Meadowview Healthcare And Rehab

Based on record review, interview, facility policy review, and document review, the facility failed to ensure an allegation of abuse was reported to facility administration, and subsequently the State Agency, for 1 (Resident #2) of 3 residents reviewed for abuse.
The findings include:
A review of a Nursing Progress Note, created by Licensed Practical Nurse (LPN) #1 on 11/01/2024 at 11:21 AM, revealed nursing documentation of an allegation of abuse from Resident #2, which read in part, Resident #2 stated someone on night shift with dark hair had kicked the resident in the night, because the resident had made the person mad.
During an interview on 06/12/2025 at 1:23 PM, the Director of Nursing (DON) indicated that on 01/24/2025, the Progress Note documentation dated 11/01/2024, was brought to the Administrator ' s attention by surveyors. At that time, the Administrator initiated an investigation into the allegation made by Resident #2 and reported the allegation to the state agency.
A review of a Social Progress Note dated 01/24/2025 at 3:00 PM, after the Administrator had been informed of the allegation documented in the progress note dated 11/01/2024, indicated the Administrator spoke with Resident #2, related to the allegation. The resident reportedly stated that they did not recall such an incident. [Resident #2] reported that [Resident #2] felt safe, secure and loved this facility.
A review of a Social Note, dated 01/24/2025 at 7:16 PM, revealed the Administrator had spoken with Resident #2 ' s responsible party about the incident.
A review of Resident #2 ' s Care Plan Report revealed the resident had diagnoses which included hallucinations, anxiety, and depression. The Care Plan Report, with a closed date of 03/18/2025, indicated the resident planned to remain in the facility under the care of hospice. The resident had impaired cognitive function, dementia or impaired thought processes related to cancer. Resident #2 was on pain medication therapy, used antidepressant medication, antianxiety medications, and psychotropic medications related to hallucinations.
A review of Resident #2's quarterly Minimum Data Set, with an Assessment Reference Date of 12/12/2024, revealed the resident had a Brief Interview for Mental Status score of 14, which indicated Resident #2 was cognitively intact.
A review of am LPN job description with a copyright date of 2023 revealed, policies and procedures would be complied with, the nurse would observe the resident for changes and notify the physician and family of changes and document findings. The nurse would report incidents and/or allegations to the supervisor or administrator. The nurse would protect the residents from abuse.
A review of LPN #1 ' s Employee Record revealed an unnamed document signed on 09/14/2024, with LPN #1's name, which indicated an employee should immediately report a suspected allegation of abuse to the Administrator or their designee. The Administrator would notify the State Agency. The Director of Nursing (DON) or designee would notify the resident ' s representative of the allegation of abuse. An acknowledgment page, signed on 09/14/2024 with LPN #1 ' s name, read in part that LPN #1 agreed to follow the policies included in the handbook.
A review of an Orientation Document dated 02/06/2019, indicated through signature that LPN #1 implied understanding of the instructions of the Abuse/Neglect policy.
A review of an In-service Education Report, dated 10/09/2024, revealed an all-staff in-service for abuse. The in-service specified how to report an allegation of abuse and to contact their supervisor immediately. The in-service was signed by LPN #1, next to her printed name.
A review of an Employee Disciplinary Action dated 04/05/2025, revealed a verbal warning for failing to report a resident-to-resident incident signed at the bottom on 04/11/2025, with LPN #1's name.
During an interview on 06/11/2025 at 3:44 PM, LPN #1 reported her employment period with the facility had been off and on for 10 years. LPN #1 confirmed the last abuse in-service was within the last month, and many times over the last 10 years. LPN #1 indicated, with suspected or alleged abuse, it was the expectation of nursing staff to notify the DON or the Administrator. LPN #1 confirmed the progress note that revealed Resident #2 reported being kicked by someone over the night, dated 11/01/2024, was her documentation. LPN #1 reported texting the DON and the Administrator about the incident. LPN #1 was unable to verify that any documentation was available to verify the notification, stating, I just messed up, I didn't document everything that I should have. LPN #1 confirmed that the expectation of direct contact for reporting allegations of abuse was not a new policy, it had always been the expectation. LPN #1 reported the DON had provided retraining and a disciplinary warning had been given.
During an interview 06/12/2025 at 1:23 PM, the DON confirmed all staff were expected to report allegations of abuse immediately in person or via phone to their direct supervisor, the DON or the Administrator. The nursing staff had not been trained to notify the DON or Administrator, via text notification, of abuse allegations. During orientation and at least quarterly, all staff were trained to report an allegation of abuse or neglect immediately to their supervisor. The DON confirmed that the physician and the resident ' s responsible party were expected to be notified of an allegation of abuse. The state agency was expected to be notified within two hours, after the notification of an allegation of abuse. The DON confirmed that LPN #1 had not reported the allegation of abuse to any administrative staff. The DON reported that LPN #1 had been retrained and disciplinary action had been taken due to the failure to report the allegation of abuse at the time it was reported to LPN #1 by the resident.
During an interview on 06/12/2025 at 1:45 PM, the Administrator indicated when an allegation of abuse was reported, an investigation was immediately initiated and reported to the state agency within two hours. The Administrator confirmed the expectation of staff was to report the allegation immediately to their supervisor, the DON, or the Administrator, either in person or via phone conversation. The Administrator indicated all staff were trained on abuse reporting during orientation, at least quarterly, and through in-service training. The Administrator confirmed, with any allegation of abuse, it was the facility ' s policy to notify the physician and the resident ' s responsible party. The Administrator confirmed that LPN #1 had not reported Resident #2's allegation of abuse on 11/01/2024, to either the Administrator or the DON. The Administrator confirmed that staff were expected to follow the facility ' s policies, and the charge nurse was expected to notify the physician and responsible party when a resident had a change of condition.
A review of a facility policy titled Abuse, Neglect and Maltreatment revealed that an alleged violation is an allegation reported by staff or others but has not been investigated, physical abuse included kicking, and employee training indicated that existing staff would receive retraining annually, and as needed. Employees were expected to report allegations of abuse immediately to the Administrator. The abuse allegation investigation was expected to be initiated immediately, investigated thoroughly, and reported to the appropriate state agency within two hours.

Based on observations, interviews, and facility document review, it was determined that the facility failed to ensure nutritive value and appearance was maintained for food preparation in 1 of 1 kitchen reviewed for food preparation and services. Specifically, the squash served for lunch on 10/07/2024 was on the steam table for two hours and twelve minutes prior to the start of resident lunch services resulting in overcooked watered-down squash.
Findings include:
During an observation on 10/07/2024 at 12:58 PM, the Kitchen Manager (KM) was plating the squash with a perforated spoon. In the pan there was mainly yellow water with pieces of limp squash.
During an interview on 10/07/2024 at 1:05 PM, the KM stated, five bags of squash was used in preparation for lunch but when it cooks so much it turns to liquid. The KM stated the squash was put on the steam table at 10:15 AM, prior to the staff's lunch being served. It was calculated that the squash had been on the steam table for two hours and twelve minutes prior to the start of the first resident's tray being served.
A review of the seasoned squash recipe from 10/07/2024 stated, after cooking the squash it should be drained.
During an interview on 10/08/2024 at 4:40 PM, Dietary Manager (DM) #14 stated the staff were served lunch prior to the residents due to staff's break time and food should only be on the steam table forty-five minutes prior to residents being served. DM #14 stated that when food is overcooked it gets watered down and it becomes unappetizing and loses nutritive value.

Based on interviews, record review, facility document review, and facility policy review, it was determined the facility failed to ensure a resident was free from chemical restraint for 1 (Resident #49) of 1 resident reviewed for chemical restraint.
Findings include:
A review of the facility's undated policy titled, Your Rights and Protections as a Nursing home Resident, indicated nursing homes can't use chemical restraints (like drugs) to discipline you for the staff's own convenience.
A review of the admission Record, indicated the facility admitted Resident #49 with diagnoses that included dementia, generalized anxiety disorder, and delusional disorders.
The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/06/2024, revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated the resident was had severe cognitive impairment.
A review of Resident #49's care plan initiated on 07/30/2024 and revised on 08/31/2024, revealed the resident was disoriented to place, had impaired safety awareness, wandering behaviors, a history of elopement from home, and an elopement from the facility on 08/30/2024. Interventions included distraction with structured activities, food, conversation, television, and books. Encourage placement of air tag watch per family. Identify patterns of wandering; purposeful, aimless, or escapist and intervene as appropriate.
A review of the Progress Note dated 07/25/2024 at 8:15 PM, revealed the Medical Director was contacted when Resident #49 became agitated with exit seeking behaviors and the resident stated they were getting out of here one way or another and that somebody better let them out so they could go home.
A review of the Order Summary Report, revealed an antipsychotic medication order, start date 07/25/2024. Resident #49 had an order to receive an antipsychotic oral tablet 1 milligram (mg) by mouth every eight hours as needed for anxiety related to dementia.
A review of the Medication Administration Record (MAR), for July 2024 revealed Resident #49 was administered the antipsychotic medication at 8:15 PM per the new order started at 8:00 PM.
A review of the Progress Note, dated 07/25/2024 at 9:03 PM revealed the antipsychotic medication was effective because Resident #49 was now sitting down for long periods of time.
A review of an Elopement Risk Evaluation, dated 07/25/2024 at 8:04 PM revealed Resident #49 was At Risk of elopement with a score of 4.
A review of the MAR, for July 2024 revealed Resident #49 was administered 1 mg of the antipsychotic medication on 07/28/2024 at 9:00 PM.
A review of the Progress Note, dated 07/28/2024 at 9:18 PM revealed Resident #49 opened the emergency door on the 500Hall. Resident #49 was taken back to the resident's room and administered an as needed order of the antipsychotic medication.
A review of the Progress Note, dated 08/01/2024 at 2:33 PM revealed Resident #49 told staff she was getting out of here and became agitated with exit seeking behaviors.
A review of the MAR for August 2024, revealed Resident #49 was administered 1 mg of the antipsychotic medication on 08/01/2024 at 2:33 PM.
A review of the Progress Note, dated 08/01/2024 at 4:31 PM revealed Resident #49 was positive for a urinary tract infection.
A review of the Progress Note, dated 08/03/2024 at 1:25 PM revealed Resident #49 was agitated and exhibiting exit seeking behaviors.
A review of the MAR, for August 2024, revealed Resident #49 was administered 1 mg of the antipsychotic medication on 08/03/2024 at 1:25 PM.
