dates.

All residents have the potential to be affected. South Hills continues to offer and host a CNA class. South Hills continues to advertise and recruit additional CNAs. The Administrator/Designee will complete a baseline audit for the last 7 days to verify compliance with minimum CNA staffing. The Administrator/Designee will provide further education to nursing staff and staffing coordinator related to the requirements for minimum CNA staffing. The Administrator/Designee will complete weekly audits to verify compliance with minimum CNA staffing. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to ensure the state minimum CNA bariatric staffing requirements were maintained for 122 of 261 shifts reviewed for staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include: As of 3/10/24 the facility had three residents identified to be approved for the bariatric rate. A review of the Direct Care Staff Daily Reports from 3/18/24 through 3/31/24, 4/1/24 through 4/15/24, 7/1/24 through 7/30/24, and 8/1/24 through 8/31/24 revealed the following days when the state minimum CNA bariatric staffing requirements were not maintained for one or more shifts: -3/18/24, 3/24/24, 3/25/24, 3/26/24, 8/3/24, 8/24/24 day and night shift; -3/19/24, 3/29/24, 3/30/24, 3/31/24, 4/8/24, 4/9/24, 4/10/24, 7/7/24, 7/13/24, 7/14/24, 7/20/24, 8/4/24, 8/10/24, 8/17/24, 8/25/24, day shift; -3/20/24, 3/22/24, 4/15/24, 7/12/24, 7/16/24, 7/22/24, 8/6/24, 8/12/24, 8/13/24, 8/19/24 evening shift; -3/27/24, 7/1/24, 7/10/24, 7/30/24, 8/1/24, 8/23/24 night shift; -3/28/24, 4/1/24, 4/4/24, 4/12/24, 4/13/24, 4/14/24, 7/6/24, 7/15/24, 7/19/24, 7/21/24, 7/23/24, 7/24/24 day and evening shift; -4/2/24, 4/11/24, 7/2/24, 7/26/24, 8/2/24, 8/7/24, 8/15/24, 8/16/24, 8/20/24, 8/22/24, 8/27/24, 8/28/24, 8/30/24 evening and night shift; -4/5/24, 4/6/24, 4/7/24, 7/4/24, 7/5/24, 7/27/24, 7/28/24, 8/9/24, 8/11/24, 8/21/24, 8/31/24 day, evening, and night shift. On 10/16/24 at 11:07 AM Staff 1 (Administrator), Staff 2 (DNS), and Staff 37 (Regional Nurse Consultant) confirmed the facility did not meet the minimum CNA to resident bariatric staffing requirements on the above dates.

All residents have the potential to be affected. South Hills continues to offer and host a CNA class. South Hills continues to advertise and recruit additional CNAs. The Administrator/Designee will complete a baseline audit for the last 7 days to verify compliance with minimum CNA staffing to include bariatric staffing. The Administrator/Designee will provide further education to nursing staff and staffing coordinator related to the requirements for minimum CNA staffing to include bariatric staffing requirements. The Administrator/Designee will complete weekly audits to verify compliance with minimum CNA staffing to include bariatric staffing requirements. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

**************************************** OAR 411-085-0360 Abuse Refer to F600, F609, and F610 **************************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F658 and F677 ***************************************** OAR 411-86-0100 Nursing Services: Staffing Refer to F725 and F732 ************************************** OAR 411-086-0260 Pharmaceutical Services Refer to F755 ***************************************

Based on observation, interview, and record review it was determined the facility failed to ensure residents were assessed to self-administer medications for 2 of 2 sampled residents (#s 13 and 47) reviewed for pain and dialysis (process to remove fluids and waste from the blood when kidney function fails). This placed residents at risk for an ineffective medication regimen. Findings include: 1. Resident 13 was admitted to the facility in 2022 with a diagnosis of kidney disease. A 2/16/24 Progress Note by Staff 16 (RD) revealed she spoke to the RD at the dialysis center for Resident 13. The note indicated Staff 16 would communicate with the resident's unit manager and see if the resident was appropriate to self-administer a phosphorous binder (medication to lower the mineral phosphate in the blood). Staff 16 also communicated with the unit manager on ensuring staff administered Resident 13's phosphorous binder with meals and not before or after meals. A 3/3/24 quarterly MDS revealed Resident 13 was cognitively intact. On 3/21/24 at 2:35 PM Resident 13 stated she/he was capable and wanted like to self-administer her/his phosphorous binder, but staff did not speak to her/him about the process. Resident 13 stated staff usually brought in the binder after meals and not with meals. On 3/21/24 at 2:38 PM Staff 16 stated she spoke to the RD at the dialysis center for Resident 13 on a regular basis. Approximately one month prior, Staff 16 stated she spoke to Staff 15 (LPN Unit Manager) to see if staff would assess Resident 13 for self-administration of the phosphorous binder. On 3/21/24 at 2:50 PM Staff 15 stated she did not assess Resident 13 for self-administration of her/his medication. 2. Resident 47 was admitted to the facility in 2023 with a diagnosis of diabetes. A 12/19/23 quarterly MDS revealed Resident 47 was cognitively intact. On 3/18/24 at 1:18 PM one tube of medicated cream for external use was observed on Resident 47's bedside table. Resident 47 stated she/he applied the cream PRN. Review of Resident 47's clinical record revealed no self-administration assessment for the cream. On 3/20/24 at 11:26 AM Staff 47 (LPN) stated a resident was to be assessed prior to a resident being able to self-administer medications. Staff 47 stated the resident also had to have an order for the self-administration, a care plan, and the medication needed stored in a secure manner. Staff 47 stated the resident did not have an assessment in her/his clinical record.

Resident #13s dialysis RD requested self-administration of the Phosphorus Binder on 2/16/24. Resident #13 will be interviewed to determine which medications he would like to self-administer. A Self-Administration of Medication Evaluation will be completed to determine if he is safe to self-administer medications. An order for self-administration of medication will be obtained. The care plan will be updated. Resident #47 will be interviewed to determine which medications he would like to self-administer. A Self-Administration of Medication Evaluation will be completed to determine if he is safe to self-administer medications. An order for self-administration of medications will be obtained. The care plan will be updated. All residents who prefer to self-administer medications may be affected. The DON/Designee will complete a baseline audit of current residents with BIMS of 9 or higher to determine which residents prefer to self-administer medications. Residents who prefer to self-administer medications will have a Self-Administration of Medication Evaluation completed to determine if they are safe to self-administer medications. If it is determined the resident is safe to self-administer medications, orders to self-administer medications will be obtained and their care plan will be updated. The DON/Designee will provide further education to nurses on the requirements for clinically appropriate self-administration of medications. The DON/Designee will complete weekly audits on five random residents and new admissions to validate the requirements for clinically appropriates self-administration of medications have been completed. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview, and record review it was determined the facility failed to address resident choice for 5 of 22 sampled residents (#s 2, 18, 30, 35, and 38) reviewed for dining. This placed residents at risk for lack of choice and meal satisfaction. Findings include: On 3/18/24 at 10:45 AM and 11:51 AM posted daily menus were observed in the facility on the first and second floors and no weekly menus were found. On 3/18/24 at 11:41 AM Resident 35 stated she/he normally ate in her/his room and she/he no longer had choices available regarding her/his meal selections because the option was taken away. On 3/18/24 at 12:23 PM Resident 30 stated both snack and meal choices were changed, were inadequate, and she/he planned to discuss these concerns with Staff 1 (Administrator). On 3/18/24 at 12:48 PM Resident 2 stated the facility implemented a new system and the daily choice to receive one of two meal options was no longer available. Resident 2 stated she/he was aware the kitchen required a three hour notice for menu changes but the only available menu was posted in the hall and difficult to access for residents who did not get out of bed. On 3/18/24 at 1:27 PM Resident 38 indicated she/he was new to the facility, had no choices related to her/his daily meal options, and wanted an alternative to the hot dog that was provided for dinner. On 3/19/24 at 9:21 AM Resident 18 stated staff no longer discussed the daily menu with her/him, menu choices were no longer available and she/he never knew what was on the menu until it arrived. On 3/19/24 at 1:39 PM Staff 46 (LPN) was unaware of what menu for residents was accurate since not every resident room had menu information. Staff 46 stated residents constantly voiced concerns that menu choices were removed and they were not involved. On 3/21/24 at 2:35 PM Staff 31 (Dietary Manager) and Staff 16 (RD) acknowledged there were no printed menus for residents and the lack of access to menus made it difficult for residents to understand their menu choices. On 3/22/24 at 10:55 AM Staff 1 and Staff 39 (Northern Regional Director of Operations) stated there was no menu information in new admissions packets and acknowledged resident menus were to be printed, distributed and placed in every resident room.

A weekly menu and an always available menu will be placed on the wall in Resident #2s room. A weekly menu and an always available menu will be placed on the wall in Resident #18s room. A weekly menu and an always available menu will be placed on the wall in Resident #30s room. A weekly menu and an always available menu will be placed on the wall in Resident #35s room. A weekly menu and an always available menu will be placed on the wall in Resident #38s room. All residents have the potential to be affected. The Administrator/Designee will complete a baseline audit to determine all resident rooms have a current weekly menu and an always available menu on the wall of each resident room. The Administrator/Designee will provide further education to the dietary department and the activities department on having a current weekly menu and an always available menu on the wall of each resident room. The Administrator/Designee will complete a weekly audit on five random rooms and new admissions to validate a current weekly menu and an always available menu is on the wall of the residents room. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to respond timely to resident concerns related to dining for 1 of 1 Resident Council reviewed for dining. This placed residents at risk for unresolved dining issues. Finding include: The 11/2023 Council Minutes indicated: -Residents had concerns that the "always available menus" were not current in residents' rooms on the first floor. The facility responded that the menus would be updated. -Residents asked what day the weekly menu would be available each week. The facility responded "on Wednesday for the next week." The 1/2024 Council Minutes indicated no old business was reviewed. The 2/2024 Council Minutes indicated residents with dietary concerns were to attend the Dining Committee and no old business was reviewed. The 3/13/24 Council Minutes indicated residents requested weekly menus so residents could make menu choices. The facility responded they could send out a "week at a glance" menu to residents. On 3/21/24 at 2:35 PM Staff 31 (Dietary Manager) and Staff 16 (RD) acknowledged printed menus for residents were not available due to other priorities in dining. On 3/22/24 at 10:55 AM Staff 1 (Administrator) and Staff 37 (Regional Director of Social Services and Activities) acknowledged residents' concerns raised in Resident Council and Dining Committee meetings should be addressed during the next meetings the following month respectively.

All residents have the potential to be affected. The Administrator/Designee will review Resident Council and Food Council notes for the last 30 days. Any grievances and/or recommendations will be followed up verbally to the Resident/Food Council and in writing. The Administrator/Designee will provide further education to department heads on verbal and written follow-up for Resident/Food Council per requirements. The Administrator/Designee will complete monthly audits on grievances and/or recommendations from Resident/Food Council to validate verbal and written follow up has been completed per requirements. Audits will be conducted monthly for 3 months. Audit trends will be reported to facility QAPI X 3 months for review and further recommendations.

Based on interview it was determined the facility failed to have a system in place to deliver mail on Saturdays for 1 of 1 facility reviewed for Resident Council. This placed residents at risk for lack of timely written communications. Findings include: On 3/19/24 at 3:05 PM during a Resident Council meeting Resident 23 stated for a "long time" residents did not receive mail on Saturdays. On 3/21/24 at 12:04 PM, Staff 40 (Activity Director) stated when the facility had an activity assistant mail was delivered on Saturdays. The facility currently did not have anyone in that position. For approximately the last month mail was not delivered on Saturdays.

Resident #23 will receive their mail each day it is delivered to include Saturday. All residents have the potential to be affected. The Administrator/Designee will complete a baseline audit to validate residents are receiving mail each day it is delivered, including Saturdays. The Administrator/Designee will provide further education to staff on delivering mail to residents each day it is delivered, including Saturday per requirements. The Administrator/Designee will complete weekly audits to verify residents receive their mail daily, when delivered to the facility. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation and interview it was determined the facility failed to ensure past survey results were readily available for 1 of 1 facility reviewed for survey results. This placed residents and visitors at risk for not being informed of the facility's survey results. Findings include: On 3/19/24 at 3:05 PM during the resident council interview residents stated they did not know where the past survey results were kept and they thought it was at the nurses' station. On 3/21/24 at 10:23 AM the past survey results were observed in a clear wall mounted bin that was labeled "Requests, concerns, and suggestions." In the front of the survey binder, obscuring it from view, was information regarding following rules for visits, grievance forms, and other unrelated facility forms. On 3/21/24 at 10:25 AM Staff 1 (Administrator) confirmed the above noted location was where the facility normally kept the survey results.

All residents have the potential to be affected. The Administrator/Designee will complete a baseline audit to validate the Survey Binder is in a place readily accessible to residents, family members and legal representatives of residents. The Administrator/Designee will provide further education to staff related to keeping the Survey Binder is in a place readily accessible to residents, family members and legal representatives of residents. The Administrator/Designee will complete weekly random audits to validate the Survey Binder is in a place readily accessible to residents, family members, and legal representatives of residents. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to notify residents' representatives regarding changes in status or condition for 3 of 9 sampled residents (#s 19, 41, and 220) reviewed for notification failure and medications. This placed residents and responsible parties at risk for delayed notification. Findings include: 1. Resident 41 was admitted to the facility in 2022 with a diagnosis including respiratory failure. A 9/14/23 at 4:10 PM Nursing Note indicated Witness 3 (Family Member-emergency contact) called to check status of Resident 41 and no one informed her Resident 41 had COVID-19. A 9/14/23 at 6:24 PM Nursing Note indicated Staff 14 (Former DNS) called Witness 3 regarding communication complaints. Staff 14 apologized for poor communication and provided an update on Resident 41's status. On 3/21/24 at 12:13 PM Staff 13 (Social Services) stated the nurse was to notify the family member when a resident obtained COVID-19. Staff 13 stated she only sent out general notifications of COVID-19 in the building. On 3/19/24 at 8:59 AM Witness 3 stated she was not notified Resident 41 tested positive for COVID-19 on 9/11/23, but she was notified on 9/14/23 after she called to check on Resident 41's status. In an interview on 3/22/24 at 10:31 AM Staff 1 (Administrator), Staff 2 (DNS), Staff 37 (Regional Director of Social Services and Activities), Staff 38 (Regional Director of Clinical) and Staff 39 (Northern Regional Director of Operations) stated it was the resident's preference if a family was notified if the resident was their own representative. No documentation was found in Resident 41's clinical record to indicate she/he did not want Witness 3 to be notified of a change in condition. 2. Resident 220 was admitted to the facility in 2023 with diagnosis including brain damage. A 5/16/23 Investigation Report revealed on the evening of 5/16/23 Resident 220 had two episodes of wandering on facility property. A 5/18/23 Nursing Note revealed Staff 14 (Former DNS) spoke to Resident 220 and Witness 1 (Family Member) regarding Resident 220 exit seeking on 5/16/23. Witness 1 was upset that she was not notified Resident 220 left the facility unattended. Staff 14 apologized and assured education would be provided to staff. On 3/19/24 at 7:59 AM Witness 1 (Family Member) confirmed she was not notified of Resident 220's elopement and she spoke to Staff 14 about her concerns. On 3/21/24 at 8:34 AM Staff 14 confirmed the nurse did not notify Witness 1 of Resident 220's elopement. In an interview on 3/22/24 at 10:19 AM with Staff 1 (Administrator), Staff 2 (DNS), Staff 37 (Regional Director of Social Services and Activities), Staff 38 (Regional Director of Clinical) and Staff 39 (Northern Regional Director of Operations), Staff 1 stated it was recommended to attempt to reach a resident's representative the day an elopement occurred. Refer to F689 , 3. Resident 19 was admitted to the facility in 1/2020 with diagnoses including diabetes. A review of Resident 19's Physician Orders dated 10/2/22 revealed blood sugar levels were to be checked before meals and at bedtime. Staff were to call the provider for results above 300. A review of Resident 19's 2/2024 and 3/2024 Diabetic Administration Records revealed the following: -2/2024 there were 29 instances when Resident 19's blood sugar level exceeded 300. -3/2024 there were six instances when Resident 19's blood sugar level exceeded 300. A review of Resident 19's medical record revealed there was no indication the physician was notified of the resident's high blood sugars. On 3/20/24 at 6:36 PM Staff 34 (Agency LPN) stated she checked the resident's blood sugar levels and the results exceeded 300 at times. Staff 34 stated staff were expected to notify the physician when the resident's blood sugar level was outside the physician parameters. On 3/21/24 at 2:22 PM Staff 15 (LPN Unit Manager) and Staff 26 (Staff Development Coordinator RN) stated staff were expected to follow physician order parameters for monitoring blood sugar levels, including notifying the physician if Resident 19's blood sugar level exceeded 300 and documenting the notification in the resident's medical record.

Resident #19 provider will be notified of CBGs per order parameters. Resident #41 tested positive for COVID 19 on 9/11/23, daughter was notified on 9/14/23. Resident #220 exited facility unsupervised twice on 5/16/23, wife was notified on 5/17/23. Resident is not longer at facility. All residents have the potential to be affected. DON/Designee will complete a baseline audit for the last 14 days to verify residents family/ representative was notified related to change of condition. Family/ representative will be notified if they had not previously been notified of change of condition. DON/Designee will complete a baseline audit for the last 7 days to verify provider is notified of CBGs per the CBG order parameter. DON/Designee will provide further education to the nursing staff related to notification to provider related to directions given in CBG order parameter. DON/Designee will provide further education to the nursing staff related to notification to family/ representative related to resident change of condition per requirements. DON/Designee will complete weekly baseline audits to verify family/ representative are notified timely related to resident change of condition. DON/Designee will complete weekly audits of CBGs with parameters to notify the provider to verify provider was notified per the CBG order directions. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation and interview it was determined the facility failed to ensure rooms were homelike and in good repair for 2 of 10 sampled residents (#s 2 and 7) reviewed for environment. This placed residents at risk for lack of a homelike environment and disrepair. Findings include: Random observations from 3/18/24 through 3/21/24 revealed the following: -The footboard of Resident 7's bed was damaged. It was mended with electrical tape encircling its entire vertical width. Additionally, the fractured segment was angled away from the mattress, failing to align seamlessly with the bed. -A wall in Resident 2's room had multiple large gouges that exposed the underlying drywall, along with numerous black vertical streaks extending approximately four feet in width and four feet in length. On 3/18/24 at 12:57 PM Resident 2 stated the black marks and exposed drywall were present for approximately six to seven months back to when she/he moved rooms. On 3/21/24 at 11:43 AM Staff 42 (Maintenance Director) stated he was aware Resident 7's footboard was broken for roughly two weeks, but did not order a replacement for the damaged piece. Staff 42 entered Resident 2's room with the surveyor. Staff 42 was unaware of the gouges and marks on the resident's wall.

Resident #2 room walls were repaired to fix gouges and black marks on the walls. Resident #7 footboard to bed was replaced. All residents have the potential to be affected. The Administrator/Designee will complete a baseline audit on all rooms to verify beds are maintained and that walls are without gouges and paint touched up if needed. The Administrator/Designee will provide further education to staff related to a safe, clean, comfortable, and homelike environment per requirements. The Administrator/Designee will conduct a weekly audit on five random rooms to verify resident bed is in good repair and that wall is free from gouges and paint to the walls has been touched up if needed. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to ensure a resident's missing items were addressed timely for 1 of 2 sampled residents (#22) reviewed for personal property. This placed residents at risk for loss of meaningful items. Findings include: Resident 22 admitted to the facility in 2024 with a diagnosis of heart disease. On 3/18/24 at 12:38 PM Witness 8 (Family Member) stated approximately one month prior, in 2/2024, he reported to the laundry staff Resident 22's favorite shirt was missing and approximately two weeks ago the resident's new blanket went missing. Witness 8 indicated the staff stated they would look for the items but after he reported the missing items no resolution was provided. On 3/19/24 at 13:35 PM Staff 38 (Regional Director of Clinical) stated there were no missing item forms filled out for Resident 22. On 3/20/24 at 9:32 AM Staff 3 (Laundry Manager) stated a hand-written note was provided to the laundry staff indicating the resident lost a blanket. Staff looked for the item, but did not yet find it. The item did not have the resident's name on it. A grievance form was not filled out and Staff 3 was no longer able to locate the note. On 3/20/24 at 10:10 AM Staff 39 (Northern Regional Director of Operations) stated if a resident reported a missing item it should be documented on a form and staff should provide a response to the resident or responsible party within seven days.

Resident #22 grievance form related to missing shirt and blanket will be completed. All residents have the potential to be affected. The Administrator/Designee will complete a baseline interview of current residents with BIMS 9 or higher to determine if they have any missing items. Grievance form will be initiated for any identified missing item. The Administrator/Designee will provide further education to staff related to grievance process related to missing items. The Administrator/Designee will conduct a weekly audit on grievances to verify they have been followed up on timely. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview, and record review it was determined the facility failed to monitor and assess the continued use of a physical restraint for 1 of 4 sampled residents (#4) reviewed for accidents. This placed residents at risk for potential abuse or neglect. Findings include: Resident 4 was admitted to the facility in 2022 with diagnoses including muscle wasting and atrophy (shrinkage of muscles or nerve tissues). An 8/14/23 revised care plan indicated Resident 4 was an elopement risk due to dementia and wandering behavior. Interventions included distract Resident 4 from wandering and ensure a Wander Guard placed to the right wrist was working by testing the device every Thursday. A 3/2024 Documentation Survey Report indicated to verify placement of the Wander Guard on the right wrist every shift for elopement prevention. From 3/1/24 through 3/5/24 out of 15 opportunities there was no documentation the device was verified for placement four times. No documentation was found to indicate the device placement was verified from 3/13/24 through 3/22/24. A 3/2024 TAR instructed staff to test the Wander Guard weekly on Thursdays. The order was discontinued on 3/11/24. A 3/15/24 Hospice Facility Visit Note indicated Resident 4 appeared fragile and was at risk for a rapid decline. On 3/18/24 at 2:46 PM Resident 4 was in bed with a Wander Guard placed on her/his right wrist. A 3/20/24 Nursing Note indicated Resident 4 no longer attempted to elope and requested orders to discontinue the Wander Guard. On 3/21/24 at 11:35 AM Staff 15 (LPN Unit Manager) stated Resident 4 was not a wander risk. On 3/22/24 at 6:47 AM Resident 4 was in the downstairs dining room with the Wander Guard in place to right wrist. The alarm to front door triggered and a staff member stated it was Resident 4's Wander Guard causing the alarm to go off as he attempted to take Resident 4 out of the facility for an appointment.

Resident #4 wanderguard discontinued. All residents who utilize wanderguards have the potential to be affected. The DON/Designee will complete a baseline audit of residents who have an order for wanderguard to verify they have had a recent wander Eval and continue to meet wander risk criteria. The DON/Designee will provide further education to staff related to the use of wanderguards and use of restraints. The DON/Designee will complete weekly audits to verify residents who utilize wanderguards are not being physically restrained. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to report an elopement event to the State Survey Agency within 24 hours of the incident for 1 of 4 sampled residents (#220) reviewed for accidents. This placed residents at risk for accidents. Findings include: Resident 220 was admitted to the facility in 2023 with diagnosis including brain damage. A 5/16/23 Investigation Report revealed on the evening of 5/16/23 Resident 220 had two episodes of wandering on facility property. A FRI form dated 5/18/23 indicated on 5/16/23 Resident 220 walked outside to the facility smoking area without informing staff of her/his intended whereabouts. The FRI was received at the State agency via email on 5/19/23 at 12:24 AM. In an interview on 3/22/24 at 10:20 AM with Staff 1 (Administrator), Staff 2 (DNS), Staff 37 (Regional Director of Social Services and Activities), Staff 38 (Regional Director of Clinical) and Staff 39 (Northern Regional Director of Operations), Staff 1 confirmed the incident was not reported to the State Agency in a timely manner.

Resident #220 events of being outside the facility on 5/16/23 were reported to DHS on 5/19/23. The Administrator/Designee will complete a baseline audit for the last 14 days to verify residents who eloped from the facility were reported to DHS timely. The Administrator/Designee will provide further education to staff related to reporting of alleged violations timely, per requirements. The Administrator/Designee will complete weekly audits to validate all elopements from the facility are reported timely, per requirements. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed conduct a Significant Change MDS assessment within the required timeframe for 1 of 1 sampled resident (#22) reviewed for hospice. This placed residents at risk for unassessed needs. Findings include: Resident 22 was admitted to the facility 2024 with a diagnosis including heart disease. A 2/3/24 signed hospice narrative revealed the resident was approved and certified for hospice services by the physician on 2/3/24. Review of Resident 22's clinical record revealed a significant change MDS was not completed within 14 days after the resident was admitted to hospice. On 3/20/24 at 12:54 PM Staff 11 (MDS Coordinator) acknowledged she did not do the significant change MDS after the resident was admitted to hospice. Refer to F849.

Resident #22s Significant Change MDS will be completed. Residents that transition on or off hospice have the potential to be affected. The DON/Designee will complete a baseline audit on all residents who have transitioned on or off hospice to verify a Significant Change MDS has been completed within 14 days of the transition. The DON/Designee will provide further education to MDS staff related to completing Significant Change MDSs timely, per RAI with specific focus on residents who transition on or off hospice service. The Don/Designee will complete weekly audits on residents who transitioned on or off hospice to validate they are completed within 14 days of the transition. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to ensure a care plan was revised for 3 of 3 sampled residents (#s 13, 22, and 47) reviewed for dialysis, hospice and pain. This placed residents at risk for increased injury and pain. Findings include: 1. Resident 13 admitted to the facility in 2022 with a diagnosis including kidney failure. A Progress note dated 1/12/24 revealed Resident 13's dialysis (process to remove fluids and wastes from the blood when the kidneys stop functioning) start times were to change on 1/29/24. On Mondays, Wednesdays, and Fridays Resident 13 was to be at the dialysis center at 7:40 AM and dialysis was to start at 8:00 AM. A Care Plan revised on 9/12/23 revealed Resident 13 had dialysis on Monday, Wednesday, and Friday and she/he was picked up between 8:00 AM and 8:10 AM. A 3/3/24 quarterly MDS revealed Resident 13 was cognitively intact. On 3/18/24 at 2:52 PM Resident 13 stated on dialysis days she/he needed to leave the facility by 7:00 AM. On 3/21/24 at 2:50 PM Staff 15 (LPN Unit Manager) acknowledged the care plan was not updated when the dialysis times changed. Refer to F698 2. Resident 22 admitted to the facility in 2024 with a diagnosis including heart disease. A 2/3/24 signed hospice narrative revealed the resident was approved and certified for hospice services by the physician on 2/3/24. Resident 22's care plan last updated on 2/12/24 revealed the following: -Resident 22 was independent to eat. -Hospice would address the resident's advance directive status. -There was no revision of the care plan related to admission to hospice including the name of the agency. -The discharge plan was to be determined. A 2/22/24 Care Plan Conference form revealed hospice attended the conference. It was determined hospice was to review the resident's advance directive status with the resident and staff were to assist the resident with meals and transfers and not family. The form also indicated the resident was to remain at the facility for care. A 2/22/24 hospice note indicated staff were to notify hospice if Resident 22 had pain, anxiety, or agitation. Staff were also to call hospice if the resident fell. The resident's care plan was not updated to reflect hospice notification, staff only to assist the resident with cares, and the resident's plan to continue to reside in the facility. On 3/19/24 at 12:38 PM Staff 43 (CNA) stated Resident 22 had a private aide and family who assisted the resident to eat. On 3/20/24 at 9:26 AM Staff 13 (Social Services) stated she did not communicate with hospice in order to update the care plan related to advance directive information. On 3/20/24 at 1:05 PM Staff 11 (MDS Coordinator) stated if she did not attend the care conference staff were to notify her of changes which were needed to update the care plan. Staff 11 stated she was not aware of the care conference recommended changes. Refer to F849. 3. Resident 47 admitted to the facility in 2023 with diagnoses including diabetes. A 12/19/23 quarterly MDS revealed Resident 47 was cognitively intact. Progress notes revealed the following: -12/24/23 Resident 47 reported increased pain due to hemorrhoids. -1/5/24 refused cream for hemorrhoid pain due to burning. -1/31/24 Resident 47 reported rectal pain, the resident was assessed, and cream applied. -2/1/24 a new order for hemorrhoids was obtained. -2/2/24 an unscheduled provider visit occurred due to Resident 47's report of increased pain from hemorrhoids. On 3/18/24 at 1:18 PM Resident 47 stated she/he had pain for months related to hemorrhoids. Resident 47's current care plan was not revised to include pain related to hemorrhoids. On 3/20/24 at 1:05 PM Staff 11 (MDS Coordinator) stated if she was not made aware of changes she could not update the care plans. Staff 11 acknowledged Resident 47 had pain related to hemorrhoids since 12/2023 and the care plan was not updated. Refer to F697

Resident #13 dialysis care plan will be updated to reflect accurate dialysis time to include pick up. Resident #22s care plan was updated to reflect current care needs including hospice on 3/20/24, falls on 3/20/24, and need for full assistance with eating on 3/22/24. Resident #47 pain care plan related to pain will be updated to include pain trigger. Residents on dialysis, hospice or have pain have the potential to be affected. The DON/Designee will complete a baseline audit specific to dialysis, hospice and residents who experience pain to verify care plan meets current status. The DON/Designee will provide further education to Licensed nurses related to revising care plans to reflect residents current care needs per requirements. The DON/Designee will complete weekly audits on five random residents to validate the care plan reflects current care needs with specific focus on dialysis, hospice and residents who experience pain. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview, and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 3 of 9 sampled residents (#s 4, 35, and 41) reviewed for ADLs and accidents. This placed resident at risk for unmet needs. Findings include: 1. Resident 4 was admitted to the facility in 2022 with diagnoses including muscle wasting and atrophy (shrinkage of muscles or nerve tissues.) A 2/23/23 care plan indicated Resident 4 required extensive assist of one staff with bathing. A 3/2024 Documentation Survey Report (DSR) revealed no documentation Resident 4 received any type of bathing from 3/1/24 through 3/6/24. Resident 41 was admitted to the hospital on 3/6/24 and readmitted to the facility on 3/13/24. The DSR revealed no documentation Resident 4 received any type of bathing from 3/13/24 through 3/20/24. On 3/20/24 at 11:27 AM Staff 12 (CNA) stated she did not always have time to complete all assigned cares for residents and at times had to prioritize taking residents' vitals over completing showers. In an interview on 3/22/24 at 10:33 AM Staff 1 (Administrator), Staff 2 (DNS), Staff 37 (Regional Director of Social Services and Activities), Staff 38 (Regional Director of Clinical) and Staff 39 (Northern Regional Director of Operations) stated Staff 2 was new and was currently going through all of the facility systems. Staff 2 stated continued education was needed. 2. Resident 41 was admitted in 2022 with diagnosis which included stroke. A 7/9/23 Annual MDS indicated Resident 41's BIMS was a 15 which indicated she/he was cognitively intact. Resident 41 required one-person staff assistance with bathing. An 10/18/23 care plan indicated Resident 41 required partial to moderate assistance for bathing and preferred her/his bathing days on Monday and Thursday. On 3/18/24 at 1:15 PM Resident 41 was observed with oily hair and white flakes on her/his shirt. Resident 41 stated it was over a week since she/he was bathed. A review of the 3/2023 Documentation Survey Report revealed Resident 41's last bathing occurred on 3/11/24. No documentation was found in Resident 41's clinical record she/he was offered bathing from 3/12/24 through 3/21/24 (nine days). On 3/20/24 at 11:27 AM Staff 12 (CNA) stated she did not always have time to complete all assigned cares for residents and at times had to prioritize taking residents' vitals over completing showers. In an interview on 3/22/24 at 10:33 AM Staff 1 (Administrator), Staff 2 (DNS), Staff 37 (Regional Director of Social Services and Activities), Staff 38 (Regional Director of Clinical) and Staff 39 (Northern Regional Director of Operations) stated Staff 2 was new and was currently going through all of the facility systems. Staff 2 stated continued education was needed. , 3. Resident 35 was admitted to the facility in 2021 with diagnoses including stroke. A care plan revised 1/2024 revealed Resident 35 required extensive assistance of two staff for bathing and dressing and needed supervision/touching assistance with personal hygiene. a. On 3/19/24 at 1:34 PM Witness 9 (Friend) stated Resident 35's nails were often long and dirty and staff did not assist the resident. Witness 9 stated two weeks prior he cut the resident's nails. On 3/19/24 at 2:46 PM with Staff 44 (LPN) Resident 35 was observed to have long fingernails with brown debris underneath the free edges. Staff 44 acknowledged the resident's nails were long, dirty, and needed to be trimmed. Staff 44 stated the resident's nails had to be trimmed by a nurse because the resident was on blood thinning medication. Staff 44 also stated the nurses did not have Resident 35's nail care on the TAR but the CNAs were to notify the nurses when the resident's nails were long. b. Review of Resident 35's 9/2023 showers revealed the resident had nine opportunities for showers. Resident 35 received a shower or bath on 9/9/23, 9/16/23, and 9/19/23. It was documented the resident refused a shower on 9/26/23. Progress notes did not have documentation related to Resident 35's 9/26/23 shower refusal. Review of Resident 35's 3/2024 showers revealed Resident 35 had six opportunities for showers and received a shower or bath on 3/5/24 and 3/9/24. Resident 35 was documented to refuse a shower on 3/12/24. Progress Notes did not have documentation related to Resident 35's 3/12/24 shower refusal. On 3/21/24 at 3:14 PM Staff 15 (LPN Unit Manager) stated if a resident refused a shower the nurse was to communicate with the resident and document in the progress notes. The CNAs were to attempt multiple times, and offer a bed bath or a shower the next day. A request was made of Staff 15 to provide documentation the resident was provided more than three showers in 9/2023 and more than two showers in 3/2024. No additional information was provided.

Resident #4 will be offered bathing per scheduled preference. Resident #35 will be offered bathing and nail care per scheduled preference. Resident #41 will be offered bathing per scheduled preference. All dependent residents have the potential to be affected. The DON/Designee will complete a baseline audit of current residents to verify they are being offered bathing opportunities and nail care routinely. The DON/Designee will provide further education to nursing staff related to completing ADL care with specific focus on bathing and nail care. The DON/Designee will complete weekly audits on current residents to verify bathing opportunities and nail care were offered per the resident schedule. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview, and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 1 of 3 sampled residents (#502) reviewed for ADLs. This placed resident at risk for unmet needs. Findings include: Resident 502 admitted to the facility in 2024 with diagnoses including stroke and diabetes. A 5/17/24 MDS indicated Resident 502 was cognitively intact and required substantial to maximal assistance with bathing. A review of the 5/21/24 care plan indicated Resident 502 had a self-care performance deficit due to weakness and stroke. Interventions included Resident 502 required substantial to maximal assistance with bathing and refused frequently. No documentation was included related to nail care. A Documentation Survey Report (DSR; a report for tasks completed by CNAs) for 5/11/24 through 5/31/24 and 6/2/24 revealed the following: Instruction to staff to provide nail care on Sundays. -5/19/24 no documentation nail care was provided. -5/26/24 was documented Resident 502 refused. -6/2/24 no documentation nail care was provided. Instruction to CNAs to provide bathing on Sundays and Thursdays -5/12/24 no documentation Resident 502 was provided bathing. -5/14/24 bathing was provided. -5/15/24 documented as not applicable. -5/16/24 Resident 502 refused. -5/19/24 documented as not applicable. -5/23/24 bathing provided. -5/26/24 Resident 502 refused. -5/30/24 Resident 502 refused. -6/2/24 no documentation. The 5/30/24 Nursing Note and 5/31/24 Alert Note indicated Resident 502 refused bathing and signed a refusal sheet. A 6/2/24 Nursing Note revealed Resident 502 refused bathing and the nurse verified. Resident 502 stated she/he would like to bathe on 6/3/24. No documentation was found in clinical records Resident 502 was offered bathing on 6/3/24 or documentation nurses provided Resident 502 with nail care. On 6/4/24 at 11:14 AM Resident 502 stated she/he usually completed her/his own nail care but lost the clippers. Resident 502 stated she/he was scheduled for bathing on 6/3/24 but she/he did not receive bathing. Resident 502's hair appeared oily and her/his nails were past the ends of her/his fingertips. Resident 502 stated she/he would like assistance to bathe and have her/his nails trimmed. On 6/6/24 at 3:54 AM, 6:43 AM and 7:39 AM CNA staff stated they offered Resident 502 nail care and refusals were documented in the tasks section of the record, and if a resident was diabetic with no diabetic medications CNAs could provide nail care. Staff stated Resident 502 refused frequently per documentation in clinical records and she/he signed her/his refusals. Staff stated Hospice provided a bed bath on 5/28/24.

No POC Required

Based on interview and record review it was determined the facility failed to provide care and treatment as care planned, follow physician orders for blood sugar parameters, and provide bowel care for 3 of 9 residents (#s 4, 35 and 41) reviewed for accidents, and medications. This placed residents at risk for delayed treatment, constipation, and risk for adverse side effects. Findings include: 1. Resident 4 was admitted to the facility in 2022 with diagnoses including muscle wasting and atrophy (shrinkage of muscles or nerve tissues). A 7/10/23 revised care plan indicated Resident 4 had an ADL self-care performance deficit due to weakness and she/he used a soft pad call light to call for assistance. On 3/19/24 at 8:25 AM and 3/21/24 at 7:55 AM Resident 4 was in bed with a regular call light button next to him/her in bed. On 3/20/24 at 10:35 AM Staff 11 (MDS Coordinator) stated she did not know why Resident 4's call light was a regular call light and not a soft pad call light. Staff 11 stated she/he was care planned for a soft pad call light. On 3/20/24 at 11:27 AM Staff 12 (Agency CNA) stated Resident 4 would benefit from having a soft pad call light. 2. Resident 41 was admitted to the facility in 2022 with diagnosis which included dysphagia (a condition with difficulty in swallowing food or liquid). A 9/2023 comprehensive care plan indicated "Special Instructions"; medications whole in applesauce or pudding one at a time. A 9/10/23 Nursing Note indicated Resident 41 had a significant coughing episode when administered her/his medications without pudding. On 3/20/24 at 10:20 AM Staff 11 (MDS Coordinator) stated she was in the room when the nurse administered Resident 41's medication without applesauce or pudding and she/he started coughing. In an interview on 3/22/24 at 10:31 AM Staff 1 (Administrator), Staff 2 (DNS), Staff 37 (Regional Director of Social Services and Activities), Staff 38 (Regional Director of Clinical) and Staff 39 (Northern Regional Director of Operations) stated it was the expectation of staff to review the care plan for any special instructions. , 3. Resident 35 was admitted to the facility in 2021 with diagnosis of a stroke. A 9/2023 bowel record revealed Resident 35 did not have a bowel movement from 9/2/23 through 9/9/23 and from 9/20/23 through 9/28/23. A 9/2023 MAR and TAR revealed Resident 35 was administered a suppository for constipation on 9/6/23 but the results were unknown. No additional bowel care was provided. Progress notes revealed the following: -9/6/23 Resident 35 reported constipation and the nurse was notified. There was no assessment of the resident's abdomen. -9/9/23 the resident did not have a bowel movement for 21 shifts. The resident's abdomen was firm with bowel tones. The resident denied pain. The note indicated a request was made to the physician for an enema. -9/20/23 Resident 35 had a bloody bowel movement and the physician was notified. -9/21/23 and 9/22/23 the resident did not have a bloody bowel movement or abdominal pain. -9/29/23 Resident 35 did not have a bowel movement since 9/20/23. The resident had sluggish bowel tones (decreased bowel motility), denied pain and refused a suppository. On 3/20/24 at 11:59 AM Staff 15 (LPN Unit Manager) acknowledged the resident had multiple days without a bowel movement. A request was made of Staff 15 to provide documentation if bowel care was provided or the resident had additional bowel movements. No additional information was provided. On 3/20/24 at 8:46 PM Staff 45 (LPN) stated if a resident did not have a bowel movement for six shifts bowel care was to be initiated. The bowel care started with oral medications, then progressed to a suppository, then the last step was to administer an enema. If the resident did not have a bowel movement for nine shifts the physician was to be notified.

Resident #4 soft pad call light will be in place per care plan. Resident #35 will receive bowel care per provider orders. Resident #41 will receive medications per care plan instructions. All residents have the potential to be affected. The DON/Designee will complete a baseline audit of current residents who require a specialty call light device to verify it is in place and care plan has been updated to reflect the specialty device. The DON/Designee will complete a baseline audit of current residents who have not had a bowel movement for 9 shifts to verify bowel protocol has been initiated. The DON/Designee will complete baseline audit of current residents to verify residents that have special instructions related to medication administration have the information available on resident care plan and special instructions to staff. The DON/Designee will provide further education to the nursing staff related to following physician orders with specific focus on bowel care. The DON/Designee will provide further education to the nursing staff related to following care plan with specific focus related to interventions for medication administration and specialty call lights. The DON/Designee will complete weekly audit of residents who have gone 9 shifts without a bowel movement to verify bowel protocol was followed. The DON/Designee will complete weekly observation of residents with specialty call light to verify it is in place. The DON/Designee will complete weekly observation of 5 random residents to verify medication is administered per resident care plan to include any special instructions for administration. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview, and record review it was determined the facility failed to provide splints to reduce contractures (a permanent tightening of muscles, and tendons) for 1 of 1 sampled resident (#18) reviewed for position and mobility. This placed residents at risk for compromised mobility and pain. Findings include: Resident 18 was admitted to the facility in 2019 with diagnoses including contractures of the left and right elbows. An 8/1/23 revised care plan indicated Resident 18 was to receive elbow braces to her/his right and left elbows during the day for six hours. A 2/28/24 quarterly MDS revealed no splint or brace was provided to Resident 18 during a seven-day review period. The Kardex (care plan for CNAs) reviewed on 3/20/24 had no reference to Resident 18's elbow braces. On 3/19/24 at 9:44 AM Resident 18 was observed in her/his bed with no braces applied to her/his right and left elbows. Resident 18 stated her/his elbow braces were offered inconsistently and last applied three days prior. Resident 18 stated staff did not know how to correctly apply her/his elbow braces and she/he felt less painful when her/his elbows braces were in place. On 3/20/24 at 8:06 AM Staff 29 (CNA) stated she worked with Resident 18 routinely over the last two months and was not aware of the resident's need for elbow braces until 3/19/24. On 3/21/24 at 12:27 PM Staff 28 (LPN-Unit Manager) acknowledged Resident 18's left and right elbow braces were not consistently placed and needed to be in the Kardex so CNAs were aware.

Resident #18s care plan and CNA task a has been updated with a splint management. All residents with splints have the potential to be affected. The DON/Designee will complete a baseline audit on all residents with splint to verify the splints are care planned and be used per care plan. The DON/Designee will provide further education to the nursing staff related to splint management per requirements. The DON/Designee will complete weekly audits to verify splints are being utilized per care plan. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to provide care and treatment to prevent accidents for 4 of 10 sampled residents (#s 4, 22, 35, and 220) reviewed for accidents, hospice, ADLs and medications. This placed residents at risk for injury. Findings include: 1. Resident 4 was admitted to the facility in 2022 with diagnoses including dysphagia (a condition with difficulty in swallowing food or liquid). The most recent comprehensive care plan for Resident 4 revealed the following: -Interventions for nutrition: supervision and set up assistance for eating, needs to be "UP" in wheelchair for all meals, cue to take small sips between bites, mug with handle, lid and "straw as needed." -Swallowing problem with coughing or choking during meals, order for thickened liquids. Interventions: small bites and sips, use teaspoon for eating, "Do not use straws." Eat in upright position, eat slowly, chew each bite thoroughly, "Supervision/frequent checks with meals." Resident 4 ate in the dining room. A 3/11/24 hospital Speech Language Pathology Brief Note indicated Resident 4 choked and coughed with her/his lunch. Resident 4's diet was changed to puree. A 3/2024 Documentation Survey Report indicated to monitor Resident 4 and document any signs of aspiration including fever, coughing when eating or drinking, difficulty eating, gagging, drooling, regurgitating food or drink, abnormal breath sounds, and impaired voice. Documentation was completed from 3/1/24 through 3/5/24. Documentation was not restarted after Resident 4 readmitted to the facility on 3/13/24. On 3/19/24 the following was observed: -8:20 AM a staff member brought in Resident 4's breakfast tray, then left the room and continued to deliver trays. -8:25 AM Resident 4 was in her/his room eating with a teaspoon. Resident 4 had one cup with a handle and one cup with no handle with a plastic lid still on the cup. No staff were observed in Resident 4's room. Resident 4 could not be seen from the hallway. -8:40 AM Resident 4 attempted to remove a plastic lid off the cup with no handle with a spoon. Staff 12 (Agency CNA) was requested to go into Resident 4's room and assist (20 minutes with no supervision). On 3/20/24 at 11:27 AM Staff 12 (Agency CNA) stated she was told the care plan was not updated and she did not check Resident 4's care plan to see if she/he needed to be supervised during meals. Staff 12 stated she trusted the verbal report from staff and should have checked the care plan. On 3/21/24 at 11:35 AM Staff 15 (LPN Unit Manager) confirmed after Resident 4 readmitted with unclear physician orders. The orders should be clarified with the physician. Staff 15 stated Resident 4 was discussed the morning of 3/21/24 for speech and language therapy. 2. Resident 220 was admitted to the facility in 2023 with diagnoses including brain damage. A 5/16/23 admission MDS revealed Resident 220's BIMS was seven indicating severe cognitive impairment. A 5/16/23 Investigation Report revealed on the evening of 5/16/23. The first incident was witnessed by staff and the second was unwitnessed. At approximately 7:40 PM Resident 220 reported to Staff 10 (LPN) she/he wanted to go outside and walk. Staff 10 indicated to Resident 220 she/he could not go out alone but could sit out on the back patio for fresh air. Staff 6 (Agency CNA) was out on the back patio eating her lunch and witnessed Resident 220 walk toward the west side of the building. Staff 9 (OT) was in the therapy office and witnessed Resident 220 unchaining the chain to the wheelchair ramp and walk through. Resident 220 was brought back into the building. Approximately 30 minutes later Staff 10 checked on Resident 220, and she/he had her/his eyes closed in her/his recliner in her/his room. At around 9:15 PM the on-duty LPN on the second floor called down and reported Resident 220 was found in the upstairs smoking area. Resident 220 was sitting in the outside smoking area. Conclusion of the investigation was Resident 220 eloped from the facility but remained on the facility grounds. The facility gathered estimates on a more secure gate for the back patio which would prevent resident elopement in the future. A 5/18/23 Nursing Note indicated Resident 220 asked if she/he could take a walk outside after 7:30 PM. Staff 10 indicated there was a patio where Resident 220 could sit down, but could not allow her/him to walk in front of the facility. Two to five minutes later therapy staff came out of the therapy gym and stated Resident 220 had unlatched the chain which led to the back of the facility. Staff 10 led Resident 220 back to the patio and explained to the resident it was unsafe. Resident 220 was placed in her/his recliner in her/his room and was checked later and was found to be sleeping in her/his chair. 5/18/24 and 5/19/23 witness statements revealed the following occurred on 5/16/23: -Staff 17 (Admissions Coordinator) indicated on 5/16/23 at approximately 5:30 PM Resident 220 attempted to leave the building but did not leave because the door alarms sounded. Resident 220 returned to her/his room (this was not included in the investigation). -Staff 6 indicated between 7:05 PM and 7:35 PM she saw Resident 220 come outside unattended and walk past the therapy office. Later in the evening he asked for a key to get out of the back door of the first floor (this was not included in the investigation). -Staff 7 (CNA) stated between 9:00 PM and 9:15 PM she took the trash outside and saw Resident 220 sitting in a chair. Resident 220 asked to come inside the facility with Staff 7. -Security video tape revealed Resident 220 walked down to the smoking area from the sidewalk at 9:02 PM (this was not included in the investigation). Observation on 3/21/24 at 8:15 AM revealed a sliding glass door adjacent to the downstairs dining room opened to a patio area with chairs and tables. Facing the back of the facility a concrete wheelchair ramp was observed to go up the hill on the right. A chain to the wheelchair ramps off the patio area was unlatched. The wheelchair ramp went in two directions. One continued up a hill to the left and ended at small dirt path which continued up the hill to a curb and pavement. The other wheelchair ramp went from the back of the building and turned to the side of the building and ended with an approximate two to three-foot drop into shrubbery. On 3/21/24 at 7:34 AM Staff 7 (CNA) stated the main garbage dumpster was off the second floor level and when she went to take the garbage out the evening of 5/16/23 Resident 220 was sitting in the smoking section. Resident 220 stated to her that she/he needed to sit as she/he had walked all the way around the building. On 3/21/24 at 9:34 AM Staff 17 confirmed the witness statement and stated it was correct. In an interview on 3/22/24 at 10:16 AM Staff 1 (Administrator), Staff 2 (DNS), Staff 37 (Regional Director of Social Services and Activities), Staff 38 (Regional Director of Clinical) and Staff 39 (Northern Regional Director of Operations) stated it was expected of staff to have a resident at risk for elopement within line of sight or have a wander guard device placed on the resident. Staff 1 stated the facility requested a bid for a gate off the back patio and they were currently waiting for a couple more contractors to provide bids. , 3. Resident 22 was admitted to the facility in 2024 with a diagnosis of heart failure. A 1/8/24 admission MDS and associated CAAs revealed Resident 22 was at risk for falls. Resident 22 had falls prior to admission to the facility, had decreased mobility, impaired memory, and visual deficits. Resident 22 was assessed to be incontinent and staff were to check on the resident at least every two hours. A care plan would be developed to prevent falls. A care plan initiated 1/2/24 revealed staff were to keep commonly used items within reach such as water, call light and the resident's phone. Staff were also to ensure the resident wore appropriate footwear (non-skid footwear or shoes) before transfers. a. A 1/27/24 Unwitnessed fall report revealed on 1/27/24 at 2:55 AM Resident 22 was found on the floor. The resident reported she/he was going to the bathroom. The investigation indicated the call light was activated prior to her/his fall. The investigation revealed the last time staff visualized the resident the resident was in bed with her/his eyes shut. The investigation failed to indicate when the resident was last visualized or how long the call light was activated. New interventions to be implemented were non-skid socks. On 3/20/24 at 11:56 AM Staff 26 (Staff Development Coordinator) acknowledged the investigation did not indicate how long the call light was on. On 3/20/24 at 1:05 PM Staff 11 (MDS Coordinator) stated the investigation indicated new interventions included non-skid socks, but that was not a new intervention. Non-skid socks was an intervention implemented on 1/6/24, prior to the fall. No additional interventions were developed to prevent falls. b. A 2/17/24 Unwitnessed fall report revealed on 2/17/24 Resident 22 fell at 12:25 AM. The investigation revealed Resident 22 reached for her/his snack, which was not within reach, and fell. Resident 22 did not sustain an injury. On 3/20/24 at 11:55 AM Staff 15 (LPN Unit Manager) acknowledged the care plan was not followed when Resident 22 fell. 4. Resident 35 was admitted to the facility in 2021 with a diagnosis of a stroke. Review of an undated list of residents who smoked, provided by the facility on 3/18/24, did not include Resident 35. A 1/31/24 Smoking Screen indicated Resident 35 smoked two to five times a day. The resident had dexterity problems, had a history if hiding smoking materials, and a history of being noncompliant with the facility smoking policy. The resident was assessed to be able to light her/his own cigarette and was to be an unsupervised smoker. On 3/18/24 at 7:58 AM and 3/19/24 at 9:34 AM Resident 35 stated she/he smoked about three times a week, was an independent smoker and was not supervised. Resident 35 stated she/he kept her/his smoking materials in a locked box. On 3/21/24 at 9:24 AM Resident 35 was observed outside smoking with three other residents. The ground of the designated smoking area was cement and there were three designated receptacles for residents to dispose of the cigarettes. Locked boxes were observed to the right of the smoking area for residents' smoking materials. Resident 35 was not observed to have tremors or burn holes in her/his clothing. Resident 35 threw her/his cigarette in the drain grate in the ground. The drain was observed to have liquid in it. The resident did not use the designated receptacles to dispose her/his cigarettes. On 3/20/24 at 11:37 AM Staff 15 (LPN Unit Manager) stated Resident 35 occasionally smoked and usually went out with a community friend or a facility friend who lived a few rooms from the resident. Staff 15 reviewed the resident's 1/2024 smoking assessment and stated she did not perform the assessment. Staff 15 stated based on the resident's health status, which deteriorated, and the 1/2024 Smoking Assessment, the resident should be a supervised smoker due to her/his risk factors. On 3/21/24 at 2:20 PM Staff 1 (Administrator) and Staff 39 (Northern Regional Director of Operations) stated Resident 35's 1/31/24 Smoking Screen did not reflect a resident who should be independent and a new screening assessment was to be completed.