A review of an Elopement Risk Evaluation, dated 08/04/2024 at 9:23 PM, revealed Resident #49 was At Risk of elopement with a score of 4.
A review of the Progress Note, dated 08/07/2024 at 7:35 PM, revealed Resident #49 was agitated and exhibiting exit seeking behaviors. Resident #49 stated she had to get out. Resident #49 was pushing on the exit doors and setting off the alarms as they opened.
A review of the MAR, for August 2024, revealed Resident #49 was administered 1 mg of the antipsychotic medication on 08/07/2024 at 7:35 PM
A review of the Progress Note, dated 08/09/2024 at 5:48 PM, revealed Resident #49 was exhibiting exit seeking behaviors by pushing on the doors and setting off the alarms.
A review of the MAR for August revealed Resident #49 was administered 1 mg of the antipsychotic on 08/09/2024 at 5:48 PM.
A review of the Progress Note, dated 08/10/2024 at 6:21 PM, revealed Resident #49 was exhibiting exit seeking behaviors and pushing on doors.
A review of the MAR for August 2024, revealed Resident #49 was administered 1 mg of the antipsychotic medication on 08/10/2024 at 6:21 PM.
A review of the Progress Note, dated 08/14/2024 at 5:24 PM, revealed Resident #49 was exhibiting exit seeking behaviors. It was stated Resident #49 wouldn't stop pushing on the doors and trying to get outside, the door alarms kept going off.
A review of the MAR, for August 2024, revealed Resident #49 was administered 1 mg of the antipsychotic medication 08/14/2024 at 5:24 PM.
A review of the MAR, for August 2024, revealed Resident #49 was administered 1 mg of the antipsychotic medication on 08/19/2024 at 12:16 PM.
A review of the Progress Note dated 08/19/2024 at 12:51 PM, revealed Resident #49 was exhibiting exit seeking and stated she was going to get on the grass.
A review of the Progress Note, date 08/19/2024 at 12:53 PM, revealed Resident #49 tested positive for a respiratory virus and refused to stay in her room.
A review of the Progress Note, dated 08/20/2024 at 1:32 AM, revealed Resident #49 was refusing to stay in her room and wondering the halls.
A review of the Progress Note, dated 08/20/2024 at 4:47 PM, revealed communication with the Medical Director about Resident #49 behaviors of; exit seeking, wondering into other residents' rooms, bothering medication carts, and pacing. A new order for 0.5 milligrams of the antipsychotic medication was ordered to be given every evening at 5:00 PM, in addition to the as needed order.
A review of the Progress Note dated 08/20/2024 at 8:56 AM, revealed Resident #49 was wondering throughout the facility pushing on exit doors, going in and out of other residents' rooms and taking items, and refusing to sit down for even short periods of time.
A review of the MAR, for August 2024, revealed Resident #49 was administered 1 mg of the antipsychotic medication on 08/20/2024 at 8:56 AM.
A review of the Progress Note dated 08/21/2024 at 9:05 AM, revealed the Medical Director was asked to assess Resident #49's medications due to exit seeking behaviors throughout the facility.
A review of the Progress Note, dated 08/22/2024 at 4:02 PM, revealed the Medical Director increased the dose of a second antipsychotic medication to 1 mg, in response to the message about exit seeking behaviors.
During an interview on 10/11/2024 at 11:00 AM, Licensed Practical Nurse (LPN) #11 stated on 09/19/2024, that Resident #49 eloped through the first set of doors on the 500 Hall and was headed out the second set when LPN #11 intervened. LPN #11 stated a third antipsychotic was increased at that time for Resident #49. LPN #11 stated appropriate interventions for Resident #49 were to assess personal hygiene needs, redirection, and offer a snack. LPN #11 stated they try to be aware of where Resident #49 always is, even doing fifteen-minute checks on some days. Resident #49 gets irritated by some of the other residents and starts exit seeking.
During an interview on 10/11/2024 at 2:10 PM, the Administrator stated, yes, giving antipsychotics to keep Resident #49 from exit seeking, was a chemical restraint and the front hallway was unoccupied on the weekends and was not in the line of sight of staff, making a more difficult area to monitor for elopement. The Administrator stated this was not the facility for Resident #49 and family had been approached about it in care plan meetings. The Administrator stated Resident #49's family was made aware that the facility's interventions may not work, and that Resident #49 may have to be relocated to a facility with a memory care/dementia unit which is more secure.
During an interview on 10/15/2024 at 2:17 PM, Resident #49's family member stated they did not want to move Resident #49, but wanted to know why the facility accepted the resident if they could not handle the situation.

Based on observation, record review, and interviews, it was determined that the facility failed to ensure established abuse policies and procedures were implemented after receiving an allegation of abuse for 2 (Resident #21 and Resident #23) of 18 residents sampled for the implementation of abuse prohibition policies and procedures, that resulted in facility and contract staff, involved in allegations of abuse, to remain in the facility and to have continued contact with residents.
Findings include:
A review of a facility document titled, Employee Handbook, dated 2023, indicated, Grounds for Immediate Dismissal 1. Verbal or physical abuse of anyone while at the facility.
A review of a facility policy, included in the employee handbook, titled, Patient Ause/Neglect, with a policy change effective date of 09/25/2017, page 21 indicated the facility will report to state agencies as required by state and federal law within 2 hours and The facility will immediately send home the accused employee. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Page 23 indicated, if an employee, the suspected perpetrator shall be placed on immediate suspension during the investigation. Page 24 indicated, if abuse is suspected, it shall be immediately reported to the Administrator and notification of resident's representative and physician shall be made and documented.
A review of the [Contracted Lab Name] Laboratory Services Agreement, dated 10/04/2022, revealed, 3.4 Provider shall comply with the written policies and programs that have been provided to it by the Facility.'
A review of Resident #21's Progress Notes, dated 10/07/2024 at 2:39 PM, revealed an entry by the Director of Nursing (DON) that indicated the DON provided education to the lab technician (Phlebotomist) and the Certified Nursing Assistant (CNA) #1 regarding a resident's right to refuse and proper policy and procedure.
A review of Resident #21's Progress Notes, dated 10/07/2024 at 2:47 PM, revealed an entry by the DON that indicated the Administrator was notified and participated in the investigation and education. There is no documentation of notification being made to the family, physician, or state agency (SA), in Resident #21's electronic health record (EHR).
During an interview on 10/07/2024 at 4:10 PM, the DON stated the Administrator was notified of the situation with Resident #21, and the CNA #1 and the Phlebotomist were reeducated on what to do if a resident refuses blood work. The DON stated the Phlebotomist finished obtaining blood samples and was not asked to leave the building; and CNA #1 continued to work because there was a misunderstanding and not abuse.
A review of the [Contracted Lab Name] Patient Service Log dated 10/07/2024 indicated the Phlebotomist entered the facility at 1:30 PM and left the facility at 2:30 PM. The fourth entry on the log indicated Resident #21 encountered the Phlebotomist at 2:00 PM, and two residents were seen at 2:10 PM and 2:20 PM respectively.
A review of the [Contracted Lab Name] Patient Service Log dated 10/08/2024 indicated the Phlebotomist entered the facility at 10:30 AM and exited the facility at 12:00 PM. The log indicated Phlebotomist had contact with 7 residents during the visit.
During an interview on 10/15/2024 at 3:12 PM, the Administrator stated no policies or procedures were provided to [Contracted Lab Name] Labs by the facility.
During an interview on 10/11/2024 at 2:22 PM, the DON stated there was an investigation of all allegations of abuse, all parties involved were interviewed, and reporting was done to the state agency (SA), Medical Director, police, and families.
During an interview on 10/14/2024 at 10:10 AM, the Administrator stated the first incident (involving Resident #21) was reported to the SA on 10/08/2024 at 10:54 AM and should have been reported within 2 hours. The Administrator stated a pre-investigation was being done and the facility was trying to see if there was a miscommunication in order to do a soft file, it was determined there was not a miscommunication. The Administrator clarified the soft file was what the facility did if education was needed for an employee to resolve an issue. The Administrator stated the second incident was sent to the SA at 4:30 PM on Friday, (10/11/2024).
During an interview on 10/16/2024 at 3:27 PM, the Administrator stated the incidents should have been immediately reported and was not because, It did not register that it was abuse. The Administrator stated CNA #1 should have notified a nurse and had the nurse intervene, and the Phlebotomist should have been removed from the room, and both the Phlebotomist and CNA #1 should have been removed from the facility.
A review of an undated facility provided policy, titled, Your Rights and Protections as a Nursing Home Resident, stated that residents have the right to be free from verbal, sexual, physical, and mental abuse.
A review of an undated facility provided policy, titled, Resident Rights, stated that residents within the facility have the right to be treated with dignity and respect and to live in a safe, homelike environment.
A review of an undated facility provided policy , titled, NA/CNA [Nursing Assistant/Certified Nursing Assistant] Job Description, stated that the Certified Nursing Assistant's duties and responsibilities included communicating with residents and nurses and assisting with safety measures.
A review of facility provided staff in-services stated that all staff members received an in-service titled, Abuse, Neglect, and Misappropriation/Exploitation training on 12/6/2023, 2/14/2024, 6/12/2024, and 8/9/2024.
During an attempt to locate a staff member for an interview on 10/8/2024 at 10:00 AM, this Surveyor overheard a conversation between Certified Nursing Assistant (CNA) #2, CNA #3, and Resident #23. During the conversation foul language was used as there was talk of sexual intercourse and drug use.
During an interview on 10/8/2024 at 10:15 AM, CNA #2 stated that foul language and discussing of sexual intercourse or drug use was not appropriate with, or in the presence of residents.
During an interview on 10/8/2024 at 10:20 AM, CNA #3 stated that foul language and discussing sexual intercourse or drug use was not appropriate with, or in the presence of residents.
On 10/8/2024 at 10:25 AM, the Surveyor reported the verbal abuse to the Administrator, the Director of Nursing, and the Assistant Administrator.
During an interview on 10/8/2024 at 12:27 PM, Resident #23 stated that conversations between the staff and Resident #23 often consisted of foul language and can include talk of sexual intercourse and drug use. Resident #23 stated that it was typical banter and did not pose an issue for Resident #23
During an interview on 10/8/2024 at 12:45 PM, Resident #3, Resident #21, Resident #23, and Resident #30, were interviewed and stated that the staff often used foul language, and the residents did not appreciate that type of language being used in front of them.
During an observation and concurrent interview on 10/9/2024 at 10:00 AM, CNA #2 and CNA #3 were observed on the 500 Hall were Resident #23 resided. CNA #2 reported that she and CNA #3 were suspended from the facility for the remainder of their shift on 10/8/2024, but were told they could resume working on 10/9/2024.
During an interview on 10/9/2024 at 10:15 AM, the Administrator reported the alleged verbal abuse was reported and CNA #2 and CNA #3 were suspended from the facility for the rest of their shift on 10/8/2024. The Administrator reported Resident #23 was interviewed. The Administrator denied interviewing other residents or staff. The Administrator was unable to provide documentation of an investigation.
During an interview on 10/11/2024 at 3:45 PM, the Medical Director stated that Resident #23 stated no discomfort occurred due to the conversation between Resident #23, CNA #2 and CNA #3 involving foul language, sexual intercourse, and drug use. The Medical Director confirmed that due to Resident #23's diagnosis and medication regimen, Resident #23 had impaired judgement. The Medical Director confirmed that a reasonable person would have found the conversation offensive.
Review of Resident #23's Medical Diagnosis, reported multiple sclerosis, weakness, other motor neuron disease, a condition that causes sudden and uncontrollable laughing or crying, wheelchair dependence, dementia, anxiety, insomnia, and depression.
Review of Resident #23's Clinical Physician Orders, reported orders for barbiturates, tetrahydrocannabinol, muscle relaxer, antihistamines, and a narcotic.

Based on observation, record review, and interviews, it was determined that the facility failed to ensure staff involved in abuse allegations had no further contact with residents after the facility received an allegation of abuse for 2 (Resident #21 and Resident #23) of 18 sampled residents. Specifically, the facility allowed Certified Nursing Assistants (CNA) #1, CNA #2, CNA #3 and Phlebotomist, involved in the abuse allegations, to remain in the facility and to have continued contact with residents after the allegation of abuse was made.
Findings include:
A review of a facility document titled, Employee Handbook, dated 2023, indicated, Grounds for Immediate Dismissal 1. Verbal or physical abuse of anyone while at the facility.
A review of a facility policy included in the employee handbook, titled, Patient Ause/Neglect, with a policy change effective date of 09/25/2017, page 21 indicated, The facility will immediately send home the accused employee. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Page 23 indicated, if an employee, the suspected perpetrator shall be placed on immediate suspension during the investigation.
During an interview on 10/07/2024 at 2:19 PM, the surveyor notified the Director of Nursing (DON) of the observations made on the 200 Hall involving the abuse of Resident #21. The DON stated Resident #21's refusal should have been accepted, and the nurse should have been contacted. The DON stated the lab tech (Phlebotomist) and the aide would be interviewed.
A review of Resident #21's Progress Notes, dated 10/07/2024 at 2:39 PM, revealed an entry by the DON that indicated education was provided to the lab technician (Phlebotomist) and CNA #1 regarding the resident's right to refuse and proper policy and procedure.
A review of Resident #21's Progress Notes, dated 10/07/2024 at 2:47 PM, revealed an entry by the DON that indicated the Administrator was notified and participated in the investigation and education. There is no documentation of notification being made to the family, physician, or state agency (SA), in Resident #21's electronic health record (EHR).
During an interview on 10/07/2024 at 4:10 PM, the DON stated the Administrator was notified of the situation with Resident #21, and CNA #1 and the Phlebotomist were reeducated on what to do if a resident refuses blood work. The DON stated the Phlebotomist finished obtaining blood samples and was not asked to leave the building and CNA #1 continued to work because there was a misunderstanding and not abuse.
A review of the (Contracted Lab Name) Patient Service Log dated 10/07/2024 indicated the Phlebotomist entered the facility at 1:30 PM and left the facility at 2:30 PM. The fourth entry on the log indicated Resident #21 encountered the Phlebotomist at 2:00 PM, and two residents were seen at 2:10 PM and 2:20 PM respectively.
A review of the (Contracted Lab Name)Patient Service Log dated 10/08/2024 indicated the Phlebotomist entered the facility at 10:30 AM and exited the facility at 12:00 PM. The log indicated Phlebotomist had contact with 7 residents during the visit.
During an interview on 10/15/2024 at 3:12 PM, the Administrator stated no policies or procedures were provided to Alpha Labs by the facility.
During an interview on 10/11/2024 at 2:22 PM, the DON stated there was an investigation of all allegations of abuse, all parties involved were interviewed, and reporting was done to the SA, Medical Director, police, and families.
During an interview on 10/14/2024 at 10:10 AM, the Administrator stated the first incident (involving Resident #21) was reported to the SA on 10/08/2024 at 10:54 AM and should have been reported within 2 hours. The Administrator stated a pre-investigation was being done and the facility was trying to see if there was a miscommunication in order to do a soft file, it was determined there was not a miscommunication. The Administrator clarified the soft file was what the facility did if education was needed for an employee to resolve an issue. The Administrator stated the second incident was sent to the SA at 4:30 PM on Friday, (10/11/2024).
During an interview on 10/16/2024 at 3:27 PM, the Administrator stated the incidents should have been immediately reported and was not because It did not register that it was abuse. The Administrator stated CNA #1 should have notified a nurse and had the nurse intervene, and the Phlebotomist should have been removed from the room, and both Phlebotomist and CNA #1 should have been removed from the facility.

2. A review of the admission Record, indicated the facility admitted Resident #10 with diagnoses that included a brain disorder that causes memory loss, language and thinking problems, kidney disease and depression.
The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/26/2024, revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident had severe cognitive impairment. Resident #10 required substantial to maximal assistance with dressing, showering/bathing, sitting to lying and lying to sitting, from sitting to standing, transferring from chair to bed and bed to chair; required partial to moderate assistance for personal hygiene and to roll left to right; and required setup/cleanup assistance with oral hygiene and eating. Section P of the MDS did not include information related to bed rails.
A review of Resident #10's care plan, revised date of 08/14/2023, revealed the resident had an Activities of Daily Living (ADLs) self-care performance deficit related to muscle wasting and atrophy; and had a moderate risk for falls related to dementia. Interventions included being able to move and turn in bed by self with limited assistance of one staff; be sure call light was in reach; follow fall protocol. The care plan does not include information related to bed rails.
A review of Order Summary, revealed Resident #10 had an order for bed rails as an enabler, with a start date of 01/31/2024.
A review of Bed Rail Assessment, dated 10/08/2024 at 3:46 PM, indicated the resident is non ambulatory, level of consciousness fluctuates, has altered safety awareness due to cognitive decline, has no history of falls, has difficulty moving to a sitting position, poor balance, requested side rails and is visually challenged. No interventions were selected, recommendations were bilateral side rail placement to serve as an enabler to promote independence.
During an observation on 10/07/2024 at 1:35 PM, Resident #10 was in bed, and two-half rails are in up position, one on each side of upper half of resident's bed.
During an interview on 10/14/2024 at 10:33 AM, Licensed Practical Nurse (LPN) #24 stated if there is a need for side rails for a resident, or safety issues, the Director of Nursing (DON) or the Assistant Director of Nursing (ADON) would be contacted and do a bed rail assessment, and the rails would be care planned.
During an interview on 10/14/2024 at 11:39 AM, the DON stated the rails on Resident #10's bed are half rails and Resident #10 cannot lower them. The DON stated the rails are used as an enabler to assist Resident #10 with turning and are padded for protection.
During an interview on 10/14/2024 at 2:36 PM, the ADON stated Resident #10 uses the bedrails as enablers to turn and cannot lower the rails alone. The ADON stated if Resident #10 requested the rails, they are not considered a restraint and I don't think they should be able to lower them. The ADON stated the RAI (Resident Assessment Instrument) is used to complete the MDS and the bedrails are not reflected on Resident #10's MDS in Section P and would only be reflected if used as a restraint. The ADON was asked to review the guidance for Section P in the RAI, and the ADON stated the bedrails are considered a restraint for this resident. The ADON stated Resident #10's BIMS score is a 3 and is cognitively impaired. The ADON stated the family was involved in the quarterly assessment,
A review of the document provided by the ADON titled, CMS's RAI Version 3.0 Manual October 2024, Page P-5 and P-6, indicated the use of the restraint and the benefit of the restraint to the resident's medical symptom must be clear, must be documented in the medical record with a physician order and medical symptom being treated. The physician's order alone is not sufficient to employ the use of a physical restraint. CMS will hold the nursing home ultimately accountable for the appropriateness of the determination. Consideration during assessment must be given to the effect of the device on the resident and not the purpose or intent of the use as the effect may be a physical restraint.
During an observation on 10/15/2024 at 2:08 PM, Resident #10 was watching television, two-half rails were in the up position, one on each side of the upper half of the resident's bed.
During an interview on 10/16/2024 at 4:28 PM, CNA #1 stated Resident #10 used the bed rails to pull herself over, she sits up in the bed for lunch but gets in pain and asks to lay back down.
3. A review of the admission Record, indicated the facility admitted Resident #20 with diagnoses that included heart failure, chronic obstructive pulmonary disease (COPD), and arthritis.
The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/18/2024, revealed Resident #20 had a MDS score of 15 which indicated the resident was cognitively intact. No active neurological diagnosis was indicated in Section I.
A review of Resident #20's care plan, revised on 01/21/2024, did not indicate a mental disorder.
During an interview on 10/14/2024 at 11:10 AM, the DON stated the ADON was responsible for completing the MDS and the expectation was they should be accurate to create a clear picture of the resident, and the MDS was used to create a care plan. The DON stated Resident #20 would have been assessed in the 7 days prior to the MDS with an ARD of 07/18/2024. The DON stated the diagnoses used for the MDS were obtained from active diagnoses listed on the chart, based on medications, any interventions for a diagnosis. The DON stated there was no diagnosis of dementia in Resident #20's electronic health record (EHR), received no medication for dementia, did not have a dementia diagnosis during the lookback period and had not had a diagnosis of dementia since admission to the facility. The DON stated Resident #20's BIMS is 15. The DON stated Resident #20 does not have a hearing deficit and does not use hearing aids. The DON stated the MDS should accurately reflect a resident's current condition.
During an interview on 10/14/2024 at12:53 PM, the ADON stated they were responsible for accurately completing the MDS and care plan to reflect Resident #20's current diagnoses and condition to know how to care for the resident. The ADON stated Resident #20 was assessed for the MDS, 7 days prior to the ARD of 07/18/2024 and had a BIMS of 15, but did not have a diagnosis of dementia and it should not have been on the MDS or the care plan.