Resident #4 will be provided with eating supervision per care plan. Resident #22s care plan will be followed to reduce the risk of falls. Resident #35s will be re-evaluated for smoking assistance needs. Resident #220 no longer resides at the facility. DON/Designee will complete a baseline audit to verify care plans are updated and accurate related to smoking, risk for wandering, falls and meal assistance needed. DON/Designee will provide further education to staff related to following and updating residents safety care plan per requirements with specific focus on smoking, risk for wandering, fall interventions in place and meal assistance. DON/Designee will complete weekly audits on five random residents to verify staff are following the care plan related to safety with specific focus on falls and eating supervision. DON/Designee will complete weekly audits on newly admitted residents to verify has been accurately evaluated for wander and elopement risk and follow up completed if identified as risk. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview, and record review it was determined the facility failed to provide catheter care for 1 of 3 sampled residents (#6) reviewed for catheter care. This placed residents at risk for increased infections. Findings include: Resident 6 admitted to the facility in 7/2022 with diagnoses including quadriplegia (paralysis of all four limbs) and dysfunction of the bladder. Review of Resident 6's care plan revised on 12/23/23 revealed the resident had a history of UTIs related to a chronic indwelling catheter. A suprapubic (situated above the pubis) catheter was placed on 11/1/23 due to a dysfunction of the bladder. Resident 6 had an "18 FR [French Foley], 8 cc [cubic centimeter] balloon." A 1/3/24 urology clinic note revealed Resident 6 had her/his suprapubic tube replaced with an 18 French Foley catheter and placed 8cc in the balloon. There was no concern with the suprapubic replacement. Resident 6 was to have a follow-up appointment in one week to exchange the suprapubic tube. A review of Resident 6's medical record from 1/4/24 through 3/17/24 revealed no follow-up urology appointment was made. On 3/18/24 in an Alert Note from Staff 26 (Staff Development Coordinator RN) the Nurse Practitioner asked when Resident 6's last suprapubic catheter change was completed. Staff 26 was unable to locate the information and placed a call to the urology clinic. On 3/20/24 at 10:15 AM Resident 6 was observed on a gurney at the nurses' station. Staff 46 (LPN) stated the resident was scheduled for a urology appointment to have her/his suprapubic catheter changed. A 3/20/24 Nursing Note by Staff 46 at 10:57 AM revealed Resident 6 returned from the urology appointment because it had been canceled and the suprapubic catheter changes "can be done at facility, no need for [Resident 6] to go in." A 3/20/24 Order Administration note by Staff 46 at 6:58 PM revealed per urology clinic to change the suprapubic tube with "18 french Foley with 8 ml in balloon. Obtain ua [urinalysis] after changed tube and send to lab. Unable to change as appropriate size catheter not in stock. [Staff 2 (DNS)] aware and will work with supply to obtain." A 3/21/24 Alert Note revealed staff were awaiting supplies to be delivered to change Resident 6's suprapubic catheter and management was aware. On 3/21/24 at 2:09 PM Staff 15 (Unit Manager LPN) and Staff 26 (Staff Development Coordinator RN) acknowledged Resident 6 was not scheduled for a follow-up urology appointment after her/his 1/3/24 appointment, indicating the follow-up was overlooked. Staff 26 stated Resident 6 returned from the 3/20/24 appointment because the urology clinic informed the facility they could change the suprapubic catheter, but the facility lacked the correct supplies to perform the care and was waiting for the supplies.

Resident #6 will have catheter changed per provider orders. All residents with catheters have the potential to be affected. The DON/Designee will complete a baseline audit on all residents with catheters to validate order in place with catheter change and catheter care needs. The DON/Designee will provide further education to nursing staff related to catheter care, following orders related to catheters, and following the plan of care. The DON/Designee will complete weekly audits on residents with catheters to validate catheter orders are in place and catheter is changed per provider order. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview, and record review the facility failed to maintain healthy parameters of nutritional status for 1 of 3 sampled residents (#4) reviewed for nutrition. This placed residents at risk for weight loss. Findings include: Resident 4 admitted to the facility in 2022 with diagnosis including dysphagia (a condition with difficulty in swallowing food or liquid). The most recent comprehensive care plan for Resident 4 revealed the following: -Interventions for nutrition: supervision and set up assistance for eating, needs to be "UP" in wheelchair for all meals, cue to take small sips between bites, mug with handle, lid and "straw as needed." -Swallowing problem with coughing or choking during meals, order for thickened liquids. Interventions: small bites and sips, use teaspoon for eating, "Do not use straws." Eat in upright position, eat slowly, chew each bite thoroughly, "Supervision/frequent checks with meals." -Nutritional problem physician order for unavoidable weigh loss was requested on 1/16/24 because of high supplementation and meal fortification. The RD was to evaluate and make diet change recommendations; the resident ate in the dining room. Provide nutritional supplements, offer fluids at bedside. A 3/2024 MAR instructed staff to provide Resident 4 with Ensure Enlive (nutritional supplement) three times a day. From 3/1/24 through 3/6/24 the nutritional supplement was documented as refused one time. Ensure Enlive was discontinued on 3/11/24. The MAR also instructed staff to provide TwoCal (nutritional supplement) three times a day with meals. From 3/1/24 through 3/6/24 it was documented Resident 4 refused the nutritional supplement one time. TwoCal was discontinued on 3/11/24. A 3/14/24 Nutritional Evaluation indicated Resident 4 weighed 116 pounds and her/his ideal body weight was 166 pounds. Resident 4 needed an altered texture diet and liquids with no adaptive equipment, she/he received a nutritional supplement three times a day, and supplement intakes were not applicable. Resident 4 was at nutrition risk because of the altered textured diet, low body mass index, limited food choices, dementia, and dysphagia. Goals were to maintain or improve nutritional status to increase acceptance of meals. Interventions included continuation of supplements, monitor intake and monitor weight. On 3/19/24 the following was observed: -8:20 AM a staff member brought in Resident 4's breakfast tray into her/his room and then left the room to continue delivering meal trays. -8:25 AM Resident 4 was in her/his room eating with a teaspoon, Resident 4 ate in her/his room and had one cup with a handle and another cup with no handle with a plastic lid on the cup with no handle. No straws were observed. No staff were observed in Resident 4's room. Resident 4 could not be seen from the hallway. -8:40 AM Resident 4 attempted to remove the plastic lid with her/his spoon. Staff 12 (Agency CNA) was requested to go into Resident 4's room and assist (20 minutes with no supervision). On 3/20/24 at 10:35 AM Staff 11 (MDS Coordinator) stated, regarding the care plan, she somehow missed where in one area Resident 4 was care planned to use straws and another area indicated she/he did not use straws. On 3/20/24 at 11:27 AM Staff 12 stated she was told the care plan was not updated and she did not check Resident 4's care plan to see if she/he needed to be supervised or not during meals. Staff 12 stated she trusted the staff verbal report and should have checked the care plan. On 3/21/24 at 11:22 AM Staff 16 (RD) stated Resident 4 recently started hospice and she did not want to order nutritional supplements unless Resident 4 enjoyed the nutritional supplements. On 3/21/24 at 11:35 AM Staff 15 (LPN Unit Manager) stated there was a standing order if a resident did not eat 50 percent of their meal the resident was offered a health shake. Resident 4 did not drink liquid unless it was from a straw. Staff 15 confirmed after Resident 4 was readmitted, all the physician orders were unclear and needed clarified with the physician. Staff 15 stated Resident 4 refused nutritional supplements. No documention related to Resident 4's refusals of nutritional supplements was provided.

Resident #4s nutrition interventions were updated on 3/21/24 per RD recommendations. All residents have the potential to be affected. The DON/Designee will complete a baseline audit of current residents nutritional care plan to verify accurately reflects residents current needs. The DON/Designee will provide further education to nursing staff related to following resident care plan with specific focus on nutritional interventions. The DON/Designee will complete weekly audits on newly admitted residents to verify RD recommendations have been implemented and care plan updated. The DON/Designee will complete weekly observations of eating assistance provided to validate nutritional interventions are being followed. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview, and record review it was determined the facility failed to ensure pain interventions were implemented to ensure a resident's pain was managed for 1 of 1 sampled resident (#47) reviewed for pain. This placed residents at risk for decreased activity. Findings include: Resident 47 admitted to the facility in 2023 with diagnoses including diabetes. A 12/19/23 quarterly MDS revealed Resident 47 was cognitively intact. Progress notes revealed the following: -12/24/23 Resident 47 reported increased pain due to hemorrhoids. -1/5/24 refused cream for hemorrhoid pain due to burning. -1/31/24 Resident 47 reported rectal pain, she/he was assessed, and cream was applied. -2/1/24 a new order regarding hemorrhoids was obtained. -2/2/24 an acute provider visit occurred due to the resident's report of increased pain from hemorrhoids. -3/1/24 NP progress note revealed the resident continued with hemorrhoid pain and the plan was for a roho cushion. Resident 47's care plan last revised on 2/29/24 was not revised to include pain related to hemorrhoids. On 3/20/24 at 1:05 PM Staff 11 (MDS Coordinator) stated if she was not made aware of changes, she could not update the care plans. Staff 11 acknowledged Resident 47 had pain related to hemorrhoids since 12/2023 and the care plan was not updated. A 3/2024 MAR revealed the resident was to be administered a pad with witch hazel (herbal treatment) PRN for hemorrhoidal pain. There was no documentation to indicate the medication was administered or refused. The start date was 3/15/24. On 3/18/24 at 1:18 PM and 3/20/24 at 2:59 PM Resident 47 stated she/he had hemorrhoid pain for about two months. The facility was to provide witch hazel and a special cushion for her/his wheelchair but did not. Resident 47 stated she/he could not sit up for meals or go to activities due to pain. Resident 47 stated no one communicated with her/him if the witch hazel was prescribed. On 3/20/24 at 2:19 PM Staff 28 (LPN Unit Manager) stated the previous week she spoke to Resident 47's NP and the NP prescribed pads with witch hazel for the resident's hemorrhoids. Staff 28 stated she did not speak to the resident about the order. The facility did not have the pads with just witch hazel and only carried the pads with 50 percent witch hazel which caused the resident pain. On 3/20/24 at 3:03 PM and 3:05 PM Staff 47 (LPN) stated the only medicated pads in the central stores had alcohol in them. She requested the facility obtain the pads without alcohol, then provided them to the resident and the pads were effective for the resident. On 3/21/24 at 11:22 AM Staff 27 (Director of Therapy Services) stated he was not aware the NP ordered the specialized cushion on 3/1/24. Staff 27 stated on 3/20/24, once therapy was notified, the cushion was provided to the resident.

Resident #47 is receiving care and treatment for pain management. The DON/Designee will complete a baseline audit on current residents who experience pain to validate that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents choices, related to pain management. The DON/Designee will provide further education to staff related to residents receiving treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents choices, related to pain management. The DON/Designee will complete weekly audits on five random residents to validate they are receiving treatment care in accordance with professional standards of practice, the comprehensive care plan, and the residents choices, related to pain management. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview, and record review it was determined the facility failed to have adequate staff available to meet the needs of residents in a timely manner for 1 of 14 sampled residents (#10) and 1 of 2 floors (2nd floor) reviewed for staffing. This placed residents at risk for unmet needs. Findings include: 1. Resident 10 admitted in 2020 with diagnoses including difficulty in walking and a stroke. A 11/1/23 care plan indicated Resident 10 required supervision and touching assistance with transferring on and off the bedside commode and was dependent on staff for toileting hygiene, and adjusting of clothing before and after toileting. A 2/12/24 annual MDS indicated Resident 10 was continent of bowel and bladder and was cognitively intact with a BIMs of 15. On 3/19/24 at 6:40 AM Resident 10 stated call light wait times were over 15 minutes and about once a month over 30 minutes. Resident 10 stated she/he had incontinent episodes multiple times because she/he had to wait for assistance. A 3/2024 Documentation Survey Report indicated Resident 10 was incontinent on the evening shift of 3/13/24 and on night shift of 3/14/24. On 3/20/24 at 11:27 AM Staff 12 (CNA) stated approximately two shifts a week she was assigned 12 to 13 residents. Staff 12 stated at times she had to prioritize collecting vital signs over resident care. Residents complained of long call light wait times of 20 to 30 minutes. Staff 12 experienced starting her shift with residents soaked in urine or soiled with feces. On 3/22/24 at 10:10 AM in an interview with Staff 1 (Administrator), Staff 2 (DNS), Staff 37 (Regional Director of Social Services and Activities), Staff 38 (Regional Director of Clinical) and Staff 39 (Northern Regional Director of Operations) it was stated the facility continued to actively hiring staff. 2. The 11/2023 resident Council Minutes indicated staff went into residents' rooms when a call light was activated, turned it off and left without asking how they could assist the resident. Call light wait times were as long as an hour on day shift. Staff assisted residents to the restroom and then went on break or lunch leaving a resident in the restroom. The following interviews occurred on 3/18/24: -11:40 AM Resident 35 stated call light wait times were up to 30 minutes. -11:48 AM Resident 19 stated the facility was short-staffed. Call light wait times were up to 30 minutes during shift change. Resident 19 felt she/he was not cared for during rounds for incontinent checks. -12:26 PM Resident 30 stated call light wait times were 30 minutes and longer all three shifts. -12:39 PM Witness 8 (Family Member) stated short-staffing occurred all three shifts. Witness 8 came to visit in the mornings, and he would find Resident 22 incontinent and soiled. Witness 8 activated the call light and the wait was 30 minutes. -12:54 PM Resident 2 stated the facility was short-staffed and the wait for assistance with toileting was 20 to 25 minutes. -1:03 PM Resident 43 stated because the facility was short-staffed, she/he was not getting her/his showers. At times Resident 43 refused and staff did not try and reschedule them. Call light wait times were 30 minutes and she/he had to wait for water or assistance getting dressed. -1:25 PM Resident 47 stated she/he had to wait for an hour and a half the morning of 3/18/24 for the call light to be answered. -1:51 PM Resident 18 stated she/he had to wait for over an hour for call light response multiple times and the facility did not have enough staff. Resident 18 stated on the night of 3/17/24 there were only two CNAs for the second floor with approximately 40 residents. -2:47 PM Resident 13 stated there were issues with staff shortages approximately ten percent of the time which was usually weekends. -3:31 PM Resident 23 stated the facility was understaffed. Resident 23 waited over an hour for staff to answer call lights. The following interviews occurred on 3/20/24: -9:44 AM Staff 28 (Unit Manager-LPN) stated there were concerns with short staff and the facility was behind in completing wound care. -10:42 AM Staff 21 (CNA) stated the facility was consistently short of CNA staff on day and evening shift. Staff 21 stated it was difficult to find another staff member to assist when two-person assistance was required. -11:27 AM Staff 12 (CNA) stated approximately two shifts a week she was assigned 12 to 13 residents. Staff 12 stated at times she had to prioritize collecting vital signs over care of residents. Residents complained of long call light wait times of 20 to 30 minutes. Staff 12 experienced coming on shift to find residents soaked in urine or soiled in feces. -3:51 PM Staff 25 (Former CNA) stated in 11/2023 residents were not receiving their showers because the facility was short-staffed. At times Staff 25 placed someone on a bedside commode and the resident was on the commode for 30 minutes or longer. -6:36 PM Staff 34 (Agency-LPN) stated from 4/2023 to 12/2023 she worked upstairs, and she could not complete all assigned care for residents. CNA staffing was short and staff were not coming to work as assigned. Residents complained of long call light wait times as long as 45 minutes. At times CNAs went on their break and a resident was left on a bedside commode for 20 minutes or longer. CNA staff did not communicate with each other. The following interviews occurred 3/21/24: -8:44 AM Staff 36 (LPN) stated on 3/20/24 there was only one nurse to complete medication pass, process two resident admissions, complete wound care, an IV treatment, and process any discharges. The facility continued to admit residents even when short-staffed. -11:45 AM Resident 14 stated on 3/18/24 she/he waited one hour for assistance and experienced an incontinent episode in bed. Resident 14 stated with the lack of staff she/he had to clean herself/himself and it was difficult. On 3/22/24 at 10:10 AM in an interview with Staff 1 (Administrator), Staff 2 (DNS), Staff 37 (Regional Director of Social Services and Activities), Staff 38 (Regional Director of Clinical) and Staff 39 (Northern Regional Director of Operations) it was stated the facility continued actively hiring staff.

Resident #10 is receiving care in accordance with her care plan. All residents have the potential to be affected. The DON/Designee will complete a baseline audit for the last 14 days to validate sufficient staff were scheduled for each shift. The DON/Designee will provide further education to nurse managers and staffing related to scheduling sufficient staff for each shift. DON/Designee will complete weekly audits to validate sufficient staff are working for each shift. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to staff a registered nurse for 8 consecutive hours per day 7 days per week for 15 out of 123 days reviewed for staffing. This placed residents at risk for unmet assessment needs. Findings include: Review of the Direct Care Staff Daily Reports from 5/1/23 through 5/31/23, 6/1/23 through 6/31/23, 8/1/23 through 8/31/23 and 2/17/24 through 3/17/24 revealed the facility did not have RN coverage on all three shifts on the following days: 5/18/23, 5/24/23, 5/30/23, 5/31/23, 6/6/23, 8/1/23, 8/2/23, 8/9/23, 8/15/23 2/18/24, 2/27/24, 3/3/24, 3/5/24, 3/10/24, and 3/12/24. On 3/22/24 at 10:10 AM in an interview with Staff 1 (Administrator), Staff 2 (DNS), Staff 37 (Regional Director of Social Services and Activities), Staff 38 (Regional Director of Clinical) and Staff 39 (Northern Regional Director of Operations) it was stated the facility continued actively hiring staff.

All residents have the potential to be affected. The Administrator will request an RN Waiver. Facility continues to advertise and recruit additional RNs. The Administrator/Designee will complete a baseline audit for the last 14 days to verify an RN was scheduled daily. The Administrator/Designee will provide further education to nurse managers and staffing related to the requirements for an RN daily per requirements. The Administrator/Designee will complete weekly audits to verify an RN was scheduled daily for 8 consecutive hours. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 5 of 5 sampled CNA staff (#s 18, 19, 20, 21, and 22) reviewed for staffing. This placed residents at risk for lack of competent staff. Findings include: On 3/21/24 at 9:50 AM Staff 1 (Administrator) provided the most recent performance reviews for Staff 18 (CNA), Staff 19 (CNA), Staff 20 (CNA), Staff 21 (CNA), and Staff 22 (CNA). - Staff 18 was hired on 12/14/13 and the facility was unable to provide a performance review. - Staff 19 was hired on 1/9/19 and the facility was unable to provide a performance review. - Staff 20 was hired on 10/7/21 and the facility was unable to provide a performance review. - Staff 21 was hired on 12/18/15 and the facility was unable to provide a performance review. - Staff 22 was hired on 12/14/21 and the facility was unable to provide a performance review. On 3/21/24 at 10:43 AM Staff 1 (Administrator) confirmed there were no performance reviews for Staff 18, Staff 19, Staff 20, Staff 21, and Staff 22.

All residents have the potential to be affected. The DON/Designee will complete a baseline audit on all CNAs that have worked at South Hills for a year or more to validate performance reviews were completed annually and in-service education was provided based on the outcomes of the reviews. The DON/Designee will provide further education to management staff related to completing annual review and providing education based on the outcomes of these reviews. The DON/Designee will complete annual reviews for CNAs that have worked at South Hills for a year or more and will provide education based on the outcomes of these reviews. DON/Designee will complete monthly performance annual reviews for all CNAs who have worked at South Hills for a year and provide education based on the outcomes of these reviews. Audits will be conducted monthly for 3 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to address pharmacy recommendations for 1 of 5 sampled residents (#43) reviewed for medications. This placed residents at risk for medication complications. Findings include: Resident 43 was admitted to the facility in 2023 with diagnoses including arthritis and anxiety. A pharmacy review dated 12/25/23 recommended labs be obtained to evaluate several medications the resident received. There was no evidence in the clinical record the labs were obtained. On 3/21/24 at 2:54 PM Staff 26 (Staff Development Coordinator) confirmed the labs were not obtained timely.

Resident #43 had pharmacy recommendations for a Lipid Panel, CBC, CMP and A1C in 12/2023. The provider will be contacted, and labs will be completed as ordered. All residents have the potential to be affected. The DON/Designee will review the pharmacy recommendation for the last 30 days, requests for labs will be sent to the provider and labs will be completed as ordered. The DON/Designee will provide further education related to completing labs as ordered to the nursing staff. The DON/Designee will complete monthly audits related to pharmacy recommendations for labs to validate these recommendations went to the provider and are completed as ordered. Audits will be conducted monthly for 3 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to obtain routine labs to monitor medication effectiveness for 1 of 5 sampled residents (#43) reviewed for medications. This placed residents at risk for ineffective medication management and unnecessary medications. Findings include: A pharmacy review dated 12/25/23 identified the need for routine labs to evaluate Resident 43's medications used to treat high cholesterol, diabetes, vitamin D, B12 deficiencies, sodium, and potassium levels. A pharmacy review dated 2/27/24 noted the labs were ordered by the physician on 2/19/24 and requested the facility obtain a copy of the results to be included into Resident 43's clinical record. There was no evidence in Resident 43's clinical record the labs were obtained until 3/1/24. On 3/21/24 at 2:54 PM Staff 26 (Staff Development Coordinator) confirmed the labs were not obtained as recommended until 3/1/24.

Resident #43 had pharmacy recommendations for a Lipid Panel, CBC, CMP and A1C in 12/2023. The provider will be contacted, and labs will be completed as ordered. The DON/Designee will review the pharmacy recommendation for the last 30 days to validate pharmacy recommendations were sent to the provider, received back from the provider, and completed as ordered. The DON/Designee will provide further education to the nursing staff related to completing pharmacy recommendations per requirements. The DON/Designee will complete monthly audits on pharmacy recommendations to validate they were sent to the provider, received back from the provider, and completed as ordered. Audits will be conducted monthly for 3 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to adequately monitor psychotropic medications for 1 of 5 sampled residents (#19) reviewed for medications. This placed residents at risk for lack of effective medication management. Findings include: Resident 19 was admitted to the facility in 1/2020 with diagnoses including bipolar disorder with depression, personality disorder and agoraphobia (fear of entering crowded places) with panic disorder. A review of Resident 19's Physician Orders dated 2/2024 revealed the following medications: -Duloxetine (for depression) 120 mg, two tablets for mood disorder with depression. -Rexuliti (an antipsychotic) 1 mg at bedtime for bipolar disorder. A review of Resident 19's 2/2024 and 3/2024 MARs revealed facility staff were to monitor for adverse reactions to the antidepressant and antipsychotic medications each shift. Review of the monitoring documentation revealed the following: -2/2024: out of 87 opportunities facility staff did not monitor Resident 19 for adverse reactions to her/his antidepressant or antipsychotic medication on 32 occasions. -3/2024: out of 57 opportunities facility staff did not monitor Resident 19 for adverse reactions to her/his antidepressant or antipsychotic medication on 25 occasions. On 3/20/24 at 9:43 AM Staff 47 (LPN) and at 6:36 PM Staff 34 (Agency LPN) stated they were required to monitor for adverse reactions to Resident 19's antidepressant and antipsychotic medication use, but they did not consistently document appropriately in the resident's medical record. On 3/21/24 at 2:22 PM Staff 15 (LPN Unit Manager) and Staff 26 (Staff Development Coordinator RN) stated staff were expected to monitor and document adverse reactions every shift related to Resident 19's use of her/his antidepressant and antipsychotic medications.

Resident #19 psychotropic medications will be monitored for adverse side effects as ordered. All residents utilizing psychotropic medications have the potential to be affected. The DON/Designee will complete a baseline audit on all residents with orders for psychotropic medications to validate adverse side effects, behavioral, and interventions monitors are in place for each class of psychotropic medications ordered. The DON/Designee will provide further education to the nursing staff related to initiating adverse side effects, behavioral, and interventions monitors for each class of psychotropic medications ordered for residents. The DON/Designee will complete weekly audits on five randomly selected residents with orders for psychotropic medication to validate adverse side effect documentation is being completed per order. The DON/Designee will complete weekly audits on residents with new orders for psychotropic medications and new admission with orders for psychotropic medications to validate monitors for adverse side effects, behavioral, and interventions are in place for each class of psychotropic medication. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to adequately monitor residents with psychotropic medications for 3 of 3 sampled residents (#s 19, 500, and 504) reviewed for monitoring. This placed residents at risk for lack of effective medication management. Findings include: 1. Resident 19 admitted to the facility in 1/2020 with diagnoses including bipolar disorder with depression, personality disorder and agoraphobia (fear of entering crowded places) with panic disorder. A review of Resident 19's Physician Orders dated 5/30/24 revealed the following medications: -Duloxetine (for depression) 120 mg, two tablets for mood disorder with depression. -Rexuliti (an antipsychotic) 1 mg at bedtime for bipolar disorder. A review of Resident 19's 5/8/24 through 5/31/24 and 6/1/24 through 6/4/24 Monitors report revealed facility staff were to monitor for adverse reactions to the antidepressant and antipsychotic medications each shift. Review of the monitoring documentation revealed the following: -5/8/24 through 5/31/24: out of 69 opportunities facility staff did not monitor Resident 19 for adverse reactions to her/his antidepressant or antipsychotic medications on eight occasions. - 6/1/24 through 6/4/24: out of 12 opportunities facility staff did not monitor Resident 19 for adverse reactions to her/his antidepressant or antipsychotic medications on three occasions. On 6/5/24 at 10:26 AM Staff 39 (Northern Regional Director of Operations) and Staff 50 (Regional Nurse Consultant) were informed of the above information and stated they would review the issue. No additional information was provided. 2. Resident 500 was admitted to the facility in 2024 with diagnoses including depression, dementia, and anxiety. A review of Resident 500's Physician Orders for 5/2024 revealed the following medications: -Aripiprazole (an antipsychotic) at bedtime for depressive episodes. -Haloperidol (an antipsychotic) two times a day for end-of-life care. A review of Resident 19's 5/8/24 through 5/31/24 Monitors report revealed facility staff were to monitor for adverse reactions for antipsychotic medications each shift. Out of 69 opportunities facility staff did not monitor Resident 500 for adverse reactions to her/his antipsychotic medication on four occasions. On 6/5/24 at 10:26 AM Staff 39 (Northern Regional Director of Operations) and Staff 50 (Regional Nurse Consultant) were informed of the above information and stated they would review the issue. No additional information was provided. 3. Resident 504 admitted to the facility in 2024 with diagnoses including depression and bipolar disorder. A review of Resident 504's Physician Orders for 5/2024 revealed the following medications: -Latuda (an antipsychotic) at bedtime for bipolar disorder. -Nortriptyline (an antidepressant) at bedtime for insomnia and depression. A review of Resident 504's 5/22/24 through 5/31/24 and 6/1/24 through 6/4/24 Monitors report revealed facility staff were to monitor for adverse reactions to the antidepressant and antipsychotic medications each shift. Review of the monitoring documentation revealed the following: -5/8/24 through 5/31/24: out of 20 opportunities facility staff did not monitor Resident 504 for adverse reactions to her/his antidepressant on or antipsychotic medication on four occasions. - 6/1/24 through 6/4/24: out of 12 opportunities facility staff did not monitor Resident 19 for adverse reactions to her/his antidepressant or antipsychotic medication on two occasions. On 6/5/24 at 10:26 AM Staff 39 (Northern Regional Director of Operations) and Staff 50 (Regional Nurse Consultant) were informed of the above information and stated they would review the issue. No additional information was provided. ,

No POC Required

Based on interview and record review it was determined the facility failed to ensure a resident colonoscopy (scope passed through the rectum to visualize the large intestine and part of the small intestine) was rescheduled for 1 of 3 sampled residents (#35) reviewed for nutrition. This placed residents at risk for delayed treatment. Findings include: Resident 35 admitted to the facility in 2021 with a diagnosis of a stroke. A provider Progress Note dated 2/7/24 revealed Resident 35 had abnormal weight loss. A colonoscopy was scheduled for 2/15/24. After the colonoscopy additional tests would be completed to assist in diagnosing possible causes of the resident's weight loss. The resident verbalized the desire to complete the colonoscopy. Resident 35's clinical record did not indicate if the 2/15/24 colonoscopy was completed. In interview on 3/20/24 at 11:48 AM with Staff 26 (Staff Development Coordinator) and Staff 15 (LPN Unit Manager) Staff 26 stated the resident was to have the colonoscopy on 2/15/24. The preparation for the test came from the pharmacy on 2/14/24 and the resident refused to consume all the medication. The physician was notified, and the test was to be rescheduled. Staff 15 stated the notification to the resident's physician and the canceled test was not documented in the resident's clinical record. Staff 15 was not certain if a follow-up was made. On 3/20/24 at 11:59 AM Staff 48 (Medical Records) stated at this time a colonoscopy was not rescheduled for Resident 35.

Resident #35s colonoscopy appointment was scheduled on 3/20/24 for the soonest available date and he was placed on the cancellation list for an earlier appointment if available. All residents with orders for diagnostic services have the potential to be at risk. The DON/Designee will complete a baseline audit for all residents with orders for diagnostics to validate appointments have been made. The DON/Designee will provide further education to nursing staff related to prompt scheduling of ordered diagnostic orders per requirements. The DON/Designee will complete weekly audits to validate new diagnostic orders have prompt scheduling. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to obtain dental services for 1 of 1 sampled resident (#18) reviewed for dental. This placed residents at risk for dental pain and difficulty eating. Findings include: Resident 18 was admitted to the facility with diagnoses including malnutrition and quadriplegia (a form of paralysis that affects all four limbs). The 2/28/24 quarterly MDS indicated Resident 18 did not have dentures. A 3/1/24 revised care plan indicated Resident 18 had her/his teeth extracted in 5/2023 and arrangements for dental care and transportation should be coordinated. On 3/19/24 at 9:34 AM Resident 18 stated she/he continued to ask for dentures and there remained no update regarding her/his request. On 3/20/24 at 9:44 AM Staff 23 (Social Worker) stated she worked to get a denture appointment for Resident 18 and waited for Staff 2 (DNS) to speak with Resident 18 about the risks and benefit of sitting in a dental chair for an extended period of time. On 3/21/24 at 9:21 AM Staff 2 stated she was first approached in 2/2024 about Resident 18's request for dentures and acknowledged the follow-up related to her/his request was lacking.

Resident #18 declined to see ENDS (in house dental service) on 3/21/24. Per Resident #18s request, an appointment with a local provider or a provider in Salem that takes his insurance will be located and an appointment will be scheduled. All residents have the potential to be affected. The Administrator/Designee will complete a baseline audit to verify all residents have seen the dentist in the last 12 months and as requested/needed. Any resident identified to not have seen the dentist in the last 12 months and/or has a request or need to see the dentist will be scheduled for a dental visit. The Administrator/Designee will provide further education to Social Services related to scheduling dental visits per requirements. The Administrator/Designee will complete weekly audits on all new admissions and residents due for annual review to validate a dental visit has been scheduled per need/request. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview, and record review it was determined the facility failed to ensure snack requests were honored and provided for 1 of 5 sampled residents (#2) and 1 of 1 Resident Council reviewed for dining. This placed residents at risk for lack of response to dietary requests and snack preferences. Findings include: 1. Resident 2 was admitted to the facility in 2023 with diagnoses including kidney disease and diabetes. Resident 2 resided on the second floor. The 1/30/24 through 2/1/24 Snack List indicated the residents' snack refrigerator on the second floor did not have string cheese or yogurts in stock at the time the snack inventory was taken. No additional Snack List inventory sheets during the last three months were provided. A 2/8/24 revised care plan indicated to provide Resident 2 additional protein intake for wound healing. A 2/20/24 Dietary Profile indicated Resident 2 requested yogurt and sandwiches as snacks. On 3/20/24 at 8:00 AM the second floor resident snack refrigerator was observed with no yogurt. On 3/21/24 at 2:00 PM Staff 30 (Cook) stated she often stocked the residents' snack refrigerators in the evenings and lacked an adequate supply of dairy items 50 percent of the time. On 3/21/24 at 2:35 PM Staff 31 (Dietary Manager) indicated Resident 2, who requested yogurt and sandwiches as a snack, should have been provided both items. Staff 31 acknowledged the residents' snack refrigerators were not stocked with ample yogurt and cheese stick snacks to meet the requests of residents. 2. The 1/30/24 through 2/1/24 Snack List indicated the residents' snack refrigerator on the second floor did not have string cheese or yogurts in stock at the time the snack inventory was taken. No additional Snack List inventory sheets during the last three months were provided. The 3/13/24 Dining Committee minutes indicated residents voiced concerns related to the lack of an adequate amount of string cheese. Additionally Staff 31 (Dietary Manager) acknowledged the kitchen ran out of milk one day during the week and she was not informed of the issue. On 3/19/24 at 3:05 PM during a Resident Council meeting, residents in attendance indicated they did not receive snacks at bedtime when requested and items like milk, string cheese and sandwiches were insufficient. Residents believed with a grocery store in the vicinity, they should not need to go without those items. On 3/20/24 at 8:00 AM the second floor resident snack refrigerator was observed with no yogurt. On 3/21/24 at 2:00 PM Staff 30 (Cook) stated she often stocked the residents' snack refrigerators in the evenings and lacked an adequate supply of dairy items 50 percent of the time. On 3/21/24 at 2:35 PM Staff 31 (Dietary Manager) indicated she did not use available documentation in order to monitor what resident snacks were in high demand. Staff 31 acknowledged the residents' snack refrigerators were not stocked with ample snacks to meet the requests of residents.

Resident #2 will have snacks available. The DON/Designee will complete a baseline interview with current residents with BIMS of 9 or higher to determine if there are snack options available to their preference. The DON/Designee will provide further education to staff related to offering snacks to residents per their preference and a list of available snack items. The DON/Designee will complete weekly random audits on 5 residents with BIMS 9 or higher to verify If there are snacks available per their preference. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation and interview it was determined the facility failed to ensure waste was properly contained in the garbage storage area for 1 of 1 garbage area reviewed for kitchen sanitation. This placed residents at risk for exposure to pathogens related to pests. Findings include: On 3/21/24 at 12:36 PM the outside garbage area was observed with a garbage container lid open and on the ground of the surrounding area was observed broken doors, unused resident commodes, dirty disposable gloves, miscellaneous wood pieces, and outdoor debris accumulated in the corner of the building. On 3/21/24 at 12:40 PM Staff 42 (Maintenance Director) acknowledged the garbage area was dirty, not organized, and Staff 42 lacked the time since 2/2024 to clean it. On 3/21/24 at 12:44 PM Staff 41 (CNA) stated she came outside routinely and the garbage area frequently had debris around it including dirty disposable gloves on the ground. On 3/22/24 at 9:11 AM the outside garbage area was observed with Staff 31 (Dietary Manager). The lid on the garbage container was open and multiple dirty gloves were on the ground nearby. Staff 31 stated she was unaware of any requirement to monitor the garbage area but acknowledged it should be kept clean.

All residents have the potential to be affected. The Administrator/Designee will complete a baseline audit to validate garbage is contained and refuse is disposed of properly. The Administrator/Designee will provide further education to staff related to disposal of garbage and refuse properly per requirements. The Administrator/Designee will complete three random audits weekly to verify garbage is contained and refuse is disposed of properly. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to coordinate care with hospice for 1 of 1 sampled resident (#22) reviewed for hospice. This placed residents at risk for unmet needs. Findings include: Resident 22 was admitted to the facility in 2024 with a diagnosis of heart disease. A 2/3/24 signed hospice narrative revealed the resident was approved and certified for hospice services by the physician on 2/3/24. Resident 22's clinical record did not have a significant change MDS completed with an assessment of the resident's end of life care needs with coordination from hospice, resident, family, and facility. Resident 22's care plan last updated on 2/12/24 revealed the following: -Resident 22 was independent to eat. -Hospice would address the resident's advance directive status. -There was no revision of the care plan related to admission to hospice including the name of the agency. -The discharge plan was to be determined. A 2/22/24 Care Plan Conference form revealed hospice attended the conference. It was determined hospice was to review the resident's advance directive status with the resident and staff were to assist the resident with meals and transfers and not family. The form also indicated the resident was to remain at the facility for care. A 2/22/24 hospice note indicated staff were to notify hospice if Resident 22 had pain, anxiety, or agitation. Staff were also to call hospice if the resident fell. The resident's care plan was not updated to reflect hospice notification, staff only to assist the resident with cares, and the resident's plan to continue to reside in the facility. On 3/18/24 at 12:56 PM Witness 8 (Family) stated the coordination of care was not good. Witness 8 indicated the family was told they could not assist the resident to eat, but staff did not assist the resident. On 3/19/24 at 12:38 PM Staff 43 (CNA) stated Resident 22 had a private aide and family who usually assisted the resident. On 3/20/24 at 9:26 AM Staff 13 (Social Services) stated she did not communicate with hospice in order to update the care plan related to advance directive information. On 3/20/24 at 1:05 PM at Staff 11 (MDS Coordinator) stated if she did not attend the care conference, staff were to notify her of changes which were needed to update the care plan. Staff 11 stated she was not aware of the care conference changes and recommendations.

Resident #22 significant change assessment will be completed. Care plan will be updated to reflect interventions and coordination with hospice. Residents who require hospice services have the potential to be affected. The DON/Designee will complete a baseline audit on all residents who have transitioned on or off hospice to verify a Significant Change MDS has been completed within 14 days of the transition. The DON/Designee will complete a baseline audit specific hospice to verify care plan meets status. The DON/Designee will provide further education to MDS staff related to completing Significant Change MDSs timely, per RAI with specific focus on residents who transition on or off hospice service and revising care plan to reflect current needs. The Don/Designee will complete weekly audits on residents who transitioned on or off hospice to validate they are completed within 14 days of the transition and that care plan has been updated related to hospice needs/coordination. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to submit mandatory staffing information based on the payroll data journal and other verifiable and auditable data as required. This placed residents at risk for inaccurate staffing information. Findings include: Review of the Payroll Based Journal Staffing Data for fiscal year, quarter two, 2023 (4/1/23 through 6/30/24) indicated the facility failed to submit required data for the quarter. On 3/22/24 at 10:10 AM in an interview with Staff 1 (Administrator), Staff 2 (DNS), Staff 37 (Regional Director of Social Services and Activities), Staff 38 (Regional Director of Clinical) and Staff 39 (Northern Regional Director of Operations) it was stated the corporate office handled submitting data and they were unaware it was not submitted.

Payroll Based Journal (PBJ) will be reported quarterly per requirements. The Administrator/Designee will complete a baseline audit to verify the PBJ was submitted for the last quarter. The Administrator/Designee will provide further education to staff responsible for submitting the PBJ the requirements for submitting the PBJ each quarter. The Administrator/Designee will complete quarterly audits to verify the PBJ was submitted each quarter. Audits will be conducted quarterly for 2 quarters. Audit trends will be reported to facility QAPI X 2 quarters for review and further recommendations.

Based on observation, interview, and record review it was determined the facility failed to follow infection control standards for 1 of 4 sampled residents (#4) and 1 of 2 floors (1st floor) reviewed for accidents and infection control. This placed residents at risk for cross contamination. Findings include: 1. Resident 4 was admitted to the facility in 2022 with diagnoses including prostate cancer. An 8/14/23 care plan indicated Resident 4 had a catheter due to a history of prostate cancer and urinary retention. On 3/19/24 at 8:25 AM Resident 4 was observed with her/his catheter bag attached to small garbage can next to the bed. On 3/20/24 at 8:58 AM and 9:33 AM Resident 4 was observed in the dining room with her/his catheter bag attached to her/his wheelchair with approximately one fourth of the catheter bag in contact with the floor and falling out of the privacy bag. On 3/20/24 at 11:27 AM Staff 12 (Agency CNA) stated she attached Resident 4's catheter bag to the garbage can as the bed was in a low position and she did not know where else to attach the bag. On 3/22/24 at 10:28 AM in an interview Staff 1 (Administrator), Staff 2 (DNS), Staff 37 (Regional Director of Social Services and Activities), Staff 38 (Regional Director of Clinical) and Staff 39 (Northern Regional Director of Operations) were notified of Resident 4's catheter bag being secured to a garbage can and the catheter bag on the floor. , 2. On 3/21/24 at 9:15 AM Staff 32 (CNA) walked towards Room 114 and carried dirty linens in her hands instead of being placed in a disposable bag. On 3/21/24 at 10:13 AM Staff 32 was observed leaving Room 117 carrying dirty linens in her hands without a disposable bag, and then placed them in a dirty linen container in the shower room. Staff 32 stated the facility did not maintain a supply of disposable bags necessary to carry out tasks for resident care and maintain infection control standards since 12/2023. On 3/21/24 at 10:36 AM a dispenser filled with disposable bags was observed installed on the wall in the bathroom of Room 117 with Staff 33 (Housekeeper). Staff 33 stated each resident bathroom was equipped with the dispenser and she had no knowledge the facility lacked disposable bags. On 3/21/24 at 12:27 PM Staff 28 (LPN-Unit Manager) confirmed she observed staff walk out of residents' rooms without placing the linens in disposable bags. Staff 28 did not address the infection control issue with CNA staff at that time, and was not aware of the dispensers with disposable bags that were installed in residents' bathrooms. Staff 28 acknowledged disposable bags and not bare hands should be used to transport dirty linens.

Resident #4 catheter bag will be contained to keep from bag touching floor. Staff will place dirty linens in bags provided in each resident room prior to exiting the room. The DON/Designee will complete a baseline audit to verify staff are following infection control procedures with specific focus on catheter bags being covered in manner to prevent contamination from floor or other external factors. The DON/Designee will complete a baseline audit to observe staff that when they are exiting a room with dirty linens, they have those linens bagged prior to exiting the resident room. The DON/Designee will provide further education to staff related to following infection control procedures with specific focus on catheter bag covers and keeping bag from coming into direct contact with the ground and placing dirty linens in a bag prior to exiting a resident room. The DON/Designee will complete audit to verify staff are following infection control procedures with specific focus on catheter bags being covered in manner to prevent contamination from floor or other external factors. The DON/Designee will complete random audit on 10 staff to observe staff that when they are exiting a room with dirty linens, they have those linens bagged prior to exiting the resident room. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview, and record review it was determined the facility failed to follow infection control standards for 1 of 3 sampled residents (#502) reviewed for infection control. This placed residents at risk for cross-contamination. Findings include: Resident 502 was admitted to the facility in 2024 with a diagnosis of a stroke. A 5/13/24 care plan indicated Resident 502 had a catheter due to urine retention and suspected obstruction. On 6/4/24 at 11:14 AM Resident 502's catheter bag was lying on the floor next to her/his bed. At 11:24 AM Staff 11 (CNA) stated the catheter bag was not supposed to be on the floor and stated the bag was full and that was the reason the bag fell. Staff 11 re-attached the bag to the bed without emptying the bag. On 6/5/24 at 10:26 AM Staff 39 (Northern Regional Director of Operations) and Staff 50 (Regional Nurse Consultant) were informed of Resident 502's catheter bag observed on the floor.

No POC Required

Based on interview and record review it was determined the facility failed to ensure an antibiotic was indicated for use for 1 of 3 sampled residents (#60) reviewed for beneficiary. This placed residents at risk for antibiotic resistant organisms. Findings include: Resident 60 admitted to the facility in 2023 with a diagnosis of dementia with behaviors. 2/2024 through 3/2024 Vital Signs records revealed Resident 60's highest temperature was 99 F which was on 2/23/24. Progress notes revealed the following: -2/27/24 Resident 60's urinary catheter was removed on 2/26/24. -2/28/24 a NP progress note indicated the resident wanted her/his urinary catheter replaced because she/he had urgency and frequency and could not sleep. Staff monitored the resident and the staff reported the resident did not have urinary retention (urine remains in the bladder after attempting to urinate). The resident's symptoms were possibly a response from the catheter removal or a UTI. The resident did not have a fever or bloody urine. The resident's recent blood test showed a slightly elevated white count of 15.1 (normal range 4-11/elevated range could indicate an infection, stress, allergies etc.). The note indicated the resident was to be started on an antibiotic pending the results of the UA and culture. -2/28/24 Resident 60 was alert, oriented, urinated three times, and her/his bladder was not painful or distended. -2/29/24 Resident 60 continued to urinate without issue and alert charting was discontinued. -3/1/24 staff called the lab to verify if the resident's urine specimen was sent. Resident 60's antibiotic was to start 3/2/24. -3/4/24 Resident 60 had 600 ml of urine after attempting to urinate and refused to be catheterized. Resident 60 denied pain and did not have bladder distention. -3/4/24 Resident 60 was urinating without difficulty. A Final Diagnostic lab form revealed Resident 60's urine sample was submitted on 2/29/24. The resident's urine sample was not able to be tested. The information was reported to the facility on 3/4/24. A 3/2024 MAR revealed staff were to administer Cipro (antibiotic) for five days from 3/2/24 through 3/6/24. Resident 60 was administered all doses of the antibiotic. There was no documentation in the resident's record to indicate the facility notified the physician there was no urine tested and no culture to verify if the antibiotic was indicated. There was no rationale for the continued use of the antibiotic after the facility was notified the resident's urine sample was not tested. On 3/22/24 at 10:45 AM Staff 2 (DNS) was asked to provide documentation to indicate the resident met criteria to continue the use of the antibiotic or the rationale to continue the antibiotic despite no laboratory data. No additional information was provided.

Antibiotic stewardship practices will be followed for Resident #60. All residents with orders for antibiotics have the potential to be affected. The DON/Designee will complete a baseline audit on all residents on antibiotics to verify antibiotic stewardship practices are followed per requirements. The DON/Designee will provide further education to nursing staff related to antibiotic stewardship practices per requirements. The DON/Designee will complete weekly audits on residents with new orders for antibiotics to validate antibiotic stewardship practices were followed. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to ensure state minimum CNA staffing requirements were maintained for 31 of 369 shifts reviewed for staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include: Review of the Direct Care Staff Daily Reports from 5/1/23 through 5/31/23, 6/1/23 through 6/31/23, 8/1/23 through 8/31/23 and 2/17/24 through 3/17/24 revealed the facility did not have sufficient CNA staff to meet the minimum CNA to resident staffing ratios on the following days: -5/13/23 day shift -5/14/23 day shift -5/15/23 day shift -5/21/23 day shift -5/26/23 day shift -5/27/23 day shift -6/3/23 day shift -6/4/23 day shift -6/9/23 day shift -6/17/23 day shift -6/18/23 day shift -8/3/23 day shift -8/5/23 day shift -8/7/23 day shift -8/14/23 day shift -8/27/23 day shift -2/17/24 day and night shift -2/18/24 day, evening, and night shift -2/19/24 day shift -3/5/24 night shift -3/8/24 evening shift -3/9/24 evening shift -3/10/24 day and evening shift -3/11/24 evening shift -3/15/24 night shift -3/16/24 night shift -3/17/24 evening shift On 3/22/24 at 10:10 AM in an interview with Staff 1 (Administrator), Staff 2 (DNS), Staff 37 (Regional Director of Social Services and Activities), Staff 38 (Regional Director of Clinical), and Staff 39 (Northern Regional Director of Operations) it was stated the facility continued with actively hiring staff.

All residents have the potential to be affected. South Hills continues to offer and host a CNA class. South Hills continues to advertise and recruit additional CNAs. The Administrator/Designee will complete a baseline audit for the last 14 days to verify compliance with minimum CNA staffing. The Administrator/Designee will provide further education to staff related to the requirements for minimum CNA staffing. The Administrator/Designee will complete weekly audits to verify compliance with minimum CNA staffing. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

**************************************** OAR 411-086-0260 Pharmaceutical Services Refer to F554 and F756 **************************************** OAR 411-085-0310 Residents' Rights: Generally Refer to F561, F565, F576, F585 and F604 **************************************** OAR 411-085-0030 Required Postings Refer to F577 **************************************** OAR 411-086-0130 Nursing Services: Notification Refer to F580 **************************************** OAR 411-087-0100 Physical Environment Refer to F584 **************************************** OAR 411-085-0360 Abuse Refer to F609 *************************************** OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F637 and F657 ***************************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F677, F684 and F697 ***************************************** OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F688, F689, F690, F692, F757 and F758 *************************************** OAR 411-086-0100 Nursing Services: Staffing Refer to F725 and F727 **************************************** OAR 411-086-0310 Employee Orientation and In-Service Training Refer to F730 **************************************** OAR 411-086-0010 Administrator Refer to F776 and F851 **************************************** OAR 411-086-0210 Dental Services Refer to F791 **************************************** OAR 411-086-0250 Dietary Services Refer to F809 and F814 **************************************** OAR 411-086-0010 Administrator Refer to F849 **************************************** OAR 411-086-0330 Infection Control and Universal Precautions Refer to F880 and F881 ****************************************

*************************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F677 ***************************************** OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F758 *************************************** OAR 411-086-0330 Infection Control and Universal Precautions Refer to F880 ****************************************

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 04/24/2023 and 04/30/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on interview and record review it was determined the facility failed to provide the necessary services to maintain personal hygiene according to the resident's preference for 1 of 5 sampled residents (#3) reviewed for ADLs. The placed resident at risk for poor hygiene. Findings include: Resident 3 was admitted to the facility in 1/2020 with diagnoses including diabetes and morbid obesity. Review of a February 2023 ADL report revealed no documentation the resident received a shower. Review of a March 2023 ADL report revealed no documentation the resident received a shower. Review of shower sheets from February 2023 through March 2023 revealed the resident received a shower on 2/2/23 and 3/21/23. The resident refused a shower on 2/6/23 and no further documentation was provided. In an interview on 3/22/23 at 10:26 AM Resident 3, who was alert and oriented, indicated she/he received a shower on 2/2/23 and did not receive another shower until 3/21/23. Resident 3 said she/he did not receive any bed baths and did not refuse any showers. Resident 3 indicated she/he had body odor and greasy hair because she/he had gone so long without a shower. Resident 3 said she/he preferred to received at least one shower a week. In an interview on 3/22/23 at 12:00 PM Staff 1 (DNS) acknowledged the documentation showed the resident only received a shower on 2/2/23 and 3/21/23. Staff 1 also acknowledged the facility did not honor the resident's preference to receive at least one shower a week.

Resident #3s preference for bathing was reviewed and updated. Resident #3 will be offered bathing per her preference. DON/Designee completed baseline audit of current residents bathing preference to verify care plan is updated to reflect bathing preference. Identified issues will be addressed. DON/Designee will provide further education to nursing staff related to resident bathing schedules and offering bathing opportunities per the residents preference. DON/Designee will conduct an ongoing audit of residents to verify they were offered bathing opportunities according to their preference. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to assess, monitor and provide treatment timely after spilling hot coffee for 1 of 5 sampled residents (#1) reviewed for accidents. Resident 1 required hospitalization and was diagnosed with 2nd degree burns of the left thigh and back. Findings include: Resident 1 was admitted to the facility in 7/2022 with diagnoses including quadriplegia. Review of a Care Plan dated 12/29/22 revealed the resident required assistance with set up for meals but was otherwise independent with eating and drinking. Review of a Nursing Facility Reported Incident form dated 2/25/23 revealed on 2/24/23 at 8 AM Resident 1 requested coffee reheated and then spilled the coffee on himself/herself which resulted in burns to the resident chest and legs. There was no documentation on 2/24/23 at 8 AM regarding the incident in the progress notes and no documentation the resident's wound was assessed, monitored or treated until 2/25/23 at 6:35 AM. Review of a progress note dated 2/25/23 at 6:35 AM by Staff 2 (LPN) revealed "At shift change 6pm CNA stated res spilled coffee" on himself/herself and the CNA would change the resident sheets. "This morning at 5am CNA went in room to change resident". CNA reported fluid filled blisters and redness on the resident left side and back. The note indicated the DNS and the on-coming nurse were notified. Review of a progress note by Staff 2 on 2/25/23 at 7:02 AM revealed the resident's physician was notified. There was no documentation an incident report was initiated. Review of a skin assessment dated 2/25/23 at 4:56 PM revealed Resident 1 had burns to the left thigh measuring 32 cm by 12 cm. The assessment indicated the resident had just returned from a local hospital with an intact dressing over the wound. Review of an incident investigation dated 3/3/23 revealed Resident 1 sustained 2nd degree burns after spilling coffee on himself/herself. The resident requested coffee around 7-8 PM on 2/24/23. A CNA heated the coffee in a microwave, placed a lid on the cup and placed a straw through the lid to give to the resident. A CNA was notified by the charge nurse around 8 PM that the resident had spilled the coffee and needed new sheets. A CNA went to the resident's room to change the sheets and notice the resident had pink skin and informed the charge nurse. The investigation indicated the resident's burns were not assessed until the afternoon of 2/25/23. In an interview on 3/22/23 at 9:48 AM Staff 3 (CNA) stated Resident 1 requested a cup of coffee around 8:30 PM on 2/24/23 and heated the coffee in the microwave for less than a minute. Staff 3 gave the resident the coffee and told him to be careful the coffee was hot. Around 9:00 PM Staff 2 informed her the resident had spilled coffee on himself/herself and brought in new sheets and blankets to change the residents linens. Staff 3 said the resident refused the linen change and the linens did not feel wet. Staff 3 said another staff had changed the linens and at 10 PM and the resident was asleep. In an interview on 3/23/23 at 9:42 AM Staff 4 (CMA) said she administered Resident 1's medications between 7:30 PM and 8:00 PM and witnessed the resident take the medication with a cup of coffee. Staff 2 was the charge nurse from 2 PM to 10 PM and did not inform her the resident had spilled coffee. In an interview on 3/24/23 at 11:52 AM Staff 6 (CNA) said she worked on 2/24/23 on the evening shift and around 7:30 PM Resident 1 told her he/she had spilled coffee. Resident 1 said he/she told Staff 2 of the spill. Staff 2 told Staff 6 she looked at the resident's skin and Staff 6 did not know if Staff 2 did anything else. Staff 6 said she changed the resident's chux pad and sheets which were hot to the touch. Staff 6 said the resident's skin was pinker than normal and the chux pad was stuck to the resident's skin. Staff 6 said there was a coffee cup on the resident's bed side table. In an interview on 3/27/23 at 9:12 AM Staff 2 said she worked a 12 hour shift from 6 PM on 2/24/23 to 6 AM on 2/25/23. Staff 2 said she overheard another staff Resident 1 had spilled coffee on himself/herself around 7-8 PM. It was reported to her the resident's skin was red on the left side. Staff 2 checked on the resident around 12 AM. Staff 2 said she did not assess or monitor the resident's skin because she got busy. Staff 2 said on 2/25/23 around 5 AM she checked on the resident and noticed a large blister and redness to the resident's left side hip and lower back. Staff 2 said she was shocked and not aware of the injury. Staff 2 called Staff 1, completed an incident report and made a progress note. It was determined this citation met the criteria for Past Non-compliance based on the following: The facility was found in non-compliance with the regulatory requirement at F689 on 2/24/23 when Resident 1 spilled the coffee. The facility reported the incident to the State Agency on 2/25/23. The accident involving Resident 1 occurred after the most recent complaint survey of 2/21/23 and before this current survey of 3/7/23. The facility corrected the non-compliance by completion of an incident investigation, identified the regulatory non-compliance and in-serviced all staff on the following resident care plans and hot beverage policies and procedures. The facility conducted weekly audits to keep resident safe from further incidents and no additional incidents occurred since the accident on 2/24/23.