During an interview on 10/16/2024 at 2:45 PM, the Administrator stated, assessments should be accurate, residents fully/properly assessed by observation on the floor, talking to staff, reviewing the nurses' notes, and assessments. The Administrator stated there was no policy and procedure for care plans or MDSs.
Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure comprehensive assessments were accurately completed for 3 (Resident #1, Resident #10, and Resident #20) of 18 residents reviewed for assessments. The facility failed to accurately assess Resident #1 and Resident #10's use of bed rails and identify that the residents were at high risk for the use of bed rails on the annual Minimum Data Set (MDS) and to accurately assess Resident #20's current diagnosis status on the quarterly MDS assessment, which resulted in inaccurate care plans.
Findings include:
1. A review of the admission Record, indicated the facility admitted Resident #1 on 08/11/2020 with diagnoses that included hemiplegia/hemiparesis, convulsions, restlessness/agitation, psychosis, and delusional disorder.
A review of Resident #1's Order Summary Report revealed, Resident #1 had an order for full bilateral bedrails, to enable repositioning in bed, make sure they are up and tightly secured every shift, dated 05/17/2023.
On 10/15/2024 at 3:12 PM, the Administrator stated the facility did not have a policy for side rails/bedrails/full rails, restraints, or Minimum Data Sheet (MDS).
A review of the document titled, CMS's (Centers for Medicare & Medicaid Services) RAI (Resident Assessment Instrument Version 3.0 Manual) Page-5 (P-5) and Page-6 (P-6 ) provided by the Assistant Director of Nursing (ADON) stated, the use of bedrails even if they improve the resident's bed mobility must be coded by the facility as a restraint, specifically at P0100A. Also noted on P-6 was, if the resident is immobile and cannot voluntarily get out of bed because of a physical limitation or because proper assistive devices were not present, the bed rails do not meet the definition of a physical restraint.
The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/29/2024, revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 9 which indicated the resident was had moderate cognitive impairment. Resident #1 bedrails were not identified by the facility in Section P Question P0100A. Physical restraints was defined at the beginning of Section P as; any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Resident #1 was identified on Section GG Question GG 0170 as: A) Roll left and right as partial/moderate assistance defined as helper does less than half the effort, B) Sit to lying as substitutional/maximal assistance defined as helper does more than half the effort, C) Lying sitting on side of bed as substitutional/maximal assistance defined as helper does more than half the effort.
A review of Resident #1's Bed Rail Assessment, dated 01/31/2024, revealed question 3, side rail placement identified as bilateral and question 3a as, side rails/assist bars are indicated and serve as an enabler to promote independence and the resident expressed a desire to have side rails/assist bars.
A review of Resident #1's Bed Rail Assessment, dated 04/01/2024, revealed question 3, side rail placement as bilateral and question 3a as, side rail/assist bars are indicated and serve as an enabler to promote independence.
A review of Resident #1's Bed Rail Assessment, dated 07/10/2024, revealed question 3, side rail placement identified as bilateral and question 3a as, side rails/assist bars are not indicated at this time.,
A review of Resident #1's care plan revised, revealed the resident had a self-care performance deficit related to intercranial injury related to gunshot wound, seizure, muscle spasm, delusions, agitation, psychosis, hemiplegia-affecting dominate side. Interventions for bed mobility included the resident can move/turn in bed independently with the use of full rails.
During an observation on 10/07/2024 at 12:01 PM, Resident #1 was in bed with bilateral upper and lower half side rails up resulting in 2 full rails. Both right side half rails were wrapped in gray foam pipe insulation for padding. The left lower half rail was wrapped in gray foam pipe insulation for padding. Resident #1 was observed as mobile and used the bedrails for bed mobility to both pull themselves up in bed and reposition from side to side. An overhead trapeze was also installed on the bed but was not positioned for Resident 1's use.
During an observation on 10/09/2024 at 10:05 AM, Resident #1 was in bed with the right upper half rail up and bilateral lower rails up resulting in a full rail on the right side but only a half rail on the left lower side. Both right side half rails were wrapped in gray foam pipe insulation for padding. The left lower half rail was wrapped in gray foam pipe insulation for padding. Resident #1 was observed as mobile and used the bedrails for bed mobility to both pull themselves up in bed and reposition from side to side. An overhead trapeze was also installed on the bed but was not positioned for Resident #1's use.
During a concurrent interview and observation on 10/10/2024 at 2:14 PM, Resident #1 stated, no ability to move their right side but was able to pull and move in the bed with their left side. Resident #1 demonstrated and used bilateral upper rails and right lower rail to move up in the bed and turn side to side. Resident #1 was not able to see or reach the knobs to remove the half side rails from the bed frame or the mechanism to lower the half side rails if desired.
During an interview on 10/10/2024 at 2:23 PM, Certified Nursing Assistant (CNA) #20 stated, Resident #1 used the bedrails for mobility in the bed and to assist during peri-care. Resident #1 was able to turn on their side to assist the CNA's during care. CNA #20 stated no knowledge of the padding on the bedrails.
During as interview on 10/10/2024 at 2:31 PM Licensed Practical Nurse (LPN) #6 stated, Resident #1 rails were up so the resident could move in the bed, but did not know why the rails were padded LPN #6 assumed for safety.
During an interview on 10/15/2024 at 1:11 PM, Registered Nurse (RN) #12 stated, Resident #1 used the bedrails as an enabler to pull up in bed. RN #12 stated, yes, 4 half rails up (2 full rails) is still a restraint. RN #12 stated employment since 2017 and doesn't remember any previous interventions for Resident #1.
During an interview on 10/15/2024 at 1:31 PM, the ADON stated, Resident #1's annual or quarterly assessments do not identify bedrails under restraints because it's not required for enablers for bed mobility. The ADON stated the discrepancy on the 01/31/2024, 04/01/2024, and 07/10/2024, Bed Rail Assessments were just an error, and nothing has changed with the resident. The ADON also stated the resident was immobile and bed rails do not need to be identified on the assessment. The ADON stated, even though Resident #1 used all 4 attached bedrails for bed mobility since Resident #1 cannot get out of bed without a mechanical lift the resident was immobile. The ADON stated, yes, Resident #1 was being identified as both immobile and requiring bed rails for independent bed mobility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, it was determined that the facility failed to ensure care plans accurately reflected the resident's needs and interventions for care of 5 (Residents #10, #20, #21, #23, and #25) of 18 sampled residents.
Findings include:
1. A review of the admission Record, indicated the facility admitted Resident #10 with diagnoses that included a brain disorder that causes memory loss, language and thinking problems, kidney disease and depression.
The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/26/2024, revealed Resident #10 had a Brief Interview for Mental Status score of 3 which indicated the resident had severe cognitive impairment. Resident #10 required substantial to maximal assistance with dressing, showering/bathing, sitting to lying and lying to sitting, from sitting to standing, transferring from chair to bed and bed to chair; required partial to moderate assistance for personal hygiene and to roll left to right; and required setup/cleanup assistance with oral hygiene and eating. Section P of the MDS did not include information related to bed rails.
A review of Resident #10's care plan, revised date of 08/14/2023, revealed the resident had an Activities of Daily Living (ADLs) self-care performance deficit related to muscle wasting and atrophy; and had a moderate risk for falls related to dementia. Interventions included being able to move and turn in bed by self with limited assistance of one staff; be sure call light was in reach; follow fall protocol. The care plan does not include information related to bed rails.
A review of Order Summary Report, revealed Resident #10 had an order for bed rails as an enabler, with a start date of 01/31/2024.
A review of Bed Rail Assessment, dated 10/08/2024 at 3:46 PM, indicated the resident is non ambulatory, level of consciousness fluctuates, has altered safety awareness due to cognitive decline, has no history of falls, has difficulty moving to a sitting position, poor balance, requested side rails and is visually challenged. No interventions were selected, recommendations were bilateral side rail placement to serve as an enabler to promote independence.
During an observation on 10/07/2024 at 1:35 PM, Resident #10 was in bed, and two-half rails were in the up position, one on each side of the upper half of the resident's bed.
During an interview on 10/14/2024 at 10:33 AM, Licensed Practical Nurse (LPN) #24 stated if there is a need for side rails for a resident, or safety issues, the Director of Nursing (DON) or the Assistant Director of Nursing (ADON) would be contacted and do a bed rail assessment, and the rails would be care planned.
During an interview on 10/14/2024 at 11:39 AM, the DON stated the rails on Resident #10's bed are half rails and Resident #10 cannot lower them. The DON stated the rails are used as an enabler to assist Resident #10 with turning and are padded for protection.
During an interview on 10/14/2024 at 2:36 PM, the ADON stated Resident #10 uses the bedrails as enablers to turn and cannot lower the rails alone. The ADON stated if Resident #10 requested the rails, they are not considered a restraint and I don't think they should be able to lower them. The ADON stated the RAI (Resident Assessment Instrument) is used to complete the MDS and the bedrails are not reflected on Resident #10's MDS in Section P and would only be reflected if used as a restraint. The ADON was asked to review the guidance for Section P in the RAI, and the ADON stated the bedrails are considered a restraint for this resident. The ADON stated Resident #10's BIMS score is a 3 and is cognitively impaired. The ADON stated the family was involved in the quarterly assessment,
A review of the document provided by the ADON titled, CMS's RAI Version 3.0 Manual October 2024, Page P-5 and P-6, indicated the use of the restraint and the benefit of the restraint to the resident's medical symptom must be clear, must be documented in the medical record with a physician order and medical symptom being treated. The physician's order alone is not sufficient to employ the use of a physical restraint. CMS will hold the nursing home ultimately accountable for the appropriateness of the determination. Consideration during assessment must be given to the effect of the device on the resident and not the purpose or intent of the use as the effect may be a physical restraint.
During an observation on 10/15/2024 at 2:08 PM, Resident #10 was watching television, two-half rails were in the up position, one on each side of the upper half of the resident's bed.
During an interview on 10/16/2024 at 4:28 PM, Certified Nursing Assistant (CNA) #1 stated Resident #10 used the bed rails to pull herself over, she sits up in the bed for lunch but gets in pain and asks to lay back down.
2. A review of the admission Record, indicated the facility admitted Resident #20 with diagnoses that included heart failure, chronic obstructive pulmonary disease (COPD), and arthritis.
The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/18/2024, revealed Resident #20 had a MDS score of 15 which indicated the resident was cognitively intact. Minimal difficulty hearing and no use of a hearing aid was documented in Section B. No active neurological diagnosis was indicated in Section I.