********************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F677 ********************************** OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F689 **********************************

Based on interview and record review it was determined the facility failed to properly secure controlled medications for 3 of 5 Sampled residents (#s 2, 3 and 6) reviewed for misappropriation. This placed residents at risk for loss of medications. Findings include: 1. Resident 2 admitted to the facility in 2017 with diagnoses including complex regional pain syndrome. Resident 2 had a physician's order to receive scheduled Oxycodone (a controlled medication used to manage pain) for her/his pain. On 3/11/22 174 tabs of Resident 2's Oxycodone were noted to be missing from the locked medication cart. A review of the resident's 3/2022 MAR revealed no missed doses of the medication. On 9/27/22 at 3:12 PM and 4:11 PM Staff 2 (Interim Director of Nursing) confirmed Resident 2's Oxycodone was not properly secured and was unaccounted for. 2. Resident 3 admitted to the facility in 2020 with diagnoses including chronic pain. Resident 3 had a physician's order to receive Lyrica (a controlled medication used to manage nerve pain) bid for her/his pain. On 3/11/22 60 capsules of Resident #3's Lyrica were noted to be missing from the locked medication cart. A review of the resident's 3/2022 MAR revealed no missed doses of the medication. On 9/27/22 at 3:12 PM and 4:11 PM Staff 2 (Interim Director of Nursing) confirmed Resident 3's Lyrica was not properly secured and was unaccounted for. 3. Resident 6 admitted to the facility in 2021 with diagnoses including anxiety. Resident 6 had a physician's order to receive lorazepam (a medication used to manage anxiety) PRN. On 5/3/22 10 tabs of Resident 6's lorazepam were noted to be missing. On 9/27/22 at 3:12 PM Staff 2 (Interim Director of Nursing) confirmed Resident 6's lorazepam was unaccounted for.

F602 Free from Misappropriation Resident #2 controlled medication will be secured properly. Residents #3 controlled medications will be secured properly. Resident #6 is no longer at the facility. Residents with orders for controlled medications are at risk. DON/Designee completed baseline audit of residents with controlled medication orders to verify ordered medications are available and secured. Identified inaccuracies will be addressed. DON/Designee initiated further education to licensed nurses and CMAs on 10/20/2022 and ongoing related to misappropriation of residents ordered controlled medications. DON/Designee initiated further education to licensed nurses and CMAs 10/20/2022 related to the shift-to-shift controlled medication count process. DON/Designee will conduct ongoing audit of the shift-to-shift count to verify shift count is accurate and that controlled medications are secure. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to adequately manage diabetes and follow physician's orders for 1 of 3 sampled resident (#4) reviewed for wound care. This placed residents at risk for complications from diabetes and poor wound outcomes. Findings include: Resident 4 admitted to the facility in 2/2022 for care following a below the knee amputation. The resident also had a diagnosis of diabetes. a. A 3/1/22 physician's order instructed staff to inject eight units of insulin lispro (a rapid acting insulin that begins to work immediately after injecting to prevent blood glucose from rising) with meals. The resident's Diabetes Administration Record (DAR) revealed the resident received eight units of insulin lispro at 11:30 AM. A 3/8/22 Progress Note indicated Resident 4 left the facility to go to dialysis at approximately 12:00 PM. A later 3/8/22 Progress Note revealed Resident 4 was sent to the hospital from dialysis due to hypoglycemia (low blood sugar). On 9/8/22 at 1:02 PM Witness 1 stated Resident 4 usually was able to eat an early lunch prior to leaving for dialysis however on 3/8/22 she/he did not get anything to eat prior to leaving the facility. On 9/15/22 at 11:53 AM Resident 4 reported she/he did not eat lunch on 3/8/22 before she/he left for dialysis. The resident stated on that day the bus to bring her/him to dialysis was early. Resident 4 reported facility staff administered the fast acting insulin right before she/he had to get on the bus. On 9/27/22 at 4:13 PM Staff 2 (Interim Director of Nursing) acknowledged Resident 4 had a low blood sugar on 3/8/22 at dialysis and had no previous episodes of low blood sugar during dialysis. b. A 2/28/22 provider encounter note indicated Resident 4's surgical wound had started to have some yellowish, bloody drainage. The note indicated nursing was to monitor the wound closely and inform the resident's surgeon of the change. The note further revealed the resident was to be seen by a wound care specialist for evaluation. A 2/28/22 written physician's order instructed staff to contact the surgeon's office and inform them of the change in the wound and request a stump protector. A review of the resident's electronic health record revealed no documentation to indicate the surgeon's office was ever notified. There was also no indication the facility followed through with obtaining the wound care consult. On 9/27/22 at 12:57 PM Staff 4 (LPN Unit Manager) confirmed there was no follow up with the resident's surgeon's office or for a wound care consult.

F684 Quality of Care r/t verifying residents meals are provided timely before dialysis and surgical wounds are being followed with proper notification to providers. Resident # 4 no longer resides at the facility Residents who receive insulin and go to dialysis are at risk Residents who have surgical wounds are at risk DON/Designee completed baseline audit of surgical wounds to verify wounds have been assessed and are being treated and physician recommendations are being followed. DON/Designee initiated education to Licensed Nurses on 10/20/2022 and ongoing related to meals being served timely following insulin administration with specific focus on residents who leave the facility for dialysis. DON/Designee initiated education to Licensed Nurses on 10/20/2022 and ongoing related to following providers orders with specific focus on surgical wound follow up. DON/Designee will conduct audits of residents who receive dialysis and insulin to verify on dialysis days that the resident had sufficient time to consume meal prior to leaving. DON/Designee will audit current residents with surgical wounds to verify orders are in place and being followed. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

************************** OAR 411-085-0360 Abuse Refer to F602 ************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F684

Based on observation, interview, and record review it was determined the facility failed to ensure dignity for 1 of 3 sampled residents (#21) reviewed for catheter. This placed residents at risk for lack of dignity. Findings include: Resident 21 was admitted to the facility in 4/2021 with diagnoses including depression and history of UTIs. An 4/23/21 care plan revealed Resident 21 had a catheter with interventions including monitor and document intake and output as per facility policy. An 10/26/21 Quarterly MDS revealed Resident 21 had a BIMS score of 14 indicating she/he was cognitively intact. On 12/7/21 at 9:20 AM Resident 21's catheter bag was observed uncovered hanging off the side of her/his bed within view from the hallway. Resident 21 stated she/he did not like her/his bag uncovered. In an interview on 1/7/22 at 12:14 PM Staff 1 (Administrator), Staff 49 (Interim DON) and Staff 50 (Regional Nurse Consultant) stated if a resident wanted their catheter bag covered in their room and visible from the hallway, staff should cover the bag .

Resident #21 catheter bag will be covered to maintain dignity. DON/Designee completed baseline audit of current residents with urinary catheters 02/11/2022 to determine if catheter bag is covered to provide dignity. Identified inconsistencies addressed. DON/Designee initiated further education to staff 02/11/2022 and ongoing on facility policy F550 on Resident Rights with specific focus on dignity and covering of catheter bag. DON/Designee will conduct ongoing audit of current residents with urinary catheters to verify catheter bag is covered to provide dignity. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to notify a resident/responsible party prior to change of administration of medication for 1 of 3 sampled residents (#3) reviewed for medications. This placed residents at risk for lack of informed consent. Findings include: Resident 3 was admitted to the facility in 2019 with diagnoses including fibromyalgia and osteoarthritis of the hip. Resident 3's Clinical Resident Profile indicated she/he was her/his own responsible party. A 9/5/19 Admission MDS revealed Resident 3 had a BIMS score of 15 indicating she/he was cognitively intact. The MDS indicated Resident 3 did not have a diagnosis of Parkinson's disease. A 9/6/19 signed physician order instructed staff to administer pramipexole (used in the treatment of some movement disorders) one milligram, take three tablets at bedtime, doctor's comments: appointment pending. A 3/2020 MAR instructed staff to administer Pramipexole dihydrochloride one milligram, administer three tablets by mouth at bedtime for Parkinson's disease "Needs diagnosis" with a start date of 8/29/19. A signed pharmacist Consultation Report dated 4/23/20 revealed no diagnosis or documentation in Resident 3's record which supported continued use of pramipexole dihydrochloride. Staff 15 (Nurse Practitioner) made a hand written note on the report she agreed there was no apparent diagnosis and would gradually reduce the medication of the next two weeks. If Resident 3 developed any symptoms a diagnosis would be documented to support the use of pramipexole dihydrochloride. No documentation was found in clinical record Resident 3 was notified of the gradual dose reduction of the medication. A 5/2020 MAR instructed staff to administer pramipexole dihydrochloride two tablets at bedtime for Parkinson's disease with a start date of 4/23/20 and discontinued on 5/7/20. On 5/7/21 the MAR instructed staff to administer pramipexole dihydrochloride one milligram one tablet for Parkinson's disease and monitor for leg pain with a discontinued date of 5/26/21. A 6/9/20 Provider order sheet instructed staff to administer pramipexole daily for restless leg syndrome. A 6/2020 MAR instructed staff to administer Pramipexole 0.125 milligram one tablet a day with a start date of 6/10/20. A 6/16/20 Confidential Referral Form indicated Resident 3 reported in 6/2020 she/he had a terrible episode of restless leg syndrome and could not hold still. Staff were providing a muscle relaxer which did not work, and Resident 3 had to argue to get the medication for restless leg syndrome. The medication was ordered but the dosage was not high enough. In an interview on 1/7/22 at 11:29 AM Staff 1 (Administrator), Staff 49 (Interim DON) and Staff 50 (Regional Nurse Consultant) confirmed staff should contact a resident of a change of medication when they are their own responsible party.

Resident #3 no longer resides at the facility. DON/Designee completed baseline audit of the last 7 days of current residents who have experienced a medication change that alters treatment to verify that resident and/or responsible party were notified of the change. Identified inconsistencies addressed. DON/Designee initiated further education to LN staff 02/11/2022 and ongoing on facility policy F552 on Resident Rights with specific focus on notifying resident and/or responsible party of medication changes that alter treatment. DON/Designee will conduct ongoing audit of current residents with medication change that alters treatment to verify resident and/or responsible party were notified. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to comprehensively assess 1 of 3 sampled residents (#15) reviewed for pain. This placed resident at risk for adverse reactions. Findings include: Resident 15 was admitted to the facility in 4/2021 with diagnoses including Rheumatoid arthritis. An 10/31/21 Quarterly MDS indicated Resident 15 did not receive scheduled pain medications and received PRN pain medications. Resident 15 was unable to answer her/his frequency of pain. A 11/2021 MAR instructed staff to administer oxycodone by mouth every eight hours PRN for pain. From 11/1/21 through 11/7/21 Resident 15 was administered oxycodone nine instances. A 11/8/21 Nursing Note indicated Nursing staff found 18 oxycodone tablets in Resident 15's bedside table. The oxycodone medication was the same medication Resident 15 stated she/he threw away on a previous day. Staff 2 (DNS) and Staff 51 (Nurse Practitioner) were alerted, and the continued self-administration of a different medication, carbidopa-levodopa (to treat symptoms of Parkinson's disease), was discussed. Staff 51 did not want to change the administration times or methods and was going to leave it as-is per the facility medication self-administration policy. Staff 2 and the Staff 8 (Unit Manager) spoke to Resident 15 about the issue of her/his decision to hold on to part of her/his oxycodone medication. No assessment was found in clinical records for Resident 15's self-administration of medication. In an interview on 1/7/22 at 12:13 PM Staff 1 (Administrator), Staff 49 (Interim DNS) and Staff 50 (Regional Nurse Consultant) stated the expectation of the staff was to evaluate residents for self-administration of medications.

Resident #15 has been evaluated for Self-Administration of Medications on 02/11/2022. DON/Designee completed baseline audit of current residents with BIMs of 12 or higher who have expressed desire to self-administer medications to verify that a Self-Administration of Medications evaluation has been completed. Identified inconsistencies addressed. DON/Designee initiated further education to LN staff and CMAs 02/11/2022 and ongoing on facility policy F552 on Resident Rights with specific focus on right to self-administer medication and facility process to complete self-administration evaluation prior to determine safety. DON/Designee will conduct ongoing audit of current residents who have expressed desire to self-administer medications to verify that a Self-Administration of Medications evaluation has been completed. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to ensure residents were free from neglect related to a failure to provide proper and necessary care, goods, and services for 2 of 6 residents (#s 10 and 12) reviewed for incontinence and resident rights. Resident 10 developed multiple wounds to the buttocks. Findings include: 1. Resident 10 was admitted to the facility in 8/2020 with diagnoses including chronic pain, obesity, and muscle weakness. 11/30/20 and 12/1/20 care plans indicated Resident 10 had actual skin impairment with interventions including use a draw sheet or lifting device to move, and boost Resident 10 up in bed and use caution during transfers. The care plan indicated Resident 10 had a colostomy (an opening for the colon, or large intestine, through the abdomen) and catheter. A 2/21/21 Wound Evaluation indicated Resident 10 had a blister on her/his groin (right inner thigh) which measured an area of 5.12 cm2, a length of 3.26 cm by a width of 2.41 cm. Treatment included cleaning with normal saline with no dressing and the practitioner was notified. The 2/2021 Documentation Survey Report revealed the following: Skin Observation -2/24/21 Resident 10 was identified to have an open area which was a new skin condition. There was no documentation of the location of the new skin condition. A 2/24/21 Injury Investigation document indicated Resident 10 was found by a CNA to have several open areas, including under the left side of the pannus, under both buttocks, on the thighs and one to the right inner thigh. The open areas to the buttocks were nearly identical straight line shaped wounds which appeared like a slice. Each was approximately 5 cm long by .5 cm wide and 0.5 cm deep with some scabbing to the outer edges of the wounds and open at the bases. The wounds were red and beefy at the open areas, the area on Resident 10's thighs were bright red covering the area starting between her/his thighs and wrapping around both sides to the entirety of her/his buttocks bilaterally. The area to the right inner thigh had the appearance of a small hole which looked like a large pimple had popped and left a crater in her/his skin. Resident 10 was unable to give a description. Resident 10 was oriented to person, situation, place, and time. The wounds were cleaned and dressed, and barrier cream was applied. A note on 3/3/21 indicated nursing took pictures and documented the size, shape, and depth of the wounds. The incident appeared to have been caused when Resident 10 was pulled up in her/his bed improperly with excess peri-area moisture present and possibly her/his catheter laying over her/his leg in the same place all the time irritating her/his legs. The CNAs were instructed regarding the proper way to pull a resident up in bed and reminded to frequently check the skin of the residents who frequently had moisture build up on their skin. No abuse or neglect was found at this time. A 3/3/21 Nursing Note indicated Witness 39 (Former LPN) completed wound rounds and Resident 10 had several long abrasions on her/his backside. It was Witness 39's opinion the wounds were inflicted by care staff pulling the brief out from under Resident 10 repeatedly, causing the abrasions on the fragile moist skin. Staff were informed the brief was not necessary as Resident 10 had an ostomy and a catheter in place. On 11/24/21 at 8:23 AM Witness 8 (Former CNA) confirmed in 3/1/21 she came to work and went to assist another CNA to provide a brief change and repositioning for Resident 10. Witness 8 stated Resident 10's bottom was "shredded" with an odor of infection. Resident 10's wounds were weeping, and it was obvious she/he was not getting repositioned. The resident's nurse came in to assess Resident 10's wounds and stated the wounds looked worse to her than the previous week. On 12/7/21 at 9:59 AM Resident 10 stated at times at night when she/he needed assistance with bed mobility and pushed her/his call light button, sometimes she/he wondered "oh god are they ever going to come in". In an interview on 1/7/22 at 11:00 AM Staff 1 (Administrator), Staff 49 (Interim DON) and Staff 50 (Regional Nurse Consultant) stated they would have to be present and do their own investigation to determine if abuse and neglect was ruled out or not for Resident 10's wounds. Refer to F684 2. Resident 12 was admitted to the facility in 3/2021 with diagnoses including blindness, need for assistance with personal care and cognitive communication deficit. A 3/11/21 care plan indicated Resident 12 had an ADL self-care performance deficit and required extensive assistance of two staff members to dress. A 3/13/21 Admission MDS revealed Resident 12 had no concerns with behaviors and required extensive assistance with bed mobility with two-person physical assist. Resident 12 required limited assistance with dressing with two-person physical assist. A 3/13/21 Cognitive loss Dementia CAA revealed Resident 12 did not demonstrate confusion, had a pleasant mood state, was not hearing impaired, and was able to communicate her/his needs well and make her/his needs known. On 11/24/21 at 8:59 AM Witness 9 (Complainant) stated she was in the facility on 4/12/21 to visit a family member, she walked by Resident 12's room, the privacy curtain was not drawn and the door was wide open. Resident 12 was exposed and was partially covered with a brief and Witness 9 could see her/him from the hallway. Resident 12 kept saying "help me, help me" and the staff were walking by the room and no one stopped to assist Resident 12. Witness 9 continued down the hallway and when she returned to Resident 12's room, she/he was still calling out for help and her/his brief had fallen off fully exposing her/his genitals. Witness 9 stated she reported the incident to the charge nurse and the charge nurse stated, "Believe me, I know" and did nothing to assist Resident 12. On 12/13/21 at 11:09 AM Staff 41 (CNA) stated Resident 12 was a resident a lot of staff ignored. Resident 12 was bed bound and blind. Staff went in to assist Resident 12's roommate but quietly left without assisting Resident 12. Staff 41 stated the staff would not get Resident 12 dressed. Staff 41 stated almost every shift she worked at the facility Resident 12 was not dressed and was not covered. On 12/14/21 at 10:11 AM Staff 46 (CNA) stated Resident 12 would remove her/his brief. On 12/13/21 at 11:23 AM Staff 42 (CNA) stated there were instances Resident 12 did not have any clothes on; she/he took off her/his hospital gown off. Staff 42 stated Resident 12 did not use her/his call light often. Staff 42 stated during 4/2021 there were a lot of residents who needed a lot of care and it could take up to 45 minutes to assist a resident so other residents had long wait times. On 12/15/21 at 11:46 AM Staff 40 (CNA) stated Resident 12 undressed herself/himself. Resident 12 called out for assistance frequently and staff members finished what they were doing first and did not prioritize Resident 12. In an interview on 1/7/22 at 11:57 AM Staff 1 (Administrator), Staff 49 (Interim DON) and Staff 50 (Regional Nurse Consultant) stated they expected staff to go in and assist the resident right away unless they were dealing with an emergent situation and then they should ask another staff member to go in and assist.

Resident #3 no longer resides at the facility. Resident #10 will remain free from further abuse or neglect. CP will be followed. Resident #12 no longer resides at the facility. DON/Designee completed baseline audit of the last 30 days of current residents incidents to verify that that abuse and neglect were ruled out. Identified inconsistencies addressed. DON/Designee initiated further education to staff 02/11/2022 and ongoing on facility policy F600 on abuse and neglect with specific definitions of abuse. DON/Designee will conduct ongoing audit of residents who experience an incident to verify abuse and neglect ruled out and that care plan was followed. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to ensure residents were free from misappropriation for 1 of 3 sampled residents (#3) reviewed for resident rights. This placed residents at risk for loss of property. Findings include: Resident 3 was admitted to the facility in 2019 with diagnoses including blindness and anxiety. An 8/29/19 Inventory of Personal items document revealed Resident 3 had multiple carrying bags. A 6/7/20 Quarterly MDS revealed Resident 3 had a BIMS score of 15 and was cognitively intact. A 6/8/20 public complaint revealed Resident 3 heard people coming into her/his room but could not see them. Resident 3 called out, but the person did not answer. In 5/2020 Resident 3's bag and a book about cats was found in another resident's room. Resident 3 wanted to file a report with the police but was told by the DNS it was the resident's word against other people. Resident 3 felt dismissed. Additionally Resident 4 went into Resident 3's room and the facility did not prevent Resident 4 continued access to Resident 3's room. A 6/16/20 Confidential Referral Form indicated Resident 3 had personal items taken and some broken from her/his room. Resident 3 reported people snuck into her/his room and she/he attempted to call the police but the "temporary head" informed Resident 3 not to call as it was her/his word over the other person. On 11/23/21 at 12:16 PM Witness 2 (Former CNA) stated Resident 3 reported to him that her/his personal property was taken out of her/his room. Resident 3 was blind but had good hearing. The person went through her/his possessions. Witness 2 stated he spoke to the Unit Manager about the concern, but they were dismissive of the report. On 12/13/21 at 9:54 AM Witness 19 (Former LPN) stated she remembered Resident 3 and in 5/2020 and 6/2020 CNAs reported to her Resident 3 was missing personal items and Witness 19 assisted in looking for the items. Witness 19 reported the concern to the Unit managers, and stated the issue should have gone through a grievance process. The perpetrator was narrowed down to Resident 4 who was going into Resident 3's room without knocking or asking permission to enter. On 12/13/21 at 10:50 AM Staff 36 (CNA) stated Resident 3 complained of other residents taking her/his personal items. Staff 36 stated it usually was not resolved and she told another CNA and it was also reported to the nurse on the night shift. On 12/13/21 at 11:56 AM Witness 22 (Former CNA) stated he spoke with Resident 3 about her/his missing personal items. Resident 4 would go in and visit Resident 3 and leave with soda or chips, and Witness 22 stated he reported the concern to his nurse and supervisor. On 12/14/21 at 9:47 AM Staff 24 (CNA) stated she thought Resident 4 was stealing from Resident 3. On 12/13/21 at 10:33 AM and 12/21/21 at 1:09 PM Staff 1 (Administrator) stated there were no grievances filed for Resident 3 in 5/2020 or 6/2020. Staff 1 did not have any documentation which stated anything about missing items for Resident 3 or about another resident taking items from Resident 3. In an interview on 1/7/22 at 11:00 AM Staff 1 (Administrator), Staff 49 (Interim DON) and Staff 50 (Regional Nurse Consultant) stated no grievances were found and it was expected of staff to start a grievance when personal items were reported missing.