A review of Resident #20's care plan, revised on 01/21/2024, page 4 revealed the resident had a risk for communication problems r/t (related to) minimal difficulty hearing and page 4 revealed on 07/18/2024 had no hearing deficits. Interventions included positioning resident when in groups, monitor and record deterioration of respiratory status, oral motor function, hearing impairment, poor fitting/missing dental appliances, and ability communicate.
During an interview on 10/14/2024 at 11:10 AM, the DON stated the ADON was responsible for completing the MDS and the expectation was they should be accurate to create a clear picture of the resident, and the MDS was used to create a care plan. The DON stated Resident #20 would have been assessed in the 7 days prior to the MDS with an ARD of 07/18/2024. The DON stated the diagnoses used for the MDS were obtained from active diagnoses listed on the chart, based on medications, any interventions for a diagnosis. The DON stated there was no diagnosis of dementia in Resident #20's electronic health record (EHR), received no medication for dementia, did not have a dementia diagnosis during the lookback period and had not had a diagnosis of dementia since admission to the facility. The DON stated Resident #20's BIMS is 15. The DON stated Resident #20 does not have a hearing deficit and does not use hearing aids. The DON stated the MDS should accurately reflect a resident's current condition, So we know how to take care of Resident #20, or any other resident, there was no policy or procedure on completing the MDS or care plan, the ADON had extra training of how to complete them.
During an interview on 10/14/2024 at 12:53 PM, the ADON stated they were responsible for accurately completing the MDS and care plan to reflect Resident #20's current diagnoses and condition to know how to care for the resident. The ADON stated Resident #20 was assessed, for the MDS, 7 days prior to the ARD of 07/18/2024 and did not have a diagnosis of dementia and it should not have been on the MDS or the care plan. Diagnoses are identified for the MDS by looking at their medical diagnosis in the EHR, review of the physician orders to see if the physician identified a new diagnosis while seeing residents. The ADON stated, Resident #20 has a BIMS of 15, does not have a current diagnosis of dementia, is not currently taking any medication for dementia, does not have a hearing aid, and there is a contradiction in the care plan indicating resident has no hearing deficits. The ADON stated she utilized the RAI Manual and was Resident Assessment Certified, there was no policy and procedure for completing the MDS or care plans.
3. Review of an untitled, confidential document, located in the risk management history (Incident and Accident [I&A]) of the electronic health record revealed Resident #21 experienced 63 falls from 10/2023 to 10/2024.
A review of the admission Record, indicated the facility admitted Resident #21 with diagnoses that included a decreased blood flow to the brain, convulsions, mental illness, and nerve damage of the extremities.
A review of a revised care plan, dated 01/09/2024, revealed Resident #21 had unavoidable falls r/t [related to] noncompliance with interventions. Interventions included continuing fall precautions, educating the resident on fall precautions, and following facility protocol for fall precautions.
A review of the quarterly MDS with an ARD of 08/09/2024 revealed Resident #21 had a BIMS of 12, was independent standing from a seated position, required supervision with toilet transfer and was independent walking 10 feet; and had two or more falls since prior assessment with no injury, and two or more falls with injury.
A review of a fall risk evaluation, dated 09/11/2024 at 7:37 AM, revealed Resident #21 was alert and oriented (AO) x3, ambulatory, incontinent, had adequate vision, balance problems with standing and walking, requires assistive device for ambulation, and had 3 or more falls in 3 months.
During an interview on 10/07/2024 at 12:09 PM, Resident #21 stated they fell in bathroom while toileting.
During an interview on 10/11/2024 at 12:29 PM, LPN #11 stated Resident #21 is a fall risk and had 8 falls in the last year. The care plan should reflect the interventions for fall and the ADON was responsible for updating the care plan and changes were made based on what was triggered in risk management and fall risk assessments. Current interventions included follow facility protocol - which LPN #11 stated was will have decreased falls. LPN #11 stated it was important to have the care plan be accurate and reflect a resident's needs in order to give them the best care and giving them what they need.
During an interview on 10/14/2024 at 10:50 AM, the DON stated Resident #21 had greater than 25 falls since November. Care plans are established by the MDS coordinator (ADON) and interventions are added when we review falls in morning meetings. Risk evaluations are completed after each fall on how likely they are to fall; medications currently being taken and what interventions we can change. The DON stated there was no root cause done. The DON stated interventions currently in place included non-skid strips in front of toilet, non-slip pad in the wheelchair, non-skid strips at bedside, verbal education, encouraging activities in evening, and to have staff to assist with bedtime routine after the evening meal. The DON stated it was important for the care plan to be accurate and reflect the residents' needs, So that everyone can take the best care of that resident and know how to take care of them.
During an interview on 10/14/2024 at 12:14 PM, the ADON stated Resident #21 had 59 falls since November of 2023 and fall risk assessments were done after each one and should be accurate to ensure interventions are in place on the care plan, which gives us a chance to better help our residents and staff knows what to do.
4. A review of the admission Record, indicated the facility admitted Resident #25 with diagnoses that included a brain disorder causing forgetfulness, limited social skills, impaired thinking abilities; low blood pressure that causes lightheadedness, dizziness, fainting; anxiety disorder; weakness and cataracts.
The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/25/2024, revealed Resident #25 had a Staff Assessment of Mental Status (SAMS) score of 3 which indicated the resident had severe cognitive impairment. Resident #25 required partial to moderate assistance with oral hygiene, shower/bathing, dressing, personal hygiene, sitting to standing, transfer from bed to chair and walking; substantial to maximal assistance with toileting; and supervision or touch assistance with eating.
A review of Resident #25's care plan, with an initiated date of 08/15/2023, revealed Resident #25 had an actual/potential risk for falls related to decreased mobility, impaired vision and decreased safety awareness. Resident #25 experienced falls on 07/08/2023, 06/19/2024, and 09/02/2024 with no injuries reported. Interventions included follow facility fall protocol.
A review of the Order Summary Report, revealed Resident #25 had medications that included two medications for rapid heart rate, a medication for mood, and a medication for difficulty sleeping.
A review of the Fall Risk Evaluation, dated 09/02/2024 indicated Resident #25 was alert and oriented or comatose, had 1-2 falls in past 3 months, was chair bound, had poor vision, had a balance problem while standing and walking, had decreased muscular coordination, had a change in gait pattern when walking through a doorway, was jerking or unstable when making turns, required assistive devices, had no drop in blood pressure from lying to standing, no change in medications and had 1-2 predisposing diseases.
During an interview on 10/14/2024 at 11:30 AM, the DON stated Resident #25 had 4 falls and risk evaluations were done after each fall to determine how likely they are to fall again, what medications they have and what interventions could be changed. None related to medications. Interventions in place are a concave mattress, and wheelchair for ambulation.
During an interview on 10/14/2024 at 12:40 PM, the Assistant Director of Nursing (ADON) stated the interventions in place for Resident #25 included the fall protocol, a concave mattress, assist with change of position and toileting every 2 hours. The ADON could not describe the facility fall protocol stating it was interventions put in place.
During an interview on 10/14/2024 at 12:14 PM, the ADON stated care plans are established when a new resident is admitted . An MDS assessment is completed and triggers what goes on the care plan. The care plans are reviewed quarterly with the MDS and sooner if something changes. Staff notify me of any changes that may be needed to the care plans. The ADON stated she does not know what FMP is on the care plan.
During an interview on 10/15/2024 at 2:00 PM, CNA #17 stated they provide care for the residents based on asking the residents what they want done, and if the resident is unable to communicate we will ask the nurse or go to the (electronic health record) for the care plan. CNA #17 stated they do not know what FMP , or fall protocol is, Unless it is that we tell the nurse and assist the resident back up.
During an interview on 10/15/2024 at 4:20 PM, the Administrator stated there was no policy and procedure for care plans or MDS, on falls, there was no facility fall protocol, and no FMP protocol. The Administrator clarified FMP protocol was a functional maintenance program for RNAs (Restorative Nurse Aides), and there was not currently a program in place.
During an interview on 10/16/2024 at 2:45 PM, the Administrator stated assessments should be accurate, residents fully/properly assessed by observation on the floor, talking to staff, reviewing the nurses' notes, and assessments. The Administrator stated he expects interventions to be in the care plan for falls.
During an interview on 10/16/2024 at 10:18 AM, CNA #9 stated they ask someone if they do not know how to care for a resident and if they do not know they would ask the resident. CNA #9 does not know what FMP or fall protocol is.
5. A review of Resident #23's care plan dated 07/10/2023, stated focus Resident #23 is a smoker. Interventions included to instruct Resident #23 locations, times, and safety concerns. Resident #23 requires supervision while smoking. Resident #23's smoking supplies are stored with Resident #23.
A review of Resident #23's care plan dated 07/10/2023 did not report any use of marijuana or THC products.
A review of Resident #23's Minimum Data Set, dated [DATE], Section J reported no documentation of Resident #23's smoking preference or marijuana use.
A review of Resident #23's Medical Diagnosis , reported the resident had diagnoses to include multiple sclerosis, weakness, asthma, motor neuron disease, dementia, anxiety, insomnia, and depression.
A review of Resident #23's Order Summary Report, reported barbiturates, oxygen, muscle relaxers, narcotics, a mixed drink as needed, and tetrahydrocannabinol (THC).
During a concurrent observation and interview on 10/9/2024 at 3:30 PM, tetrahydrocannabinol (THC) gummies were observed in the medicine cart for the 500 Hall. Licensed Practical Nurse (LPN) #6 stated the THC Gummies belonged to Resident #23 and were brought in by a friend. LPN #6 stated the Medical Director prescribes the THC gummies for Resident #23. LPN #6 stated she did not know if the THC gummies were on Resident #23's care plan.
During a telephone interview on 10/9/2024 at 4:41 PM, the Medical Director stated Resident #23 had a state medical marijuana card and was provided with THC gummies via Resident #23's health care proxy. The Medical Director stated that Resident #23 used the THC gummies for anxiety and pain relief. The Medical Director stated he was unaware of how Resident #23's health care proxy obtained the THC gummies. The Medial Director stated the orders for the THC gummies are provided to the nurses based on the concentration of THC in the gummies the health care proxy was able to obtain. The Medical Director stated if the concentration of THC in the gummies varies from one supply to the next the nurses notify the Medical Director and the order is adjusted. The Medical Director stated there is no protocol for the THC dosing as THC gummies are not FDA approved. The Medical Director stated that as an employee of a federally funded facility the Medical Director is not licensed to dispense THC products.