Resident #3 is no longer a resident. NHA/Designee completed baseline audit of the last 30 days of missing item reports to verify a grievance was completed. NHA/Designee initiated further education to staff 02/11/2022 and ongoing related to facility policy F600 related to Abuse and F585 with specific focus on misappropriation of property and grievance process. NHA/Designee will conduct ongoing audit of residents who experience missing items to verify misappropriation is ruled out and that the grievance process was followed. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview, and record review it was determined the facility failed to provide care and services to maintain good grooming and hygiene for 5 of 8 sampled residents (#s 1, 10, 11, 13, and 14) reviewed for ADLs. This placed residents at risk for poor hygiene and weight loss. Findings include: 1. Resident 1 was admitted to the facility in 4/2021 with diagnoses including dementia and stroke. a. An 4/8/21 care plan indicated Resident 1 had an ADL self-care performance deficit with limited mobility. Resident 1 required assistance of one staff due to cognition and Resident 1 was to eat in the dining room. An 4/12/21 Five-day MDS indicated Resident 1 required limited assistance with one-person physical assist with eating. An 4/2021 Documentation Survey Report revealed from 4/8/21 through 4/21/21 a total of 39 opportunities for Resident 1 to receive assistance with eating: -Two instances of no documentation. -Two instances of independent no setup or physical help from staff. -Two instances the activity did not occur. -Six instances of independent with setup help only. -Nine instances of supervision with oversight, encouragement or cueing with set up help only. -Ten instances of limited assistance one-person physical assist. -Three instances of extensive assistance one-person physical assist. -Four instances of total dependence one-person physical assist. On 11/24/21 at 8:38 AM Witness 12 (Family Member) stated Resident 1 was not assisted at mealtimes and staff told the family they could not assist with Resident 1's meals. Witness 12 stated Resident 1 was not brought to the common areas to eat. On 12/15/21 at 11:39 AM Staff 40 (CNA) stated it was difficult to assist the residents who required assistance with eating, as there were five residents who required assistance in 4/2021 and had to split them among the staff. One resident ate in her/his room and at times the other residents did not want to go to the dining room to eat. In an interview on 1/7/22 at 11:11 AM Staff 1 (Administrator), Staff 49 (Interim DON) and Staff 50 (Regional Nurse Consultant) stated they would like to review for additional information. No additional information was provided. b. An 4/8/21 care plan indicated Resident 1 had an ADL self-care performance deficit with limited mobility. Resident 1 required assistance of one staff to provide a bath or shower as necessary. An 4/12/21 Five-Day MDS indicated Resident 1 required extensive assistance with one-person physical assistance with personal hygiene and bathing activity did not occur. An 4/2021 Documentation Survey Report indicated Resident 1's bathing was on Tuesdays and Fridays on the evening shift. From 4/8/21 through 4/21/21 Resident 1 did not receive any type of bathing. Documentation on 4/12/21 indicated the activity did not occur and no other documentation was completed for Resident 1's bathing. On 11/24/21 Witness 12 (Family Member) stated when the facility brought Resident 1 out of the facility, she/he smelled "horrible", and she/he had dried feces on her/him. On 12/15/21 at 11:39 AM Staff 40 (CNA) stated it was difficult to provide showers in 4/2021 as she had a difficult time completing all her required assignments each day, and a couple of times a week she did not have time to complete a resident's shower. In an interview on 1/7/22 at 11:11 AM Staff 1 (Administrator), Staff 49 (Interim DON) and Staff 50 (Regional Nurse Consultant) stated they would like to review for additional information. No additional information was provided. 2. Resident 10 was admitted to the facility on 8/2020 with diagnoses including difficulty in walking, muscle weakness and required assistance with personal cares. An 10/28/20 care plan indicated Resident 10 had an ADL self-care performance deficit and required assistance of one to two staff to provide a bath or shower as necessary. a. The Documentation Survey Report for 2/2021 indicated Resident 10 had one bed bath on 2/1/21, refused a shower on 2/15/21 and received no other bed bath or shower for the month of 2/2021. Shower Day Audit sheets for 2/2021 indicated the following: -2/2/21 bed bath -2/8/21 shower -2/21/21 bed bath -no date refused No documentation was found in clinical records Resident 10 received a shower for 12 days from 2/9/21 through 2/20/21. The Documentation Survey Report for 3/2021 indicated Resident 10 received no bed bath or shower for the month of 3/2021. Resident 10 refused two instances with no documentation found in clinical records indicating she/he was asked again or provided a shower or bed bath the next day due to her/his refusals. Shower Day Audit sheets for 3/2021 indicated the following: -3/2/21 bed bath -3/4/21 Resident 10 stated will have one on 3/5/21 before appointment. -3/8/21 Refused -3/9/21 bed bath -3/23/21 handwritten note indicated Resident 10 wanted to wait until later. Staff reported if she/he did not get one with "me" she may not get one later. -3/30/21 bed bath A 3/30/21 Administration Note indicated Resident 10 had a bed bath on 3/30/21. On 11/24/21 at 8:23 AM Witness 8 (Former Staff) stated during 3/2021 the staff were not providing residents with showers because the facility was short staffed. On 12/17/21 at 8:20 AM Witness 29 (Former CNA) stated from 1/2021 through 3/2021 she did not always have time to complete showers for residents because the facility was short staffed. On 12/17/21 at 10:56 AM Witness 30 (Former CNA) stated in 2/2021 Resident 10 refused her/his showers at times, but staff did not go back and reapproach her/him to ask again. In an interview on 1/7/22 at 11:47 AM Staff 1 (Administrator), Staff 49 (Interim DON) and Staff 50 (Regional Nurse Consultant) stated they did not hear of staff documenting residents refusing showers when they did not refuse, rather staff were too busy. b. The 10/2021 Documentation Survey Report revealed Resident 10 was to have showers on Monday and Thursday days PRN. The report indicated Resident 10 received no showers in 10/2021. A CNA Skin and Shower Review documents for 10/2021 indicated the following: -10/11/21 received a bed bath -10/14/21 received a shower -10/21/21 received a shower A 11/20/21 Quarterly MDS revealed Resident 10's BIMS score was 11 indicating she/he had a moderate cognitive impairment. Resident 10 required physical help with bathing with one-person physical assist. The 11/2021 Documentation Survey Report revealed Resident 10 was to have showers on Monday and Thursday days PRN. Resident 10 received a shower on 11/18/21 and refused on 11/22/21. CNA Skin Shower Review documents for 11/2021 indicated the following: -11/4/21 received a shower. -11/22/21 Resident 10 refused and was documented she/he wanted one shower a week. -11/25/21 received shower -11/29/21 Resident 10 refused shower and only wanted one shower a week. No documentation was found in clinical records Resident 10 received a shower for 13 days from 11/5/21 through 11/17/21. On 12/7/21 Resident 10 stated she/he went a couple of weeks without a shower. Resident 10 stated if she/he refused a shower it was because she/he did not feel well, but staff did not come back again to offer later. Resident 10 stated she/he thought to herself/himself "you blew it this time [girl/boy]" about assisting with her/his shower. In an interview on 1/7/22 at 11:47 AM Staff 1 (Administrator), Staff 49 (Interim DON) and Staff 50 (Regional Nurse Consultant) stated they did not hear of staff documenting residents refusing showers when they did not refuse, rather staff were too busy. 3. Resident 11 was admitted to the facility in 2015 with diagnoses including depression and dementia. A 1/13/20 Care plan indicated Resident 11 refused to accept cares routinely with interventions including allow Resident 11 to make decisions to provide a sense of control, give clear explanation of all care activities prior, if possible negotiate a time for the ADL cares so the resident participated in the decision making process and return at the agreed upon time. If Resident 11 resisted ADL cares, reassure, leave and return five to 10 minutes later and try again, provide Resident 11 with opportunities for choice during care provision, praise Resident 11 when her/his behavior was appropriate. A 1/10/21 Quarterly MDS indicated Resident 11 was cognitively intact with a BIMS score of 15. Resident 11 was totally dependent on one-person for physical assistance with showers. A 2/2021 Documentation Survey Report indicated in 2/2021 Resident 11 did not receive any type of bathing. Records indicated Resident 11 refused seven instances and it was documented "NA" on three instances. A 3/2021 Documentation Survey Report indicated in 3/2021 Resident 11 did not receive any type of bathing or showers. Records indicated Resident 11 refused eight instances and it was documented "NA" three instances. In an interview on 1/7/22 at 11:00 AM Staff 1 (Administrator), Staff 49 (Interim DON) and Staff 50 (Regional Nurse Consultant) stated staff were expected to complete a risk and benefit with a resident if the resident continued to refuse showers. 4. Resident 13 was admitted to the facility in 2013 with diagnoses including Alzheimer's disease. A 6/24/20 care plan indicated Resident 13 had oral health problems with worn down teeth with interventions including to monitor for any signs of oral problems, alert nursing if any of the following occured: painful gums, toothache, signs of abscess, lips cracked, loose teeth, tongue appears black, inflamed, or smooth, and ulcers or lesions in the mouth. A 1/4/21 Quarterly MDS indicated Resident 13 required extensive assistance with one-person physical assist with personal hygiene. The 4/2021 Documentation Survey Report indicated personal hygiene which included brushing Resident 13's teeth on day and evening shift from 4/1/21 through 4/13/21: -4/1/21 day and evening shifts no documentation personal hygiene was completed. -4/2/21 evening shift resident was independent with no setup or physical help from staff. -4/5/21 day shift the activity was not completed. -4/9/21 evening shift the activity was not completed. -4/10/21 day shift the activity was not completed. -4/11/21 evening shift the activity was not completed. -4/13/21 evening shift the activity was not completed. An 4/13/21 at 10:03 AM nursing "Hospice" Note indicated the CNA attempted oral care on Resident 13 and her/his tongue was black and scabbed. Resident 13's mouth was bleeding from sores. Resident 13 refused food and drink since 4/10/21 per the aide. Hospice was notified of Resident 13's change of condition but Hospice did not follow up on the concern until 9:30 AM on 4/13/21 (three days later). An 4/13/21 Alert Note indicated Staff 28 (CNA) gavea bed bath to Resident 13 and found bleeding sores, and scabs in Resident 13's mouth and her/his tongue was black tinged. Resident 13 had a bed bath on 4/12/21 with unreported findings. An 4/13/21 Hospice Routine Visit Summary report indicated Hospice spoke to Staff 39 (LPN) and it was reported Resident 13 had not eaten in three to five days and had nothing to drink for the last two days. On 12/22/21 at 8:28 AM Staff 28 (CNA) stated Resident 13 did not like staff caring for her/him and it would depend on the staff member if she/he trusted them to complete care. Staff 28 stated she had a good relationship and could provide care; other staff would not keep trying with her/him so the care would not get completed. In an interview on 1/7/22 at 12:08 PM Staff 1 (Administrator), Staff 49 (Interim DON) and Staff 50 (Regional Nurse Consultant) confirmed they expected staff to complete Resident 13's personal hygiene including oral care. 5. Resident 14 was admitted to the facility in 2/2020 with diagnosis including amputation of the right foot diabetes and obesity. A 2/14/21 Annual MDS indicated bathing did not occur in the seven-day look back period, and Resident 14 had a BIMS score of 15 indicating she/he was cognitively intact. Resident 14 did not have rejection of care behaviors. A 2/14/21 care plan indicated Resident 14 was at risk for a decline in self-care performances of ADL care needs and rarely accepted a shower when she/he did agree to accept a shower she/he required extensive assist of one staff. No additional documentation was found in clinical record on interventions for Resident 14 to accept showers. The 5/2021 Documentation Survey Report revealed Resident 14 was to a receive a shower or bathing on Wednesday and Saturday evenings. For the month of 5/2021 Resident 14 had eight opportunities for showers and one shower she/he did not receive. Resident 14 had one incident when she/he was out of the facility and no documentation was found the shower was rescheduled. The 6/2021 Documentation Survey Report revealed Resident 14 was to receive a shower or bathing on Wednesday and Saturday evening. For the month of 6/2021 Resident 14 did not receive a shower or a bath. The documentation indicated Resident 14 refused one instance on 6/5/21. The 10/2021 Documentation Survey Report indicated Resident 14 was to receive a shower or bathing every Wednesday and Saturday evening. In the month of 10/2021 Resident 14 received one bed bath in the month and received no other showers or bed baths. CNA Skin Shower Review sheets for Resident 14 indicated the following for 10/2021: -10/6/21 refused her/his shower. -10/9/21 received her/his shower. -10/13/21 refused her/his shower and stated she/he was exhausted due to not sleeping well. -10/21/21 refused her/his shower -10/24/21 received her/his shower (15 days between showers) The 11/2021 Documentation Survey Report indicated Resident 14 was to a receive shower or bathing every Wednesday and Saturday evening. In the month of 11/2021 Resident 14 received one shower in the month and received no other showers or bed baths. CNA Skin Shower Review sheets for Resident 14 indicated the following for 11/2021: -11/12/21 received her/his shower. -11/20/21 refused her/his shower. -11/27/21 refused and stated she/he was not feeling well and was reapproached three times. On 12/20/21 at 10:56 AM Staff 12 (CNA) stated she had been directed to not provide any showers to residents on days the facility was short staffed. Staff 12 stated Resident 14 normally did not refuse showers. On 1/3/22 at 10:43 AM Staff 35 (CNA) stated Resident 14 did not normally refuse her/his showers and reported to Staff 35 that staff would not give her/him a shower. Staff 35 stated some of the staff ignored some of the residents if they did not like the residents. In an interview on 1/7/22 at 12:09 PM Staff 1 (Administrator), Staff 49 (Interim DON) and Staff 50 (Regional Nurse Consultant) stated they expected staff to go over the risk and benefits with Resident 14 for continued refusals of showers.

Resident #1 is no longer a resident. Resident #10 will be offered bathing per preference. Resident #11 is no longer a resident. Resident #13 is no longer a resident. Resident #14 will be offered bathing per preference. DON/Designee completed baseline audit of current residents the last 30 days to verify residents are receiving hygiene services to include oral care and baths per plan of care. Identified inconsistencies addressed. DON/Designee completed baseline audit of current residents who require assistance with dining to verify assistance is provided. Identified inconsistencies addressed. NHA/Designee initiated further education to nursing staff 02/2112022 and ongoing related to facility policy F677 related to Quality of Life with specific focus on bathing, oral care, and assistance with dining. DON/Designee will conduct ongoing audit of bathing, oral care, and dining assistance e to verify bathing, oral care and dining assistance is being provided per plan of care. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to assess wounds, provide care, and follow physician orders for 4 of 13 sampled residents (#s 1, 10, 22 and 23) reviewed for medications, accidents and non-pressure skin. This placed residents at risk for unmet needs. Findings include: The facility's 10/2019 Skin and Wound Management Guidelines indicated the following: -Nursing staff will keep physician informed related to wound healing. DNS and Unit Manager will verify the physician notification was resent. -Newly identified facility acquired wound: Notify treatment wound care nurse if available if not available, notify the physician and obtain a treatment order and enter order in clinical records. -Initiate alteration in skin integrity care plan or update existing care plan and implement interventions. 1. Resident 1 was admitted to the facility in 4/2021 with diagnoses including dizziness and giddiness. An 4/8/21 Hospital Discharge Orders Report instructed staff to administer midodrine (to treat people with symptoms of low blood pressure when standing) two five mg tablets (total of 10 mg) by mouth three times daily. An 4/8/21 Nursing Note indicated Resident 1 had a diagnosis of Hypo-orthotactics (low blood pressure) and took midodrine to increase her/his blood pressure. Resident 1 could not get up for an hour after taking the medication due to her/his blood pressure dropping. Resident 1 could only stand for five to 10 minutes before becoming dizzy and lightheaded. An 4/2021 MAR instructed staff to administer the following: -Midodrine one five mg tablet by mouth three times a day for orthostatic hypotension with a start date of 4/8/21 and discontinue date of 4/9/21. -Midodrine one five mg tablet by mouth three times a day with meals for orthostatic hypotension with a start date of 4/9/21. An 4/9/21 signed physician order instructed staff to administer midodrine at mealtimes. No documentation was found in clinical records a physician order to change Resident 1's medication from two five mg tablets to one five mg tablet three times a day. On 11/24/21 Witness 12 (Family Member) stated they had Resident 1 on two pills for blood pressure. In an interview on 1/7/22 at 11:14 AM Staff 1 (Administrator), Staff 49 (Interim DON) and Staff 50 (Regional Nurse Consultant) stated they would like to review for additional information. No additional information was provided. 2. Resident 10 was admitted to the facility on 8/2020 with diagnoses including chronic pain, obesity, and muscle weakness. A 11/30/20 care plan indicated Resident 10 had actual skin impairment with interventions including use a draw sheet or lifting device to move, boost Resident 10 up in bed and use caution during transfers. A 2/21/21 Wound Evaluation indicated Resident 10 had a blister on her/his groin (right inner thigh) which measured an area of 5.12 cm2, a length of 3.26 cm by a width of 2.41 cm. Treatment included cleaning with normal saline with no dressing and the practitioner was notified. The 2/2021 Documentation Survey Report revealed the following: Skin Observation -2/24/21 Resident 10 was identified to have an open area which was a new skin condition. No documentation was found regarding the location of the new skin condition. A 2/24/21 Injury Investigation document indicated Resident 10 was found by a CNA to have several open areas, including under the left side of the pannus, under both buttocks, on the thighs and one to the right inner thigh. The open areas to the buttocks were nearly identical straight line shaped wounds which appeared like slices approximately 5 cm long by 0.5 cm wide and 0.5 cm deep with some scabbing to the outer edges of the wounds and open at the bases. The wounds were red and beefy at the open areas, the area on Resident 10's thighs were bright red covering the area starting between her/his thighs and wrapping around both sides to the entirety of her/his buttocks bilaterally. The area to the right inner thigh had the appearance of a small hole which looked like a large pimple had popped and left a crater in her/his skin. Resident 10 was unable to give a description. Resident 10 was oriented to person, situation, place, and time. The wounds were cleaned and dressed, and barrier cream was applied. A note on 3/3/21 indicated nursing took pictures and documented the size, shape, & depth of the wounds. The incident appeared to have been caused when Resident 10 was pulled up in her/his bed improperly with excess moisture present on her/his skin and possibly her/his catheter laying over her/his leg in the same place all the time irritating her/his legs. The CNAs were instructed the proper way to pull a resident up in bed and reminded to frequently check the skin of the residents who frequently had moisture build up on their skin. No abuse or neglect was found at thattime. No documentation was found in the clinical record for physician orders in 2/2021 for treatment of Resident 10's wounds to the left side of pannus, both buttocks, and both thighs. A 3/3/21 Nursing Note indicated Witness 39 (Former LPN) completed wound rounds and Resident 10 had several long abrasions on her/his backside. It was Witness 39's opinion the wounds were inflicted by care staff pulling the brief out from under Resident 10 repeatedly, causing the abrasions in the fragile moist skin. Staff were informed the brief was not necessary as Resident 10 had an ostomy and a catheter in place. A 3/3/21 Skin and Wound Evaluation indicated Resident 10 had an abrasion to the right ischial tuberosity (sit bone), which was in-house acquired, and it was unknown how long the wound was present. The wound measured an area of 13.5 cm2, a length of 6.0 cm by a width of 3.5 cm. The wound bed was 50 percent epithelial and 50 percent granulation. There was evidence of an infection with redness and inflammation and was pink or red with a light amount of bloody exudate (fluid from a wound). The wound edges were attached, surrounding tissue was erythema (superficial reddening of the skin) and excoriated (damage or remove part of the surface) and fragile. Resident 10's pain level was a three out of 10. The goal of care was healable, no cleansing solution with no dressing applied, moisture barrier used, and the progress was to monitor. The notes on the assessment indicated there was a very small open area on inner left thigh and education was provided to Resident 10 about allowing care and frequent position changes. A 3/3/21 Wound Evaluation indicated Resident 10 had an in-house acquired right ischial tuberosity abrasion with measurements of an area of 3.52 cm2, a length of 5.99 cm by a width of 3.54 cm. The wound bed was 50 percent epithelial (tissues line the outer surfaces of organs) with redness and inflammation with a light amount of exudate which was bloody. Resident 10's pain level was a three out of 10, with no treatments and no dressing. Additional care was moisture control and moisture barrier. The photo with the evaluation had sticker marker on the left buttock area which showed three similar line shaped wounds to the left buttock and left ischial tuberosity area. No documentation was found in clinical records Resident 10's right ischial tuberosity wound was assessed from 3/4/21 through 5/5/21. A 3/3/21 Skin and Wound Evaluation indicated Resident 10 had an abrasion to the left buttock, which was in-house acquired, and unknown how long the wound was present. The wound measured an area of 1.3 cm2, a length of 2.6 cm by a width of 0.7 cm. The wound bed was 50 percent epithelial and 50 percent granulation. The wound was pink or red and there was a light amount of sanguineous bloody exudate. The wound edges were attached, surrounding tissue was erythema and excoriated and fragile. Resident 10's pain level was a three out of 10. The goal of care was healable, no cleansing solution with no dressing applied, with moisture barrier used and the progress was to monitor. The notes on the assessment indicated there was a very small open area on inner left thigh and education was provided to Resident 10 about allowing care and frequent position changes. No documentation was found in clinical records Resident 10's left buttock wound was assessed from 3/4/21 through 3/24/21, 20 days in between assessments. The 3/2021 Documentation Survey report revealed Resident 10 was started on repositioning every two hours on the evening of 3/25/21. A 7/7/21 Signed physicians order instructed staff to check to make sure Resident 10's chuck (bed pad) was changed, dated, and timed three times a day for wound care and protection from further skin break down with a start date of 3/25/21. A 3/2021 TAR instructed staff to check to make sure Resident 10's chuck was changed, dated, and timed three times a day for wound care and protection from further skin break down with a start date of 3/25/21 and discontinued date of 5/28/21. No documentation was found in the clinical record regarding physician orders in 3/2021 for treatment of Resident 10's wounds to the left side of pannus, both buttocks, and both thighs. A 3/25/21 Skin and Wound Evaluation indicated Resident 10 had an abrasion to the left buttock, which was in-house acquired, and unknown how long the wound was present. The wound measured an area of 46.8 cm2, a length of 14.9 cm by a width of 10.4 cm. The wound bed was not described, there was bleeding with a light amount of sanguineous bloody exudate, the wound edges were attached and surrounding tissue was erythema. The goal of care was healable with no dressing; cleansing solution was water; moisture barrier was used, and the progress was to monitor. The notes on the assessment indicated there was a very small open area on inner left thigh and education was provided to Resident 10 about allowing care and frequent position changes. No documentation was found in clinical records for physician orders in 4/2021 for treatment of Resident 10's wounds to both buttocks, and both thighs. No documentation was found in clinical records Resident 10's right and left buttock wounds were evaluated from 3/26/21 through 5/4/21. A 5/5/21 Wound Evaluation indicated Resident 10 had an abrasion to the right ischial tuberosity, which was in-house acquired, and unknown how long the wound was present. The wound measured an area of 31.1 cm2, a length of 4.5 cm by a width of 8.6 cm. The wound bed was 100 percent epithelial. The wound edges were attached and the surrounding tissue was normal in color. Pain level was a five out of 10 during cleaning. The goal of care was healable; cleansing solution was soap and water and generic wound cleanser with no dressing applied. Additional care was a foam mattress and incontinence management. The photo with the evaluation had the sticker marker on the right buttock. A 5/5/21 Wound Evaluation indicated Resident 10 had an abrasion to the right ischial tuberosity (left buttock and left ischial tuberosity) which was in-house acquired, unknown how long the wound was present. The wound measured an area of 19.13 cm2, a length of 5.65 cm by a width of 3.2 cm. The wound bed was 100 percent epithelial. The wound and edges were attached, and the surrounding tissue was normal in color. Pain level was a five out of 10 during cleaning. The goal of care was healable; cleansing solution was soap and water and generic wound cleanser with no dressing applied. Additional care was a foam mattress and incontinence management. The photo with the evaluation had a sticker marker on the upper left buttock the area was red covering the left buttock down to the left ischial tuberosity. A 11/20/21 Quarterly MDS revealed Resident 10's BIMS score was 11 indicating she/he had a moderate cognitive impairment. On 11/24/21 at 8:23 AM Witness 8 (Former CNA) confirmed in 3/1/21 she came to work for evening shift and another CNA reported to her the facility was short staffed and no showers were provided to the residents. Witness 8 went to assist another CNA to provide incontinent care and repositioning for Resident 10. Witness 8 stated Resident 10's bottom was "shredded" with an odor of infection. Resident 10's wounds were weeping, and it was obvious she/he was not getting repositioned. The resident's nurse came in to assess Resident 10's wounds and stated the wounds looked worse to her than the previous week. On 12/7/21 at 9:59 AM Resident 10 stated at times during the night when she/he needed assistance with bed mobility and pushed her call light button, Resident 10 stated sometimes she/he wondered "oh god are they ever going to come in". In an interview on 1/7/22 at 11:00 AM Staff 1 (Administrator), Staff 49 (Interim DON) and Staff 50 (Regional Nurse Consultant) stated the facility started a performance improvement plan as they identified concerns with their wound treatments and assessments. Staff 1, Staff 49 and Staff 50 stated they would have to be present and do their own investigation to determine if abuse and neglect would be ruled out or not for Resident 10's wounds. Refer F600 3. Resident 22 was admitted to the facility in 10/2019 with diagnoses including dementia and muscle weakness. A 10/18/19 care plan indicated Resident 22 was at risk for impaired skin integrity with interventions including specialty wheelchair cushion. A 9/24/21 Injury of "Known" investigation revealed a CNA reported Resident 22 had a wound. Staff 7 (RN) reported she noticed no new wounds were entered in clinical records. On assessment of the wound Staff 7 saw Resident 22 had a foam bandage with light exudate (fluid seeping out of wound) over a small skin tear. Resident 22 was not aware how the injury happened she/he stated there usually was an air-filled cushion under her/his bottom and pillows under her/his legs to protect them from metal parts of the wheelchair. Resident 22 did not have sensation to her/his lower body. Staff 7 removed the soiled bandage, put the wound information into clinical records, cleaned it with normal saline and recovered it with foam. Other information indicated there were hard metal pieces on the wheelchair which needed to be covered by cushions. Resident 22 lacked sensation with no ability to independently reposition. Agency staff who transferred the resident into the wheelchair were unfamiliar with her/his care. The witnesses section indicated a late entry that Resident 22 requested the CNAs put her/him back into bed from being up in her/his wheelchair at 2:35 PM. CNAs noted there was no cushion or pillows under Resident 22 when they removed her/his brief, and they noticed a metal piece from the wheelchair created a hole in the skin on her/his buttock. CNAs informed the charge nurse who assessed the wound and informed CNAs she would put it into clinical records later. A 10/2021 TAR instructed staff to cleanse Resident 22's right buttock with wound cleanser and replace the foam bandage every other day and as needed. The wound round team was tasked to get photos weekly every day shift every two days for a skin tear with a start date of 9/28/21 and discontinued on 10/18/21. No documentation was found in clinical records Resident 22 had physician ordered treatment for the right buttock wound from 9/24/21 to 9/28/21. On 12/17/21 at 10:11 AM Staff 27 (CNA) stated Resident 22 was care planned to have a special wheelchair cushion. Staff 27 discovered the wound when she was transferring Resident 22 and found the previous CNA did not place the cushion under Resident 22 causing the wound. In an interview on 1/7/22 at 11:00 AM Staff 1 (Administrator), Staff 49 (Interim DON) and Staff 50 (Regional Nurse Consultant) confirmed staff should obtain physician orders for a wound as soon as the wound was identified. 4. Resident 23 was admitted to the facility in 6/2020 with diagnoses including dementia with behavior disturbance. A 6/15/20 care plan indicated Resident 23 was at risk for falls with interventions including bed cane bilaterally and evaluate and treat as ordered or PRN. A 6/22/20 Admission MDS assessment indicated Resident 23 was cognitively impaired with confusion, weakness, unsteady gait, impaired balance, and extremely poor safety awareness. A 6/29/20 at 4:15 PM Un-Witnessed Fall investigation indicated Resident 23 was found on the floor sitting and leaning on her/his left arm. Resident 23 cut the left side of her/his lip with redness on the bridge of her/his nose and around her/his left eye. Vital signs were collected, and pressure applied to the bleeding to the left side of the lip. Resident 23 was placed on neurological monitoring and vitals taken every 15 minutes with an ice pack for cold compress. Resident 23's bed was lowered and she/he was not taken to the hospital. Resident 23 was oriented to self only. A note on the investigation indicated the fall occurred on 6/30/20 at 2:30 PM. Abuse and neglect were ruled out indicating Resident 23 was in front of the nurses' station for supervision by staff due to her/his history of impulsive behavior. The nurse practitioner ordered to keep Resident 23 in the facility for monitoring as she/he was at baseline for vitals, neurological and behavior at the time of the fall. Resident 23 was placed on alert monitoring. A 7/2/20 Nursing Note indicated the fall occurred 6/30/20 and Resident 23 did not have a clear description why she/he fell. Vitals were collected and Resident 23 was placed on neurological monitoring and vitals take every 15 minutes. A 6/30/20 nurse practitioner Encounter Note indicated Resident 23 had a "couple" of falls today within 24 hours and "lightly struck her head" with a laceration to her/his upper lip. Nursing reported Resident 23's hallucinations were increased and there may be auditory hallucinations as well. Resident 23 was not demonstrating any blood pressures under a 100. Resident 23's heart rate "roughly runs" 90 to 100 beats per minute. Blood pressure 106/52, temperature 96.9, heart rate 72 beats per minute, respiratory rate was 20. Resident 23 had redness to the left side of her/his face. Resident 23 was alert, disoriented and appeared to be hallucinating. Resident 23 was on alert charting and neurological checks. Printed 12/22/21 Blood Pressure Summary, Respiration Summary and Pulse Summary reports for Resident 23 indicated the following: Blood Pressures -6/30/20 at 6:43 AM 106/52 -7/1/20 at 5:42 AM 125/80 -7/1/20 at 9:43 AM 110/82 -7/1/20 at 4:06 PM 130/82 Respirations (breaths per minute) -6/30/20 at 6:43 AM 20 -7/1/20 at 5:44 AM 17 -7/1/20 at 9:43 AM 15 -7/1/20 at 4:06 PM 18 Pulse (beats per minute) -6/30/20 at 6:43 AM 72 -7/1/20 at 5:43 AM 65 -7/1/20 at 9:43 AM 100 -7/1/20 at 4:06 PM 114 Resident 23 sustained a fall at 2:30 PM on 6/30/20 and no documentation was found in the clinical record Resident 23's vitals were collected after the fall until 7/1/20. A 7/1/20 Administration Notes indicated Resident 23 was administered multiple medications and vomited after the administrations. A 7/1/20 Nursing Note indicated Resident 23 had a reduction in blood pressure and vomiting after dinner. The nurse practitioner was notified and received orders for promethazine (to treat and prevent nausea and vomiting). A 7/2/21 Nursing Note indicated Resident 23 was started on Clysis (the introduction of large amounts of fluid into the body usually by parenteral injection to replace fluid loss (as from hemorrhage or in dysentery or burns), to provide nutrients, or to maintain blood pressure). Witness 44 (Former CNA) came out of Resident 23's room at 1:00 AM and informed Witness 20 (Former LPN) that she/he appeared deceased. CPR was started and 911 called Local law enforcement came to facility for a statement. No documentation was found in the clinical record Resident 23's vitals were obtained on 7/2/20. On 1/7/22 at 8:16 AM Witness 43 (Former LPN) stated on 7/1/20 Resident 23 started vomiting and Witness 43 contacted the practitioner. Witness 43 stated she was instructed to have Resident 23 have some tests and it was determined to keep Resident 23 at the facility. Witness 43 stated she remembered the standard of practice for vitals and neurological checks every 15 minutes times four times, then once every 30 minutes times four times then hourly for 24 hours. Witness 43 stated she remembered a sheet to document the information on but did not remember if Resident 23 had such a sheet. In an interview on 1/7/22 at 12:22 PM Staff 1 (Administrator), Staff 49 (Interim DON) and Staff 50 (Regional Nurse Consultant) stated neurological and vital checks are indicated they should start off every 15 minutes then staff were expected to follow the guide on the form for completing neurological evaluationsat specific times and checking of vitals for a resident who has had a head injury with a fall.