During a concurrent observation and interview on 10/15/2024 at 11:00 AM, Certified Nursing Assistant (CNA) #7 accompanied Resident #23 to the facilities smoking area. Certified Nursing Assistant #7 stated that Resident #23 previously smoked cigarettes but currently used E-cigarettes. CNA #7 stated she knew how to assist Resident #23 with smoking or vaping because the she had worked at the facility a long time. CNA #7 denied observing Resident #23's smoking evaluation or safe to smoke assessment.
A review of Resident #23's Smoking Safety Evaluation, dated 10/11/2024, did not indicate if Resident #23 utilized tobacco products or could store the products.

Based on observation, interview, and record review, the services provided or arranged by the facility did not meet professional standards of quality for 1 (Resident #23) of 1 sampled resident.
The findings include:
Review of Resident #23's Medical Diagnosis, reported multiple sclerosis, weakness, other motor neuron disease, a condition that causes sudden and uncontrollable laughing or crying, wheelchair dependence, dementia, anxiety, insomnia, and depression.
A review of Resident #23's Order Entry, on 10/9/2024 at 3:00 PM reported, THC Gummies 25mg (milligrams) 1 gummy every 2 hours as needed, not to exceed 5 gummies in 24 hours verbal order per Medical Director dated 9/2/2024. Previous orders included: 15 mg/1000 mg may have 1-2 gummies every 2 hours as needed up to 10 per day on 8/11/24. THC gummies 600mg THC/15 mg [brand] may have two gummies each shift if 25 mg is not available, every 8 hours for pain/anxiety, not to exceed 6 gummies per day on 8/1/24.
During a concurrent observation and interview on 10/9/2024 at 3:30 PM, THC gummies were observed in Licensed Practical Nurse (LPN) #6's medicine cart. LPN #6 stated that the THC gummies belonged to Resident #23. LPN #6 stated that the THC gummies are counted each shift, such as one would a narcotic. LPN #6 stated that at times the bag of THC gummies indicates there are 20 individual's gummies per bag but upon opening bag less than 20 THC gummies are counted. LPN #6 stated that two nurses log the THC gummies in the narcotic book and correct the count.
During a telephone interview on 10/9/2024 at 4:41 PM, the Medical Director stated that Resident #23 had an active state medical marijuana card, and that Resident #23's healthcare proxy procures the THC gummies for Resident #23. The Medical Director stated that Resident #23 uses the THC gummies for anxiety and pain relief. The Medical Director denied any knowledge of how Resident #23's health care proxy obtained the THC gummies. The Medical Director stated that orders for the THC gummies are provided based on the facilities communication of what concentration of the THC gummies Resident #23's health care proxy was able to obtain. The Medical Director stated the order for Resident #23's THC gummies were titrated based off reported pain and/or anxiety levels. The Medical Director denied being aware of what signs or symptoms the facility staff should monitor for. The Medical Director stated Resident #23 knows when the THC gummies are needed. The Medical Director stated that due to no FDA (Federal Drug Administration) oversight, no set dosing recommendations or guidelines were available for the THC gummies. The Medical Director denied having licensure to prescribe medical marijuana, THC gummies, or fill out paperwork related to medical marijuana due to working for the federally funded facility where Resident #23 resided.
During a telephone interview on 10/10/2024 at 8:57 AM, Resident #23's health care proxy stated that the THC gummies were procured from manufacturers in two nearby states either through direct pick up or mail delivery. Resident #23's health care proxy stated the bags of THC gummies were brought into the nursing facility and handed to the nursing staff. Resident #23's health care proxy stated that the dosage provided to Resident #23 was determined by the Medical Director. Resident #23's health care proxy stated that while Resident #23 did have a medical marijuana card, and the card was only active for one state. Resident #23's health care proxy denied having a caregiver marijuana card. Resident #23's health care proxy stated that it was not necessary to have a medical marijuana card for the [two nearby states].
During a telephone interview on 10/10/2024 at 9:34 AM, Licensed Practical Nurse (LPN) #24 stated Resident #23's healthcare proxy brought the THC gummies to the facility. LPN #24 stated no training was provided, either by administration or the Medical Director, with regard to administering the THC gummies or monitoring for side effects. LPN #24 stated that the nursing staff looked up THC gummy administration information on the search engines. LPN #24 denied knowing if the THC gummies were on Resident #23's care plan or minimum data set. LPN #24 stated that Resident #23 requested the THC gummies when Resident #23 received narcotic medications during medication pass.
During an interview on 10/14/2024 at 11:27 AM, the Director of Nursing (DON) stated that no formal education had been provided to the staff regarding the administration or monitoring of the THC gummies.
During an interview on 10/14/2024 at 11:30 AM, the Administrator stated that no formal education had been provided to the staff concerning the administration or monitoring of the THC gummies. The Administrator denied knowledge of how THC gummies were obtained. The Administrator stated that the Medical Director prescribes the THC gummies. The Administrator denied knowledge of what class or schedule of medication the Medical Director was licensed to prescribe. The Administrator stated that the THC gummies that were within the facility for Resident #23 were removed from the facility and returned to the health care proxy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, it was determined that the facility failed to monitor and maintain safe hot water temperatures, which were found to be up to 151 degrees Fahrenheit (F), on all residential wings/units of the facility, including the shower rooms. Further, staff failed to implement the system for reporting and acting upon ongoing concerns related to excessively hot water in resident care areas. Specifically, direct care staff with knowledge of excessively hot water temperatures did not record this information on the facility's Maintenance Log sheets as the concerns were identified. In addition, maintenance staff did not implement any additional checks of facility water temperatures to ensure they were within safe ranges after adjusting the mixing valve; and the facility failed to ensure an emergency call system was accessible to residents who used a common bathroom on the entry hall. This had the potential to affect all 48 residents in the facility; and the facility also failed to ensure a safe and secure environment by not having a monitoring system in place for residents who wandered and/or had exit seeking behaviors. This deficient practice affected one (Resident #49) of 18 sampled residents. The facility identified one current resident who was at risk for elopement.
It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to the State Operations Manual, Appendix PP, §483.25 (Quality of Care) at a scope and severity of L. The IJ began on 10/04/2024, when the Environmental Director adjusted the mixing valves to change the hot water temperature.
The Administrator, Director of Nursing (DON), and Business Office Manager were notified of the IJ on 10/08/2024 at 10:23 AM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 10/09/2024 at 1:29 PM related to hot water temperatures. The IJ was removed, for the water temperatures, prior to the exit from the facility on 10/16/2024 at 6:00 PM, however the IJ an acceptable plan of removal was not received prior to exiting the facility related to elopement.
In addition to the IJ above, the facility also failed to adequately assess, establish interventions, and provide supervision to prevent falls for 2 (Resident #21 and #25) of 18 sampled residents; failed to maintain safe and secure practices during medication preparation, which allowed Resident #49 to drink a medication left on the medication cart while the nurse was preparing medications.
Findings include:
Findings include:
1. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/13/2024, revealed Resident #18 had a Brief Interview for Mental Status (BIMS) score of 15 that indicated resident was cognitively intact. Resident #18 used a manual wheelchair for ambulation, required substantial to maximal assistance with toileting, had active neurological diagnoses with deficit to left side.
During an interview on 10/07/2024 at 11:27 AM, Resident #18 stated the facility had issues with the hot water temperature, and during a shower, the knob was set on cold and only hot water was coming of the faucet and burned the top of Resident #18's thigh. Resident #18 could not remember the staff member assisting with the shower.
During an observation and interview on 10/07/2024 at 12:08 PM, the surveyor, with permission, entered Resident #21's bathroom and turned on the sink's hot water faucet, and placed their right hand under running water. The surveyor pulled their right hand out of the water stream due to the hot temperature, causing a red area on the back of the surveyor's hand. Resident #21 stated the water was hot and had received a burn while they were washing their hands, but did not report it to anyone. Resident #21 denied blistering and had only reddened hands.
During an observation on 10/07/2024 at 1:24 PM revealed a white paper with all capital, black letters, hanging in the shower room, that indicated, Caution: do not turn on straight hot water. you must adjust the temperature with cold water to prevent burns.
The quarterly MDS, with an ARD of 07/18/2024, revealed Resident #20 had a BIMS score of 15 which indicated the resident was cognitively intact. Resident #20 required partial to moderate assistance with toileting, bathing, and ambulation, and had a diagnosis of hand numbness and tingling caused by a pinched nerve.
During an interview on 10/07/2024 at 3:20 PM, Resident #20 reported the water in the restroom sink had been scalding since Friday 10/4/2024 and had not washed their hands in their room since that time. Resident #20 stated the issue had been reported to the nurse and had not been fixed.
During observations on 10/07/2024, a surveyor obtained hot water temperatures in shower rooms and resident rooms. Any common bathroom accessible to residents and staff. Temperatures were as follows:
- At 2:30 PM Hot water coming from faucets in the bathroom in resident room # 310 was 139 F, Assistant Administrator used facility thermometer. The Assistant Administrator was unable to continue testing and Medical Records assisted the surveyor with the remaining water temperatures. Two rooms on each hall were checked. Hot water temperatures ranged from 139 F to 145 F. The Environmental Director was not at the facility.
- At 2:33 PM Hot water coming from faucet in bathroom in resident room # 301 was 143 F, Medical Records used facility thermometer.
- At 2:38 PM Hot water coming from faucet in bathroom in resident room # 201 was 145 F, Medical Records used facility thermometer.
- At 2:40 PM Hot water coming from faucet in bathroom in resident room # 404 was 141 F, Medical Records used facility thermometer.
- At 2:42 PM Hot water coming from the faucet in bathroom in resident room # 501 was 135 F, Medical Records used facility thermometer.
- At 2:52 PM Hot water coming from faucet in bathroom in resident room [ROOM NUMBER] was 141 F, Medical Records used facility thermometer.
- At 3:52 PM hot water coming out of shower head faucet in double shower room was 135 F, taken by surveyor.
- At 4:00 PM hot water coming out of the faucet in Resident #20 - room [ROOM NUMBER] bathroom was 148 F, taken by surveyor.
- At 5:04 PM hot water coming out of faucet in Resident #18 - room [ROOM NUMBER] bathroom was 145 F, Administrator used facility provided thermometer.
- At 5:09 PM hot water coming out of the faucet in Resident #21 - room [ROOM NUMBER] bathroom was 148 F, Administrator used facility provided thermometer.
- At 5:14 PM hot water coming out of the faucet in Resident #30 - room [ROOM NUMBER]A bathroom was 143 F, Administrator used facility provided thermometer.
- At 5:23 PM hot water coming out of faucet in room [ROOM NUMBER] was 145 F, and Rooms #103, 105 and 107 were 151 F. No residents are housed on 100-hall, however, Resident #49 was observed wandering into rooms on 100-hall by surveyor.
- At 5:34 PM hot water coming out of faucet in room [ROOM NUMBER] was 148 F, taken by Environmental Director, using a meat thermometer and confirmed by surveyor using non touch infrared thermometer. The Environmental Director stated hot water heaters were installed by (Company Name), a local plumbing company and the mixing valve could not be bypassed.
During an observation on 10/07/2024 at 3:38 PM Administrator escorted surveyor to boiler room where three on-demand hot water heaters installed. The temperature on all three hot water heaters was set to 170° F.
During interviews on 10/07/2024 at 3:55 PM, Certified Nursing Assistant (CNA) #4 stated they were unaware of any maintenance to the hot water being done recently, had noticed very hot water in all rooms, and was only aware of one resident who complained of hot water being especially hot and that was Resident #20, on 200-hall. CNA #4 stated to ensure water temperatures are comfortable for residents, staff test the water on their own arm without gloves. CNA #4 stated no residents have been burned yet. CNA #4 stated room [ROOM NUMBER] is too hot, and Resident #20 will not use the sink, and staff will not wash their hands in resident rooms, they use hand sanitizer after leaving rooms due to the temperature of the hot water.
During interviews on 10/07/2024 at 3:57 PM, CNA #5 stated they were unaware of any maintenance on the hot water being done recently, had not noticed the water temperature being too hot and has not had a resident complain about the water temperature, and was not aware of anyone being burned by hot water. To ensure resident comfort when bathing, CNA #5 tested the temperature of the water on their wrist.
The quarterly MDS, with an ARD of 08/15/2024, revealed Resident #30 had a BIMS score of 15 which indicated the resident was cognitively intact. Resident #30 required partial to moderate assistance with toileting and ambulation, used a manual wheelchair, required substantial to maximal assistance bathing, and had a neurological brain disorder.
During an interview on 10/07/2024 at 3:57 PM, Resident #30 stated the water, in a shared restroom, was really hot since admission to the facility in February and was scared to use the water in the room. Resident #30 stated an aide was notified but could not recall the name of the aide.
During an interview on 10/07/2024 at 3:57 PM, CNA #17 described the process used when providing resident showers by turning the water faucet half-way between hot and cold, and spraying it on the residents' leg and adjusting it per resident preference.
During interviews on 10/07/2024 at 4:00 PM, Licensed Practical Nurse (LPN) #6 stated she had been employed at the facility for one week, was not aware of any service done on hot water heaters, and had noticed the water got hot and had to turn on a lot of cold water to try to adjust the temperature. LPN #6 stated no one had complained about the water temperature or of being burned by the hot water.
During an interview on 10/07/2024 at 5:15 PM , the Environmental Director (ED) stated water temperatures were checked weekly. The ED stated water coming out of a resident's bathroom faucet was 148 degrees F, it would be a concern. The Environmental Director further stated anything over 120 degrees was of concern as it was a scald issue for residents and would expect staff to remove residents from the water. The Environmental Director stated the facility installed on-demand hot water heaters (HWH) that were set at 170 F, and there was a brass 2.5-inch mixing valve, a 1.5-inch pipe that sent water to the kitchen and laundry, and 2.5- inch pipe that carried water to other areas. The Environmental Director explained the mixing valve mixed in the cold water to keep the temperature at a goal, When I can get the mixing valve to work, the goal of the resident rooms was 115 degrees F to 120 degrees F. The Environmental Director stated the last time the mixing valve was adjusted was on Tuesday (10/01/2024) due to a CNA reporting there was no hot water to provide a shower, so the mixing valve was adjusted. The Environmental Director stated changes were not documented and was not aware changes needed to be documented.
A review of a facility logs titled, Weekly Water Temperatures, dated 10/09/2023 to 10/01/2024, revealed water temperature readings were 115 degrees in all tested areas. Logs were not provided for the first week in October 2023, the fourth week in September 2024. The last documented entry was on 10/01/2024.
A review of an untitled document identified as Maint. Log, revealed an entry on 10/05/2024 that indicated the bathroom water in room [ROOM NUMBER] gets too hot.
During a phone interview on 10/07/2024, at 5:56 PM the plumbing company representative stated three on-demand hot water heaters were installed by the company and the hot water temperature can be adjusted all the way down to 120 degrees F at the hot water heaters and could be set up to bypass the mixing valve completely. The company representative stated the 2.5-inch mixing value was hard to come by and the last one was ordered from New Jersey. The representative further stated that at the time of installation the temperature was turned up to 170 F for the dishwasher in the kitchen.
On 10/07/2024 at 6:01 PM, surveyors notified the Administrator and DON of unsafe water temperatures in resident bathrooms, common areas, and bath/shower rooms and no further showers/baths for residents should be done in the shower rooms until water temperatures are in the safe zone.
During an interview on 10/07/2024, at 6:14 PM the Dietary Manager stated the dishwasher was a low temperature dishwasher and reaches a temperature of 125 degrees Fahrenheit and nothing in the kitchen required water temperatures to reach 170 degrees Fahrenheit. When the sink water was turned on it was very hot and steamy. The dietary manager stated it is very hot, be careful. The water temperature in the sink was 145 F.
During an interview on 10/07/2024 at 6:20 PM, the Administrator stated signs were posted on shower doors that instructed that residents were not to receive showers or baths.
During an interview on 10/07/2024 at 6:20 PM, the Administrator stated signs were [NAME] d 10/07/2024 after 6:01 PM on shower room doors that residents are not to receive showers/baths. Photos taken by surveyor. Signs were posted at 6:23PM. DON stated signs were posted because the facility was told they could not give showers until further notice. DON is unsure of why but thinks the temps were too high. No in-services were conducted.
During an observation on 10/07/2024, the main hall bathroom was accessible to residents, staff, and visitors. The bathroom door opened to the left, pushing inward. An emergency pull cord was located on the back of the door, over 5 feet from the floor, centered from left to right, would not be accessible to a resident, staff or visitor who was on the floor, or on the toilet, requiring assistance. The emergency pull device was just above surveyor's head, while standing, surveyor's height is 5' 4. The lock on the bathroom door was a slide lock and located above and to the right of the emergency light, requiring the surveyor to fully extend their arm to activate lock.
During an interview on 10/08/2024 at 09:52 AM, CNA #2 stated Resident #18 did not notify the CNA of any burn. Showers did have to be stopped on 10/07/2024 due to cold water being too hot and the issues with the hot water were going on for about 2 weeks. CNA #2 stated Resident #18 received a shower on 10/107/2024 before lunch and was not documented until later in the afternoon. Resident #18 did complain about the temperature, the water was tested on CNA #2's arm and Resident #20 told CNA #2 it was still too warm, and CNA #2 turned the water down again. CNA #2 did not notify the nurse to assess Resident #20 for burns because the water was adjusted.
During an interview on 10/11/2024 at 11:48 AM, CNA #8 stated staff were made aware of hot water temperatures on Monday and were told to stop doing showers and whirlpool baths and began doing bed baths, after checking water temperatures with a thermometer. CNA #8 stated reporting of repairs was done by writing on a clipboard in the charting room and needed to include the problem, room or location and the Environmental Director would take it from there, and the Environmental Director or a nurse would notify staff of any issues, problems or needed repairs that would affect the residents.
During an interview on 10/11/2024 at12:03 PM, LPN #11 stated staff were made aware of hot water temperatures on Monday or Tuesday, and bed baths were begun with temperatures being checked with a thermometer. LPN #11 stated anything that involved residents, or the facility would be on the nurse's 24-hour report sheet and the nurse would call or text the information to the Administrator, DON and the Medical Director, and LPN #11 stated the CNAs do not receive the 24-hour report and are notified verbally by the nurse. LPN #11 stated residents are notified if they can understand, if not, families are notified.
During an interview on 10/11/2024 at 2:13 PM, the DON stated she was not notified of the hot water temperatures until Monday, she contacted the Environmental Director and educated staff to begin checking water temperatures before providing bed baths. The DON stated residents were notified of the hot water temperatures, families were not notified and could not provide a reason.
During an interview on 10/14/2024 at 11:51 AM, RN #12 stated the bathroom is used by residents, staff, and visitors and an ambulatory resident may be able to engage the lock. RN #12 stated if a resident fell in the bathroom, hopefully someone would hear them fall and check on them because there is no call light in the bathroom. RN #12 clarified there is no call light next to the toilet in the bathroom and the one on the door would be out of reach if a resident was on the floor near the door.
During an interview on 10/16/2024 at 12:45 PM, CNA #1 stated the problem of hot water was identified when providing a shower to a resident and the water was not turning colder. CNA #1 stated the nurse was notified. CNA #1 could not recall a specific date but was prior to surveyors' arrival.
During an interview on 10/16/2024 at 2:51 PM, the Administrator did not recall being notified of the hot water issues, had a phone tree to notify staff of hazards and risks, but the document was not up to date and was not used for notification of hot water issues. The Administrator then stated on Saturday evening something was said about adjusting water temperatures and was notified on Monday of a maintenance log entry made on Saturday about hot water.
During an observation on 10/16/2024 at 12:34 PM, the surveyor obtained follow-up hot water temperatures in room [ROOM NUMBER] bathroom sink 77 degrees F; room [ROOM NUMBER] bathroom sink 75 degrees F.
During an observation on 10/16/2024 at 12:28 PM, hot water heaters number 1 and 2 were set to 110 F, and number 3 was at 140 F.
During an interview on 10/16/2024 at 3:00 PM, the Administrator stated residents did not normally use the bathroom on the main hall and if they did fall someone would either hear them or would find them if they were missing by calling an elopement. The Administrator stated there was a cord on the back of the main door, up high and it is not low enough for someone to reach if they were on the floor and there was not an emergency call light in the toilet area.
2. A review of the facility's undated new hire paperwork, facility policy titled, Elopement Policy and Procedure, indicated, if the resident is not found after an organized search of the facility the Administrator and Director of Nursing (DON) should be notified and the staff would be directed to notify the authorities/law enforcement to assist.
A review of the admission Record, indicated the facility admitted Resident #49 on 07/25/2024 with diagnoses that included dementia, generalized anxiety disorder, and delusional disorders.
The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/06/2024, revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated the resident was had severe cognitive impairment.