Resident #1 is no longer a resident. Resident #10 wounds will be assessed and treated per facility orders. Resident #22 wound will be assessed and treated per facility orders. Resident #23 no longer a resident. DON/Designee completed baseline audit of current residents with wounds to verify residents are receiving weekly wound/skin assessments, treatments are being completed and physician wound orders are implemented timely. Identified inconsistencies addressed. DON/Designee completed baseline audit of current residents who experienced an unwitnessed fall or fall with head injury in the last 7 days to verify neurological checks were completed. Identified inconsistencies addressed. DON/Designee completed baseline audit of current residents who take Midodrine to verify medication is being administered per the physician order. DON/Designee initiated further education to Licensed Nurse staff 02/11/2022 and ongoing related to policy F684 related to facility Skin and Wound Program, completing treatments, and following physician orders. DON/Designee initiated further education to Licensed Nurse staff 02/11/2022 and ongoing related to policy F684 related to following physician orders with specific focus on midodrine and completing neurological checks for residents that experience an unwitnessed fall or fall with head injury. DON/Designee will conduct ongoing audit of residents with wounds to verify weekly assessments are completed and treatments are provided per physician orders. DON/Designee will conduct ongoing audit of residents who experience an unwitnessed fall or fall with head injury to verify neurological checks were completed. DON/Designee will conduct ongoing audit of residents who take midodrine to verify provider orders were followed for administration. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to implement, follow, and maintain pressure ulcer treatments and prevent pressure ulcers for 2 of 3 sampled residents (#s 13 and 22) reviewed for pressure ulcers. This placed residents at risk for developing and worsening pressure ulcers. Findings include: 1. Resident 22 was admitted to the facility in 10/2019 with diagnoses including dementia and muscle weakness. A 12/16/20 Annual Pressure Ulcer Injury CAA revealed Resident 22 was at high risk for future pressure ulcers due to total dependence for bed mobility and all ADLs, incontinence of bowel, no sensation to the body past her/his armpits, suprapubic catheter, and risk for malnutrition. Resident 22 had a chronic pressure ulcer to her/his sacrum which was taking a long time to heal because of incontinence, lack of mobility and no sensation. Resident 22 was on an air mattress, wheelchair pressure relieving cushion, frequent repositions, and health shakes. An 10/18/21 Injury of "Known" investigation revealed Resident 22 was found to have a pressure ulcer on the coccyx during a brief change on 10/7/21. The notes portion of the investigation dated 12/7/21 indicated abuse and neglect were ruled out as Resident 22 was dependent on staff for all ADLs and Resident 22 did not like to be repositioned onto her/his side. The wound was identified on 10/7/21 and multiple wound assessments were opened and resolved. The wound was a re-occurring wound which resolved and re-opened based upon acceptance of cares from staff. The physician was notified on 10/18/21. An 10/18/21 Nursing Note indicated Resident 22 had a Stage 2 (partial-thickness skin loss into but no deeper than the dermis) coccyx wound which was pink and blanchable with a small opening just between the buttock crack. No documentation was found in clinical records for treatment to the Stage 2 pressure ulcer to the coccyx in 10/2021. An 10/18/21 Skin and Wound Evaluation did not document what type of wound it was, the location of or how long the wound was present. The wound dimensions were an area of 0.7 cm2, a length of 1.2 cm and a width of 1.0 cm. The wound bed was epithelial (tissues which line the outer surfaces of organs), with no documentation of the percentage. There was no evidence of infection, and no exudate (fluid seeping out of wound). There was no description of the edges of the wound, the surrounding tissue, what the treatment was for the wound and the progression of the wound. An 10/18/21 Wound Evaluation indicated the wound was undiagnosed with body location not set. The photo accompanying the evaluation displayed a wound on Resident 22's coccyx which was the focus in the photo. Another wound on the right ischial tuberosity was partially visible in the photo. The area of the wound was .73 cm2, 1.21 cm length, and .99 cm width. The evaluation indicated "yes" for the wound bed epithelial, no infection or exudate. There was no description on the evaluation of the edges of the wound, the surrounding tissue or the treatment for the wound. No documentation was found in clinical records Resident 22's wounds were evaluated for 16 days from 10/19/21 through 11/2/21. An 10/27/21 care plan indicated Resident 22 was at risk for impaired skin integrity, with interventions including air mattress, attempt to reposition frequently, document refusals, good nutrition and hydration, identify potential causative factors and eliminate and resolve where possible, use barrier cream daily, monitor and document location, size and treatment, pad bed rails, wheelchair arms and other sources which could cause injury and perform and document weekly skin checks. A 11/2/21 Skin and Wound Evaluation indicated Resident 22 had a Stage 2 pressure ulcer to the coccyx which was in-house acquired with an area of .8 cm2, a length of 1.1 cm and a width of 1.0 cm. There was no description of the wound bed, if there was evidence of an infection, if there was exudate, or the edges or surrounding tissue of the wound. There was also no documentation of the treatment for the wound, if the dressing was intact and what was the progression of the wound. A 11/3/21 Skin and Wound Evaluation indicated Resident 22 had a Stage 2 pressure ulcer, the location was not documented, with dimensions of an area of 2.5 cm2, a length of 10.2 cm and a width of 1.5 cm. The wound was 100 percent granulation with no sign of infection, and a light amount of serosanguineous (containing or consisting of both blood and serous fluid) exudate. The wound edges were attached, the surrounding tissue was fragile and was at risk for breakdown. The dressing was intact with the use of a generic wound cleanser and a foam dressing. Progress was "monitoring" and notes stated Resident 22 continued with small wounds on the coccyx and the right ischial tuberosity. A 11/3/21 Wound Evaluation indicated Resident 22 had a Stage 2 pressure ulcer with body location not set, the age was unknown and was in-house acquired. The photo with the evaluation exhibited a wound on Resident 22's coccyx and one wound on Resident 22's right ischial tuberosity. The dimensions of the wound measured (unknown which wound) an area of 2.53 cm2, 10.17 cm length and a width of 1.55 cm. The evaluation did not document which wound was evaluated. The wound was 100 percent granulation with light serosanguineous exudate. The edges of the wound were attached with fragile surrounding tissue, the dressing was intact with generic wound cleanser no debridement and with a foam dressing. Additional care was an air flow pad, nutrition supplementation, repositioning devices and turning repositioning program. Notes indicated Resident 22 continued with small wounds on her/his coccyx and right ischial tuberosity and the practitioner was notified. No documentation was found in clinical records Resident 22's wounds were evaluated for 14 days from 11/4/21 through 11/16/21. A 11/17/21 signed physician orders instructed staff to clean the coccyx wound with wound cleanser or normal saline, pat dry, apply skin prep to the area surrounding the wound, apply collagen powder and hydrogel mixture (provides soothing effect and promotes faster cell regeneration in a wound) to the wound bed: and cover with bordered foam dressing, every day and PRN for wound healing. Wound care pictures were to be updated in clinical records every Wednesday every day shift for wound monitoring with a start date of 11/11/21. The 11/2021 TAR instructed staff to complete the following wound treatments: -Clean coccyx wound with wound cleanser or normal saline, pat dry and apply skin prep to peri wound. Apply collagen powder and hydrogel mixture to the wound bed and cover with bordered foam dressing with a start date of 11/12/21. -Wound care pictures updated in clinical records every Wednesday every day shift for wound monitoring with a start date of 11/17/21. A 11/17/21 Wound Evaluation indicated Resident 22 had a Stage 2 pressure ulcer with location not set, age unknown, and was in-house acquired. The picture associated with the evaluation exhibited a wound on Resident 22's right ischial tuberosity. The dimensions of the wound were an area of 1.07 cm2, a1.53 cm length, and 1.12 cm width. The evaluation did not include a description of the wound bed, if there was exudate, the edges of the wound, surrounding tissue, treatment, or the progress of the wound. A 11/17/21 Skin and Wound Evaluation indicated Resident 22 had a Stage 2 pressure ulcer with no location documented. Dimensions of the wound were an area of 1.1 cm2, a length of 1.5 cm and a width of 1.1 cm. There was no documentation of the wound bed, if the wound had exudate, a description of the edges, surrounding tissue, the progress of the wound, what the wound treatment was and if there was a dressing. A 11/17/21 Skin and Wound Evaluation indicated Resident 22 had a Stage 2 pressure ulcer to the coccyx, in-house acquired with dimensions of an area of .5 cm2, 1.1 cm length and a width of 0.8 cm. There was no documentation of the wound bed, if there was exudate, a description of the edges, surrounding tissue, if there was dressing, or progress of the wound. In an interview on 1/7/22 at 12:17 PM Staff 1 (Administrator), Staff 49 (Interim DON) and Staff 50 (Regional Nurse Consultant) stated they expected staff to obtain physician orders as soon as a wound was identified and to complete comprehensive and weekly evaluations. 2. Resident 13 was admitted to the facility in 2013 with diagnoses including Alzheimer's disease. A 1/4/21 Quarterly MDS revealed Resident 13 required limited assistance with one-person physical assist for bed mobility. An 4/2021 Documentation Survey Report revealed the following: Skin Observations -4/1/21 no documentation skin was checked or refused on day and evening shifts. -4/2/21 no documentation skin was checked or refused on day and night shifts. -4/5/21 no documentation skin was checked or refused on day shift. -4/6/21 no documentation skin was checked or refused on day and night shifts. -4/7/21 no documentation skin was checked or refused on day and night shifts. -4/9/21 no documentation skin was checked or refused on day and evening shifts. -4/11/21 no documentation skin was checked or refused on night shift. -4/13/21 no documentation skin was checked or refused on night shifts. Bed mobility -4/1/21 no documentation Resident 13 was repositioned or refused on day and evening shifts. -4/2/21 no documentation Resident 13 was repositioned or refused on night shift. -4/6/21 no documentation Resident 13 was repositioned or refused on day and night shifts. -4/7/21 no documentation Resident 13 was repositioned or refused on night shift. -4/11/21 no documentation Resident 13 was repositioned or refused on night shift. -4/13/21 no documentation Resident 13 was repositioned or refused on night shift. An 4/13/21 Alert Note indicated Staff 28 (CNA) gave a bed bath to Resident 13 and she/he was found to have Stage 2 (partial-thickness skin loss into but no deeper than the dermis) pressure ulcer on the right hip with red spots on the skin. Resident 13's back was red and she/he had toenails which were overgrown. Resident 13 had a bed bath on 4/12/21 with unreported findings. Opti foam (foam dressing that has a silicone adhesive border), was placed on Resident 13's ulcers, hospice, unit manager and DNS were notified. An 4/13/21 Hospice Routine Visit Summary report indicated Hospice spoke to Staff 39 (LPN) and it was reported Resident 13's back was red from pressure. Resident 13 had an unstageable pressure injury on the right posterior hip and a 4 x 4 dressing was applied. The was encouraged CNA to turn and reposition the resident every two hours. On 12/22/21 at 8:28 AM Staff 28 (CNA) stated Resident 13's pressure ulcers happened after she/he was left in the same position all night long and she/he had one pressure ulcer on her/his right hip and one on the shoulder blade. In an interview on 1/7/22 at 12:06 PM Staff 1 (Administrator), Staff 49 (Interim DON) and Staff 50 (Regional Nurse Consultant) stated they expected regular repositioning of a resident. Staff 50 stated she assumed repositioning was completed with other cares provided to a resident.

Resident #13 is no longer a resident. Resident #22 wounds will be assessed per facility guidelines and treatment will be provided per physician orders. DON/Designee completed baseline audit of current residents with wounds to verify residents are receiving weekly wound/skin assessments, treatments are being completed and physician wound orders are implemented timely. Identified inconsistencies addressed. NHA/Designee initiated further education to Licensed Nurse staff 02/11/2022 and ongoing related to policy F686 Pressure Ulcers related to facility Skin and Wound Program, completing treatments, and completing physician orders. DON/Designee will conduct ongoing audit of residents with wounds to verify weekly assessments are completed and treatments are provided per physician orders. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to ensure the resident environment remained free from accident hazards and residents were evaluated for supervision for 3 of 10 sampled resident (#s 3, 8 and 22) reviewed for accidents and pressure ulcers. This put residents at risk for accidents. Findings include: 1. Resident 22 was admitted to the facility in 10/2019 with diagnoses including dementia and muscle weakness. A 10/18/19 care plan indicated Resident 22 was at risk for impaired skin integrity with interventions including a specialty wheelchair cushion. A 9/24/21 Injury of "Known" investigation revealed a CNA reported Resident 22 had a wound. Staff 7 (RN) reported she noticed no new wounds were entered in clinical records. On assessment of the wound Staff 7 saw Resident 22 had a foam bandage with light exudate (fluid seeping out of wound) over a small skin tear. Resident 10 was not aware how the injury happened but she/he stated there usually was an air-filled cushion under her/his bottom and pillows under her/his legs to protect them from metal parts of the wheelchair. Resident 22 did not have sensation to her/his lower body. Staff 7 removed the soiled bandage, put the wound information into clinical records, cleaned it with normal saline and recovered it with foam. Other information indicated there were hard metal pieces on the wheelchair which needed to be covered by cushions. Resident 22 lacked sensation with no ability to independently reposition. Agency staff who transferred the resident into the wheelchair were unfamiliar with her/his care. The witnesses section indicated a late entry note that Resident 22 requested the CNAs put her/him back into bed from being up in her/his wheelchair at 2:35 PM. CNAs noted there was no cushion or pillows under Resident 22 when they removed her/his brief and they noticed a metal piece from the wheelchair created a hole in the skin on her/his buttock. CNAs informed the charge nurse who assessed the wound and informed CNAs she would put it into clinical records later. On 12/17/21 at 10:11 AM Staff 27 (CNA) stated she discovered Resident 22 in her/his wheelchair and there was no cushion and a piece of the wheelchair caused a hole in Resident 22's skin. On 1/11/22 at 10:02 AM Staff 1 (Administrator), Staff 49 (Interim DON) and Staff 50 (Regional Nurse Consultant) stated staff were expected to followed Resident 22's care plan. Refer to F684 2. Resident 3 was admitted to the facility in 8/2019 with diagnoses including morbid obesity and arthritis of hip. An 8/30/19 ADL care plan indicated Resident 3 had ADL self-care defecit, with interventions including two-person mechanical lift transfers and to ensure Resident 3 was transferred only with a bariatric lift (uniquely designed electronically operated resident lift for the safe of lifting of heavier residents.) A 9/12/19 care plan indicated Resident 3 was at risk for falls with interventions including call light within reach, activities that promote exercise, use mobility aides when ambulating or transferring, commonly used items in reach, and wear appropriate footwear prior to transfers. On 6/16/20 a public complaint was received which indicated on 6/12/20 the CNA on duty brought in a standard mechanical lift to transfer Resident 3 instead of a bariatric lift. While moving across the room the lift started to tip over. Resident 3 landed in her/his wheelchair on the right-hand arm of the wheelchair. Resident 3 landed on her/his painful hip and leg and the wheelchair started to tip over. Both CNAs assisted in getting the wheelchair in the correct position. On 12/10/21 Witness 26 (Former CNA) stated in 6/2020 while transferring Resident 3 the lift started to tip and another CNA quickly placed Resident 3's wheelchair under Resident 3. Witness 26 stated Resident 3 did not fall far, and it just scared her/him. Witness 26 stated she grabbed the wrong lift unintentionally for Resident 3's transfer and did not get the bariatric lift. In an interview on 1/7/22 at 11:30 AM Staff 1 (Administrator), Staff 49 (Interim DON) and Staff 50 (Regional Nurse Consultant) sated they expected staff to read a resident's care plan and the stickers on the Hoyer before transferring a resident. 3. Resident 8 was admitted to the facility in 11/2020 with diagnoses including cognitive communication deficit and muscle weakness. A 11/8/20 Admission MDS indicated Resident 8 required limited assistance with dressing with one-person physical assist, required one-person physical assist with locomotion on and off the unit. A 11/9/20 Nursing Note indicated Resident 8 had some slight confusion. An 11/18/20 nurse practitioner Encounter Note indicated OT had concerns regarding Resident 8's cognition and wanted speech therapy to complete an evaluation to understand Resident 8's cognitive status. An 11/20/20 Cognitive Linguistic Quick Test revealed Resident 8 had moderate cognition concerns in memory and language. Resident 8 scored mild cognitive severity concerns overall. On 11/24/21 at 9:49 AM Witness 6 (Complainant) stated on 11/22/20 Resident 8 arrived at the front doors of the bank and the doors were locked. The bus left the resident at the door. Three staff from the bank assisted Resident 8 into the bank in her/his wheelchair. Resident 8 stated she/he needed to update the security on her/his account. Resident 8 was in a hospital gown, socks, and a blanket on her/his lap with hair matted and she/he had an odor. Resident 8 knew who she/he was but was confused. Witness 6 stated she had to ask Resident 8 many questions to find out where she/he came from. Witness 6 stated the bank was about 15 to 20 minutes away from the facility. Witness 6 stated when she called the facility, they reported they did not know Resident 8 had left the facility. Resident 8 did not know if the ride company was going to come back for her. After 45 minutes in the bank a ride company came to pick up Resident 8 to return her/him back to the facility. Witness 6 stated she spoke with the facility later and the facility reported to her the receptionist was new and did not know residents could not just leave. The facility reported they updated Resident 8's care plan and contacted the ride company and told them not to just pick up residents without staff confirmation. On 12/1/21 at 8:43 AM Witness 17 (Former Receptionist) stated in 11/2020 Resident 8 sounded familiar that she/he went to the bank and obtained a ride back to the facility. Witness 17 stated the resident's sign-out sheet was at the nurse's station. Witness 17 stated in 11/2020 she was so busy she did not have anything to do with the residents. On 12/10/21 at 8:44 AM Witness 24 (Former CNA) stated Resident 8 had moments of confusion. On 12/17/21 at 10:05 AM Staff 27 (Medical Records) stated on 11/22/20 Resident 8 called the transportation service by herself/himself and scheduled the ride to the bank by herself/himself. The bank called the facility to inform the facility Resident 8 was at the bank. Resident 8 did not tell anyone she/he needed to go to the bank. Resident 8 had confusion and Staff 27 stated she would never schedule for Resident 8 to go on an outing by herself/himself and family should escort her/him on an outing. Staff 27 stated the facility's policy was for residents to sign out when leaving the facility and to sign in upon returning. No documentation was found in clinical records indicating Resident 8 went to the bank on her/his own on 11/22/20 in her/his hospital gown and if Resident 8 was assessed after the incident to determine if it was safe for her/him to go out into the community unaccompanied. In an interview on 1/7/22 at 11:33 AM Staff 1 (Administrator), Staff 49 (Interim DON) and Staff 50 (Regional Nurse Consultant) stated if a resident was alert and oriented they would remind them of the policy of notifying staff before going on an outing. If the resident exhibited changes in cognition the provider would be notified and a note would document what occurred as well as an evaluation.

Resident #3 no longer a resident. Resident #8 no longer a resident. Resident #22 care plan will be followed. DON/Designee will complete baseline audit of last 30 days current resident incidents to verify care plan was being followed. Identified inconsistencies addressed. DON/Designee will complete baseline audit of current residents who leave the facility on their own to verify they have physician order to leave facility unattended. DON/Designee initiated further education to staff 02/11/2022 and ongoing related to F689 Policy related to Accident Hazards with focus on following resident care plan and verifying that residents who leave the facility unattended have a provider order. DON/Designee will conduct ongoing audit of residents who experience an incident to verify care plan was being followed. DON/Designee will conduct ongoing audit of residents who leave the facility unattended to verify they have provider order. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview, and record review it was determined the facility failed to provide adequate catheter care for 1 of 6 residents reviewed for catheterization (#s 3 and 13). This placed residents at risk for unmet catheter needs. 1. Resident 13 was admitted to the facility in 2013 with diagnoses including benign prostatic hyperplasia (flow of urine is blocked due to the enlargement of the prostate gland). Signed physician orders dated 4/6/21 instructed staff to complete the following: -Change Resident 13's catheter each month on the 19th every night shift starting on the 19th and ending on the 19th every month for benign prostatic hyperplasia with a start date of 3/19/17. -Nurse order: Every shift to perform catheter bag and care assessment. Ensure the bag was leak free, odor free and appeared to be in general good condition with a start date of 3/28/18. -Flush Resident 13's catheter with 60 ccs of sterile water every eight hours as needed for sedimentation with a start date of 11/4/19. -Cleanse area around the catheter, pat dry, cover with a split sponge every evening shift with a start date of 2/22/21. The 4/2021 Documentation Survey Report from 4/1/21 through 4/13/21 indicated for Resident 13's catheter care output and catheter cleansing care the following: -4/1/21 no documentation completed on day or evening shift. -4/6/21 no documentation completed on day shift. -4/7/21 no documentation completed on night shift -4/11/21 no cleansing care on night shift -4/13/21 no cleansing care on night shift. An 4/2021 TAR instructed staff to cleanse the area around Resident 13's catheter, pat dry, and cover with split sponge every evening shift. From 4/7/21 through 4/13/21 it was documented Resident 13 refused treatment four instances. No documentation was found in clinical records that staff attempted treatment at a later instance, or the physician was notified of refusals. An 4/5/21 Administration Note indicated a nursing order to perform catheter bag care and assessment every shift, ensure the bag was leak free, odor free and appeared to be in general good sorts. Resident 13 refused all cares from nursing staff on day shift. An 4/9/21 Administration Note indicated a nursing order to perform catheter bag care and assessment every shift, ensure the bag was leak free, odor free and appeared to be in general good sorts. The catheter was changed per Hospice nurse due to limited output, sediment blocking the catheter and black flakes in thecatheter. The return was blood tinged but draining well. The Hospice nurse was at the bedside that shift to assess catheter placement and blood tinge. An 4/12/21 Nursing Note indicated Resident 13 refused food, drink, and other care on day shift with 100 ml output, and was hard to rouse. Hospice was notified. On 12/21/21 at 11:41 AM Witness 10 (Complainant) stated there was neglect to Resident 13 by the nursing staff. When changing Resident 13's catheter the staff member found the catheter was moldy. On 12/22/21 at 8:28 AM Staff 28 (CNA) stated she felt the facility staff were "slacking" on flushing Resident 13's catheter on a regular basis. Staff 28 stated not flushing a resident's catheter occurred frequently and she observed the catheter with mildew. In an interview on 1/7/22 at 12:00 PM Staff 1 (Administrator), Staff 49 (Interim DON) and Staff 50 (Regional Nurse Consultant) stated they expected orders in place for cleaning for catheters and if a nurse could not complete the task to assign it to a CNA. Staff 1, and Staff 50 stated they did not observed a resident with mold or mildew in a catheter. 2. Resident 3 was admitted to the facility in 2019 with diagnoses including morbid obesity and irritable bowel syndrome. A spreadsheet for 5/2020 and 6/2020 indicated on 5/27/20 eight cases of bariatric briefs were ordered and on 6/12/20 bariatric briefs were ordered without quantity documented. No documentation what bariatric briefs were in stock at the facility in 5/2020 and 6/2020. A 6/7/20 Quarterly MDS revealed Resident 3 was cognitively intact and was frequently incontinent of both bowel and bladder. Resident 3 was totally dependent requiring one-person physical assist with toileting. A 6/16/20 Confidential Referral Form indicated Resident 3 reported the facility staff brought in the wrong size briefs and was often out of the wipes without replacing them. On 12/10/21 at 10:25 AM Witness 26 (Former CNA) stated at times in 5/2020 and 6/2020 she had to go to storage to get Resident 3's briefs, at times could not find the correct size of brief for Resident 3 and determined the facility was out of stock. On 12/13/21 at 10:12 AM Witness 19 (Former LPN) stated there were a few times in 5/2020 and 6/2020 specific incontinent supplies were not available for Resident 3. On 12/13/21 at 10:50 AM Staff 36 (CNA) stated in 5/2020 and 6/2020 incontinent supplies for Resident 3 were not always available, it was difficult for Staff 36 to find the right sized brief. On 12/14/21 at 9:47 AM Staff 24 (CNA) stated in 5/2020 and 6/2020 there was a time when it was difficult getting supplies and sometimes bariatric supplies were on back order. On 12/14/21 at 10:00 AM Witness 33 (Former CNA) stated in 5/2020 there was "constantly" an issue with not having the correct incontinent supplies which was usually for the bariatric residents. In an interview on 1/7/22 at 11:19 AM Staff 1 (Administrator), Staff 49 (Interim DON) and Staff 50 (Regional Nurse Consultant) stated they would like to review for additional information. No additional information was provided.

Resident # 3 is no longer a resident. Resident #13 is no longer a resident. DON/Designee completed baseline audit of current residents with catheters to verify residents have catheter care orders are receiving catheter care. Identified inconsistencies will be addressed. DON/Designee initiated further education to nursing staff 02/11/2022 and ongoing related to F690 policy for Urinary Incontinence with specific focus on catheter care. DON/Designee will conduct ongoing audit of residents with catheters to verify orders are current and catheter care is being provided Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to obtain and follow physician orders for colostomy (an operation that creates an opening for the colon, or large intestine, through the abdomen) care for 1 of 3 sampled residents (#10) reviewed for bowel care. This placed residents at risk for unmet colostomy needs, and skin breakdown. Findings include: The facility's 8/2018 Colostomy, Urostomy or Ileostomy Care policy and procedures indicated the following: -The facility would provide care and services consistent with professional standards of practice and the care will be consistent with the person-centered care plan and the resident's goals and preferences. -The facility will develop a care plan related to the care of the colostomy, urostomy or ileostomy when a resident requires such care. -care plan goals related to the colostomy, urostomy or ileostomy will be consistent with the resident's goals and preferences. Resident 10 was admitted to the facility on 8/2020 with diagnoses including crohn's disease (chronic inflammation of the digestive tract) of both small and large intestine with intestinal obstruction. A 5/22/21 Critical Care Admit document revealed Resident 10 had a colostomy in place since 12/2015. A 12/2020 Care plan indicated Resident 10 had a colostomy with interventions including to the contact nurse practitioner if the stoma had any signs of alteration in tissue integrity, record ostomy output each shift, and assess stool every shift. A 7/2021 TAR instructed staff to complete the following: -Change Resident 10's colostomy bag every day shift every five days with a start date of 6/27/21 and discontinued on 7/6/21. On 7/2/21 documentation referred the reader to nursing notes. -Change colostomy wafer (a piece of medical equipment that protects the skin around an ostomy site) every day shift every five days with a start date of 6/27/21 and discontinued date of 7/6/21. -Ostomy care every day shift every five days for ostomy care with a start date of 6/26/21 and discontinued date of 7/6/21. -Document colostomy output every shift with a start date of 6/26/21 and discontinued date of 7/6/21. -Change colostomy appliance every 24 hours PRN with a start date of 6/26/21 and discontinued date of 7/6/21. A 7/7/21 Nursing Note indicated Resident 10 returned from the hospital and her/his colostomy wafer and bag were changed. The ostomy site was red in color and no signs of irritation were noted. No documentation was found in clinical records Resident 10 had physician orders in place for changing of the colostomy wafer or bag on 7/7/21. A 7/10/21 Administration Note revealed Resident 10 had a colostomy and the order needed to be clarified. A 7/17/21 Nursing Note indicated Resident 10's ostomy appliance was changed because the seal had failed, and it was beginning to leak. No documentation was found in clinical records Resident 10 had physician orders in place for changing of the colostomy wafer and bag on 7/17/21. A 7/25/21 Nursing Note indicated Resident 10's colostomy appliance was changed because of leakage. The inner ostomy wafer was cut too small to effectively allow stool to pass through into the collection bag. No documentation was found in clinical records Resident 10 had physician orders in place for changing of the colostomy wafer and bag on 7/25/21. The 8/2021 TAR revealed no treatments listed for Resident 10's colostomy. Signed physician orders dated 9/3/21 revealed no orders for the care of Resident 10's colostomy. Resident 10 was readmitted to the facility on 9/22/21. A 9/2021 Monitors report instructed staff to indicate the status of skin surrounding Resident 10's colostomy every shift and to document "1" as intact, "2" erythematous, (superficial reddening of the skin) and "3" macerated (soften or become softened by soaking in a liquid), out of 26 opportunities in the month of 9/2021 the following was documented: -Intact 19 instances -No documentation seven instances A 9/2021 TAR instructed staff to empty Resident 10's colostomy when one-third to one-half full every shift with a start date of 9/22/21. A 9/24/21 Nursing Note revealed Resident 10's colostomy was changed. No documentation was found in clinical records Resident 10 had physician orders in place for changing of the colostomy on 9/24/21. A 10/2021 Monitors report instructed staff to indicate the status of skin surrounding Resident 10's colostomy every shift with "1" as intact, "2" erythematous, and "3" macerated. Out of 90 opportunities in month of 10/2021 the following was documented: -Intact 44 instances - "I" indicated in the chart code section was ineffective 12 instances. -Zero (unknown what 0 indicated) seven instances. -No documentation was completed 28 instances An 10/2021 TAR instructed staff to empty Resident 10's colostomy when one-third to one-half full every shift with a start date of 9/22/21. No other documentation for colostomy treatments was found. On 11/6/21 Staff 7 (RN) indicated Resident 10's ostomy bag was changed for leakage. No documentation was found in clinical records for physician orders for changing Resident 10's ostomy bag or wafer on 11/6/21. Signed physician orders dated 11/22/21 instructed staff to indicate status of the skin surrounding the colostomy, and empty the colostomy when one-third to one-half full every shift with a start date of 9/22/21. A 11/2021 Monitors report instructed staff to indicate the status of skin surrounding Resident 10's colostomy every shift with "1" as intact, "2" erythematous, and "3" macerated Out of 90 opportunities in month of 11/2021 the following was documented: -Intact 44 instances - "I" indicated in the chart code section was ineffective 12 instances. -Zero (unknown what 0 indicated) nine instances. -No documentation was completed 25 instances. A 11/20/21 Quarterly MDS revealed Resident 10's BIMS score was 11 indicating she/he had a moderate cognitive impairment. On 12/7/21 at 9:59 AM Resident 10 stated they changed her/his ostomy bag "when it bursts". In an interview on 1/7/22 at 11:42 AM Staff 1 (Administrator), Staff 49 (Interim DON) and Staff 50 (Regional Nurse Consultant) stated they would expect orders to be in place for changing of an ostomy bag or wafer.

Resident #10 has current order for colostomy. DON/Designee completed baseline audit of current residents with ostomies to verify orders in place. Identified inconsistencies addressed. DON/Designee initiated further education to LNs 02/11/2022 and ongoing related to F691related to Ostomy care with specific focus on orders. DON/Designee will conduct ongoing audit of current residents with ostomies to verify orders are current. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to provide care and services for 1 of 2 sampled residents (#503) reviewed for colostomy (a surgical operation in which a part of the colon is diverted to an artificial opening) care. This placed residents at risk for unmet colostomy needs and skin breakdown. Findings include: The facility's 8/2018 Colostomy, Urostomy or Ileostomy Care policy and procedures indicated the following: -The facility would provide care and services consistent with professional standards of practice and the care would be consistent with the person-centered care plan and the resident's goals and preferences. -The facility would develop a care plan related to the care of the colostomy, urostomy or ileostomy when a resident required such care. -care plan goals related to the colostomy, urostomy or ileostomy would be consistent with the resident's goals and preferences. Resident 503 was admitted to the facility on 10/2019 with diagnoses including a colostomy. A 11/4/19 physician order indicated staff were to check the status of the skin surrounding the colostomy and document: 1. if the skin was intact 2. any erythema (redness of the skin) 3. any maceration (when skin is in contact with moisture for too long it becomes wrinkly or soggy, often associated with improper wound care) A 6/17/20 physician order indicated staff were to change the colostomy bag every five days, assess skin around the colostomy and notify the NP of increased redness or skin breakdown. The 3/1/22 through 3/28/22 Monitor document in the medical record indicated on 3/2/22, 3/5/22, 3/6/22, 3/16/22 and 3/27/22 there were missing dates the skin check was not completed. There was no further documentation to indicate Resident 503's skin was assessed every shift. The 3/2022 Task Monitor document for CNAs indicated on 3/7/22, 3/12/22, 3/19/22 and 3/21/22 staff documented Resident 503's skin was red. No documentation was found in the medical record to indicate a nurse had noted or addressed the redness identified by the CNAs or that the Nurse Practitioner was notified. On 3/28/22 at 1:53 PM Staff 28 (CNA) stated she did not check the skin around the colostomy site, the nurse did that task. On 3/28/22 at 2:49 PM Staff 52 (LPN) stated it was the nurses' responsibility to check the skin around the colostomy site daily. On 3/28/22 at 2:51 PM Staff 53 (Unit Manager) stated if staff placed a zero or "NA" on the Monitor documentation a progress note would be found in the medical record regarding the concern of the skin around the colostomy. Staff 53 stated the unmarked boxes on the Monitor documentation indicated staff did not complete the task. ,

Resident #503 physician orders are being followed for colostomy care. Residents with ostomies are at risk DON/Designee completed baseline audit on 3/30/22 of current residents with ostomies to verify orders are being followed. Identified inconsistencies addressed. DON/Designee re-educated Nurses 03/31/2022 on facility policy related to Physician orders. DON/Designee will conduct ongoing audit of current residents with ostomies to verify physician orders are being followed. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview, and record review it was determined the facility failed to provide sufficient staffing to meet the needs of residents for 1 of 7 sampled residents (#21) and 2 of 2 floors (1st and 2nd floor) reviewed for staffing. This placed residents at risk for unmet needs. Findings include: 1. Resident 21 was admitted to the facility in 4/2021 with diagnoses including depression and history of UTIs. An 10/26/21 Quarterly MDS revealed Resident 21 had a BIMS score of 14 indicating she/he was cognitively intact. A 11/9/21 Skilled Nursing Note revealed Resident 21 was depressed as sometimes she/he had to wait for care. Resident 21 stated sometimes it was over an hour wait and she/he was wet because of incontinence. Resident 21 stated CNAs would come answer her/his call light and state "I've got 20 other patients also needing to be taken care of, you will have to wait." Resident 21 stated she/he felt very miserable sometimes. On 12/7/21 at 9:13 AM Resident 21 stated call light wait times went over 30 minutes a couple of times a week. Resident 21 stated the staff would always use the excuse the facility was short staffed. Resident 21 stated she/he had to "beg" to get a shower. On 12/21/21 Staff 17 (RN) confirmed Resident 21 had to wait for care on 11/9/21. Staff 17 stated on 12/19/21 three CNAs called in sick and she was requested to work as a CNA. Staff 17 stated she reported she was going to lunch and when she returned Resident 21 had waited 45 minutes to receive care and she/he was very upset. In an interview on 1/7/22 at 11:08 AM Staff 1 (Administrator), Staff 49 (Interim DON) and Staff 50 (Regional Nurse Consultant) stated they were creative with their staffing and believed it was more a cultural concern of the staff. 2. On 11/24/21 at 8:23 AM Witness 8 (Former Staff) stated since 5/2021 the staff were not providing residents with showers due to the facility was short staffed. On 12/7/21 at 7:46 AM Resident 15 stated call light wait times were "horrible" on evening shift and sometimes on day shift. Resident 15 stated she/he had to wait up to an hour for her/his call light to be answered a couple of times a week. On 12/7/21 at 8:08 AM Resident 16 stated the staff would walk by her/his room and not answer her/his call light when it was on. Resident 16 stated she/he used to write down the call light times and keep track, but she/he no longer kept track. Resident 16 stated the longest she/he had to wait for her/his call light to be answered was three hours and 15 minutes. On 12/7/21 at 9:24 AM Resident 22 stated the facility was "pathetically run". Resident 22 stated during shift changes she/he waited up to an hour for her/his call light to be answered. Resident 22 stated there were days she/he did not see any staff members for six to eight hours if she/he did not push her/his call light for assistance. On 12/7/21 at 9:59 AM Resident 10 stated the facility was "grossly" understaffed. There was not enough people and she/he had to wait over 30 minutes a couple of times a week for her/his call light to be answered. Resident 10 stated it happened both day shift and evening shifts. At times at night when she/he needed assistance with bed mobility she/he thought "oh god are they ever going to come in". On 12/17/21 at 8:40 AM Witness 31 (Former CNA) stated in 5/2021 residents complained of long call light wait times which would go over 20 minutes because the facility was short staffed. Witness 31 stated residents who were continent would have incontinent episodes due to waiting for their call light to be answered. Residents called out for assistance if their call light was not answered and for some residents Witness 31 could assist because the resident was care planned to have a two person assist and no other staff member was available. Witness 31 stated some of the residents could not understand the facility was short staffed. On 12/20/21 at 10:56 AM Staff 12 (CNA) stated residents complained of long call light wait times and in 12/2021 she was directed not to provide any showers to residents on days the facility was short staffed. On 12/21/21 at 10:08 AM Witness 35 (Former CNA) stated from 5/2021 through 8/2021 she worked three double shifts a week and had to stay over on her shift to make sure all her assigned tasks were completed. Residents complained of long call light wait times. Witness 35 stated some residents required 30 to 40 minutes to assist and if the other staff were not assisting it made her want to "run away" from the facility. Witness 35 stated she witnessed staff documenting a resident refusal for a shower when staff did not have enough time to complete a resident's shower. On 12/22/21 at 8:28 AM Staff 28 (CNA) stated from 5/2021 through 11/2021 the facility was short staffed. Staff 28 did not have enough time to complete all her daily assigned tasks. Staff 28 stated staff documented a resident refused a shower when there was not enough staff to complete the showers. Staff 28 stated residents were upset because of long call light wait times, late meals and not getting the care they needed. Staff 28 stated there were staff who socialized in the hallways and delayed or did not answer a resident's call light because the resident was considered difficult. Staff 28 stated there was one LPN to 40 residents and she could not complete all the care required for the residents. On 1/3/22 at 10:43 AM Staff 35 (CNA) stated in 6/2021 the facility was always short staffed, and it was difficult to find assistance to help with residents who required two people assist with cares. Residents complained of long call light wait times over 20 to 30 minutes. Staff 35 stated residents had negative outcomes due to waiting such as continent residents becoming incontinent waiting for long call light response times. On 1/4/22 at 9:49 AM Staff 22 (CNA) stated in 6/2021 and 7/2021 residents complained of long call light wait times and they complained staff stated they were going to go get something for them but they never came back so the resident had to activate their call light again. Staff 22 stated she worked night shift during 6/2021 and 7/2021 the facility was short staffed every night to every other night. Residents had an odor to them and had poor hygiene due to not receiving their showers. Staff 22 stated staff members documented a resident refused a shower when they did not because they did not have enough time to complete a shower and the nurses signed the resident had refused. On 1/5/22 at 1:43 PM Staff 16 (LPN) stated since 8/2021 the facility assigned her up to 40 residents and she was informed the facility would not provide another nurse until they hit 43 residents. Staff 16 stated with checking eight to 10 resident blood sugar levels and other treatments, she could not complete all needed care for the residents. Staff 16 did not take a lunch when there were only two nurses in the building on night shift as she felt it was a liability to only have one nurse in the building. Due to the short staffing in the building Staff 16 saw an increase in resident's behaviors and call light wait times lengthened, Staff 16 stated she also assisted with call light responses to make sure the wait times were not "ridiculous". Staff 16 stated there were instances call light wait times went over 30 minutes. On 1/7/21 at 8:34 AM Staff 31 (Dietary Manager) stated staff reported they were too busy to pick up Resident 15's food tray which was physician ordered to be delivered to her/him between 7:30 and 8:00. Staff 31 stated call light wait times were better for a while when the facility was completing audits then they got worse. Staff 31 stated he heard multiple residents calling out for help and he reported it to the medication aide. Staff 31 stated the staff always told him they are too busy. Staff 31 stated he observed multiple staff going outside to have smoke breaks multiple instances a shift. In an interview on 1/7/22 at 11:08 AM Staff 1 (Administrator), Staff 49 (Interim DON) and Staff 50 (Regional Nurse Consultant) stated they were creative with their staffing and believed it was more a cultural concern of the staff.

Resident #21 needs will be met timely. Facility will make every effort to meet state Minimum CNA staffing requirements. NHA/Designee will complete baseline audit of 12/2021 through 01/31/2022 DHS staffing sheets to verify currently meeting Minimum CNA staffing requirements. NHA/Designee initiated further education to nursing staff and staffing coordinator 02/11/2022 and ongoing related to DHS staffing requirements with specific focus on Minimum CNA staffing requirements. NHA/Designee will conduct ongoing audit of DHS staffing sheets to verify facility is meeting Minimum CNA Staffing requirements. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to provide appropriate diagnosis for medications for 1 of 3 sampled residents (#3) reviewed for medications. This placed residents at risk for adverse medication side effects. Findings include: Resident 3 was admitted to the facility in 2019 with diagnoses including fibromyalgia and osteoarthritis of the hip. A 9/5/19 Admission MDS revealed Resident 3 had a BIMS score of 15 indicating she/he was cognitively intact. The MDS indicated Resident 3 did not have a diagnosis of Parkinson's disease. A 9/6/19 signed physician order instructed staff to administer pramipexole (used in the treatment of some movement disorders such as RLS) one milligram, take three tablets at bedtime, doctor's comments: appointment pending. A 3/2020 MAR instructed staff to administer pramipexole dihydrochloride one mg, administer three tablets by mouth at bedtime for Parkinson's disease; needs diagnosis with a start date of 8/29/19. A signed pharmacist Consultation Report dated 4/23/20 revealed no diagnosis or documentation in Resident 3's record which supported continued use of pramipexole dihydrochloride. Staff 15 (Nurse Practitioner) hand wrote on the report she agreed there is no apparent diagnosis and would gradually reduce the medication of the next two weeks. If Resident 3 developed any symptoms a diagnosis would be documented to support the use of pramipexole dihydrochloride. In an interview on 1/7/22 at 11:27 AM Staff 1 (Administrator), Staff 49 (Interim DON) and Staff 50 (Regional Nurse Consultant) stated they expected staff to find the diagnosis sooner for the medication.

Resident #3 is no longer a resident. DON/Designee completed baseline audit of current residents to verify correct clinical indication/diagnosis listed for medications. Identified inconsistencies addressed. DON/Designee initiated further education to LNs 02/11/2022 and ongoing related to facility policy F757 Unnecessary Drugs with specific focus on verifying an acceptable clinical indication or Diagnosis for use when obtaining orders DON/Designee will conduct ongoing audit of new orders to verify acceptable clinical indication/diagnosis is present on order. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview, and record review it was determined the facility failed to serve food in a timely manner for 1 of 3 sampled residents (#15) reviewed for food preferences. This placed residents at risk for decreased efficiency of medications. Findings include: Resident 15 was admitted to the facility in 4/2020 with diagnoses including Parkinson's disease. A 11/22/21 signed physician order instructed staff to pick up Resident 15's food tray from the kitchen at 7:30 AM to 8:00 AM at the latest each morning so the food would not effect her/his morning medications. Including Carbidopa-Levodopa (to treat Parkinson's disease). If the food tray was late it would cause problems with her/his medications, the start date was 4/16/21. A 9/30/21 Nursing Note revealed a concern on the time of Resident 15's breakfast was raised to dietary due to her/his medications and Resident 15's need to eat on time. A 11/2021 TAR instructed staff to pick up Resident 15's tray from the kitchen at 7:30 to 8:00 at the latest every morning so it would not affect her/his morning medications. Including Carbidopa-Levodopa medication. If the tray was late it caused problems with the above medication. On 11/23/21 at 8:25 AM during random observations a staff member was outside Resident 15's room and asked where Resident 15's breakfast tray was. On 11/23/21 at 8:38 AM Resident 15 stated she/he just received her/his breakfast tray and she/he needed to eat the food quickly or her/his medications would not work correctly. Resident 15 stated she/he used to mark when her/his tray was late every time on the calendar, but she/he finally gave up. On 12/07/21 at 7:44 AM Resident 15's 11/2021 calendar on her/his wall was handwritten on 11/1/21 and 11/2/21 "late" in black ink. On 1/7/21 at 8:34 AM Staff 31 (Dietary Manager) stated staff reported they were too busy to pick up Resident 15's food tray which was physician ordered to be delivered to her/him between 7:30 and 8:00. Staff 31 stated the CNAs were late about 75 percent of the time in picking up Resident 15's breakfast food tray. In an interview on 1/7/22 at 12:10 PM Staff 1 (Administrator), Staff 49 (Interim DON) and Staff 50 (Regional Nurse Consultant) stated dietary knew to bring out the food tray early and someone who was available should deliver Resident 15's food tray. Staff 1, Staff 50 and Staff 49 confirmed Resident 15's breakfast tray should not be late unless there was an emergency in the building.

Resident #15 will receive early tray as requested. NHA/Designee completed baseline audit of current residents who have requested early tray service to verify meal was served timely. Identified inconsistencies addressed. NHA/Designee initiated further education to staff 02/11/2022 and ongoing related to facility policy F809 related to meal frequency with specific focus on resident preferences. NHA/Designee will conduct ongoing audit of current residents who request early tray service to verify preference is being observed. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to maintain minimum nursing staff to meet the needs of the residents and provide appropriate RN coverage for at least eight consecutive hours between the start of day shift and the end of evening shift seven days a week for two of two floors (1st and second floors) and 11 of 107 days reviewed for staffing. This placed residents at risk for unmet assessment and care needs. Findings include: The facility's Direct Care Staff Daily Reports revealed from 5/2/20 through 5/22/20, 6/1/20 through 6/29/20, 7/3/20 through 7/31/20 and 10/22/21 through 11/22/21 there were 19 out of 107 days without eight consecutive hours of RN coverage between the start of day shift and the end of evening shift as follows: -5/9/20, 5/10/20, 5/17/20, 6/6/20, 6/8/20, 6/13/20, 6/14/20, 6/20/20, 6/21/20, 7/12/20, and 7/26/20. On 12/13/21 at 9:54 AM Witness 19 (Former LPN) stated in 5/2020 there were instances she was responsible for providing medications and treatments for over 40 residents. Witness 19 stated she could handle 20 residents, but she could not always complete her tasks when the facility was short staffed. On 1/5/22 at 1:43 PM Staff 16 (LPN) stated since 8/2021 the facility assigned up to 40 residents to one nurse and she was informed the facility would not provide another nurse until they reached 43 residents. Staff 16 stated with checking eight to 10 resident blood sugar levels and other treatments she could not complete all needed care for the residents. Staff 16 did not take a lunch break when there were only two nurses in the building on night shift as she felt it was a liability to only have one nurse in the building if she took her break. On 1/7/22 at 11:00 AM, 11:08 AM and 1/11/22 at 10:03 AM Staff 1 (Administrator), Staff 49 (Interim DON) and Staff 50 (Regional Nurse Consultant) stated they were creative with their staffing and believed it was more a cultural concern of the staff. AM Staff 1 (Administrator), Staff 49 (Interim DON) and Staff 50 (Regional Nurse Consultant) could not speak to the dates without the required RND staffing in 2020.

Facility will make all attempts to meet RN Staffing requirements. DON/Designee completed baseline audit of current schedule to verify sufficient RN coverage is scheduled. DON/Designee initiated further education to IDT 02/11/2022 and ongoing related to sufficient RN staffing requirement. DON/Designee will conduct ongoing audit of schedule to verify sufficient RN coverage occurred. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

***************************************** OAR 411-086-0130 Resident Rights: Generally Refer to F550, and F552 **************************************** OAR 411-086-0260 Pharmaceutical Services Refer to F 554 **************************************** OAR 411-085-0360 Abuse Refer to F600, and F602 *************************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F677, F684 and F691 ***************************************** OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F686, F689, F690 and F757 *************************************** OAR 411-086-0100 Nursing Services: Staffing Refer to F725 *************************************** OAR 411-086-0250 Dietary Services F809 ***************************************

************************** OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F656 ************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F691 **************************

Based on interview and record review it was determined the facility failed to develop and implement a comprehensive care plan for 1 of 3 sampled residents (#503) reviewed for colostomy (an opening in the large intestine to provide an alternate channel for feces to exit the body) care. This placed residents at risk for unmet colostomy needs and skin breakdown. Findings include: Resident 503 was admitted to the facility in 10/2019 with a diagnosis of a colostomy. A 6/17/20 physician order indicated staff were to change the colostomy bag every five days, assess skin around the colostomy and notify the NP of increased redness or skin breakdown. The 2/11/22 comprehensive care plan indicated the resident was independent with her/his colostomy care. There was no further documentation on Resident 503's care plan regarding care and services of her/his colostomy. On 3/30/22 at 9:34 AM Staff 50 (Regional Nurse Consultant) stated there needed to be more information on Resident 503's care plan regarding the care and services of her/his colostomy.

F656 Failed to have Comprehensive Care Plan Resident # 503 ostomy care plan updated 03/30/2022. Residents with ostomies are at risk DON/Designee completed baseline audit of current residents who have an ostomy on 03/30/2022 to verify comprehensive care plan is in place. Identified inconsistencies addressed. DON/Designee initiated re-education to Unit Managers and MDS Nurses on 03/30/2022 and ongoing related to comprehensive care plans. DON/Designee will conduct ongoing audit of residents who have a colostomy to verify care plan is comprehensive. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.