A review of Resident #49's care plan initiated on 07/30/2024 and revised on 08/31/2024, revealed the resident was disoriented to place, had impaired safety awareness, wandering behaviors, a history of elopement from home, and an elopement from the facility on 08/30/2024. Interventions included distraction with structured activities, food, conversation, television, and books. Encourage placement of air tag watch per family. Identify patterns of wandering; purposeful, aimless, or escapist and intervene as appropriate.
A review of Progress Note dated 07/25/2024 at 8:15 PM revealed, Medical Director was contacted when Resident #49 became agitated with exit seeking behaviors and stated they were getting out of here one way or another and that somebody better let them out so they could go home.
A review of Elopement Risk Evaluation dated 07/25/2024 at 8:04 PM revealed, Resident #49 was At Risk of elopement with a score of 4.
A review of Progress Note dated 07/28/2024 at 9:18 PM revealed, Resident #49 opened the emergency door at the 500-Hall, Resident #49 was taken back to her room and administered as needed order of an antipsychotic medication.
A review of Elopement Risk Evaluation dated 08/04/2024 at 9:23 PM revealed Resident #49 was At Risk of elopement with a score of 4. The resident had a history of attempting to leave the facility, verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door, wandered aimlessly or non-goal-directed, and the wandering behavior was like to affect the safety or well-being of the resident or others.
A review of Progress Note dated 08/07/2024 at 7:35 PM revealed Resident #49 was agitated and exhibiting exit seeking behaviors. Resident #49 stated they had to get out, Resident was pushing on exit doors and setting off the alarms as they opened.
A review of Progress Note dated 08/14/2024 at 5:24 PM revealed, Resident #49 was exhibiting exit seeking behaviors. It was stated Resident #49 wouldn't stop pushing on the doors and trying to get outside, the door alarms kept going off.
During an interview on 10/11/2024 at 11:00 AM Licensed Practical Nurse (LPN) # 11 was asked about Resident #49's elopement. LPN # 11 responded which one? LPN # 11 stated there was an elopement on 08/30/2024 where the resident was found in the parking lot, again on 09/19/2024 when Resident #49 went through the first set of doors and was going out the second set on 500-Hall when LPN #11 reached the resident, and an unknown Sunday when Resident #49 walked out the front doors with visitors.
During an interview on 10/11/2024 at 2:10 PM, the Administrator stated he was only aware of one elopement Resident #49 had on 500-Hall and was not aware of Resident #49 walking out the front door with visitors. The Administrator stated the resident was never out of sight of staff. The Administrator stated it was possible the facility staff had failed to report other occurrences. The Administrator stated the cameras were not regularly monitored and the front hallway was unoccupied on the weekends and was not in the line of sight of staff, making a more difficult area to monitor for elopement. The Administrator stated this was not an appropriate facility for Resident #49 and family had been approached about it in care plan meetings. The Administrator stated Resident #49's family was made aware the facility's interventions may not work and Resident #49 may have to be relocated to a facility with a memory care/dementia unit which was more secure.
During an interview on 10/11/2024 at 2:54 PM Certified Nursing Assistant (CNA) #20 stated they had seen Resident #49 go out the 500-Hall doors twice. CNA #20 stated she yelled Resident #49's name, the resident turned and looked, then kept going. CNA #20 stated Resident #49 walked out the front doors on a Sunday and stated it was harder on the weekends to monitor the resident. The front doors were out of sight.
During an interview on 10/15/2024 at 1:30 PM, a facility visitor stated about two months ago when entering the facility, Resident #49 walked out the front doors. In a follow-up interview on 10/16/2024 at 12:58 PM, the visitor stated the resident went to the left when exiting the facility.
During an interview on 10/16/2024 at 12:41 PM, CNA # 1 stated Resident #49 exited the front door of the facility when no one was at the front. CNA #1 exited the facility through the front doors, when the shift ended at approximately 2:30 PM. CNA #1 stated the Administrator was at the door when CNA #1 opened the door and asked if the person outside was Resident #49. CNA #1 stated yes, and the Administrator, and an unknown staff member exited the doors and ran after Resident #49. The unknown staff member reached Resident #49 who was in front of the building, in the grass up by the road. CNA #1 stated the elopement was before public school started, either at the end of July or the beginning of August.
During an interview on 10/15/2024 at 2:17 PM, Resident #49's family member stated they did not want to move Resident #49, but wanted to know why the facility accepted the resident if they could not handle the situation.
3. Review of an untitled, confidential document, located in the risk management history (Incident and Accident [I&A]) of the electronic health record revealed Resident #21 experienced 63 falls from 10/2023 to 10/2024.
A review of the admission Record, indicated the facility admitted Resident #21 with diagnoses that included a decreased blood flow to the brain, convulsions, mental illness, and nerve damage of the extremities.
A review of a revised care plan, dated 01/09/2024, revealed Resident # 21 had unavoidable falls r/t [related to] noncompliance with interventions. Interventions with an initiation date of 01/09/2024 were to continue fall precautions, educate resident on fall precautions, and follow facility protocol for fall precautions. 10/17/2023 non-skid strips were placed in front of toilet; 10/19/2023 signs placed; 10/19/23 non slip pad to w/c; 11/13/23 non-skid strips to bedside 11/21/23 toilet riser removed; 6/21/23 verbal education to staff; 6/5/24 encourage activities in common areas in evenings; 9/11/23 refer to FMP program; 9/11/24 Part B reveal; 9/11/2023 continue interventions on the at-risk plan, 06/21/2023 follow facility PP pertaining to falls; 10/01/24 staff will encourage resident to change into bed clothes after evening meal.
A review of the quarterly MDS with ARD 08/09/2024 revealed Resident #21 had a BIMS of 12, which indicated the resident was moderately cognitively impaired, was independent standing from a seated position, required supervision with toilet transfer and was independent walking 10 feet; and had two or more falls since prior assessment with no injury, and two or more falls with injury.
During an interview on10/07/2024 at 12:09 PM, Resident #21 stated they fell in the bathroom while toileting.
Review of progress note dated 08/28/2024 at 11:47 AM, revealed Resident #21 was found on floor again, with no injury.
Review of progress note dated 09/02/2024 at 2:19 PM, revealed Resident #21 was found on floor in room at 1:45 PM.
Review of progress note dated 09/10/2024 at 1:18 PM, revealed Resident #21 was found on floor at 1:00 PM in front of their recliner, stood up to go to bathroom and fell, there was no injury.
A review of skin evaluation dated 09/10/2024 at 1:32 PM, revealed Resident #21 did not have any skin issues.
A review of progress note dated 09/11/2024 at 2:31 PM, revealed Resident #21 had a bruise to right buttocks related to fall.
A review of Fall Risk Evaluation, dated 09/11/2024 at 7:37 AM, revealed Resident #21 was alert and oriented times 3, ambulatory, incontinent, had adequate vision, balance problems with standing and walking, required assistive device for ambulation, and had 3 or more falls in 3 months.
During an interview on 10/11/2024 at 12:29 PM, LPN #11 stated Resident #21 was a fall risk and had 8 falls in the last year. LPN #11 stated the care plan should reflect the interventions for falls and the Assistant Director of Nursing (ADON) was responsible for updating the care plan and changes were made based on what was triggered in risk management and fall risk assessments. Current interventions included reminding the resident to use the call light, assist every 2 hours to toilet, observe when up and about, encourage participation in activities, monitor for mood, notify of activities, follow facility protocol - which was will have decreased falls, encourage participation in activities, and do frequent checks on the resident. LPN #11 stated it was important to have an accurate care plan and reflect a resident's needs in order to give them the best care and giving them what they need. LPN #11 stated specific interventions implemented included ensuring resident was coming out of their room and sitting and visiting or doing activities.
During an interview on 10/14/2024 at 10:50 AM, the DON stated Resident #21 had greater than 25 falls since November 2023. Care plans were established by the MDS coordinator (ADON) and interventions were added when the facility reviewed falls in the morning meetings. Risk evaluations were completed after each fall on how likely the resident was to fall, medications currently being taken and what interventions the facility could change. The DON stated, We have done everything we can with Resident #21. The DON stated there was no root cause analysis done for why the resident had so many falls and that Resident #21 would get up, made their bed, and went to the bathroom without calling for assistance. The DON revealed that Resident #21 liked attention and would get on the floor and most of the incidents did not result in any injury and she was unaware if the Medical Director had evaluated Resident #21 regarding the falls. The DON stated interventions currently in place were non-skid strips in front of the toilet, non-slip pad in the wheelchair, non-skid strips at bedside, remove the toilet riser, verbal education, encouraged activities in evening, therapy and restorative therapy, and to have staff to assist with bedtime routine after the evening meal. The DON stated it was important for the care plan to be accurate and reflect the residents' needs So that everyone can take the best care of that resident and know to take care of them.
During an interview on 10/14/2024 at 12:14 PM, the ADON stated Resident #21 had 59 falls since November of 2023 and fall risk assessments were done after each one and one was done quarterly and should be accurate to ensure interventions were in place on the care plan, which gives us a chance to better help our residents and staff knows what to do. The ADON stated Resident # 21 was non-compliant with interventions and the Medical Director had said to encourage activities and place resident in common areas to help prevent falls. Interventions that have been effective was a karaoke machine and resident coming out of the room into the common area during shift change.
4. A review of the admission Record, indicated the facility admitted Resident #25 with diagnoses that included a brain disorder causing forgetfulness, limited social skills, impaired thinking abilities; low blood pressure that causes lightheadedness, dizziness, fainting; anxiety disorder; weakness and cataracts.
The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/25/2024, revealed Resident #25 had a Staff Assessment of Mental Status (SAMS) score of 3 which indicated the resident had severe cognitive impairment. Resident #25 required partial to moderate assistance with oral hygiene, shower/bathing, dressing, personal hygiene, sitting to standing, transfer from bed to chair and walking; substantial to maximal assistance with toileting; and supervision or touch assistance with eating.
A review of Resident #25's care plan, with an initiated date of 08/15/2023, revealed Resident #25 had an actual/potential risk for falls related to decreased mobility, impaired vision and decreased safety awareness. Resident #25 experienced falls on 07/08/2023, 06/19/2024, and 09/02/2024 with no injuries reported. Interventions included, educated staff, anticipate and meet needs, follow facility fall protocol and PT (physical therapy) to evaluate and treat as ordered or PRN (as needed) on 08/07/2023, educated staff to assist resident with changing positions and toileting every 2 hours, on 06[TRUNCATED]

2. A review of the admission Record, indicated the facility admitted Resident #10 with diagnoses that included a brain disorder that causes memory loss, language and thinking problems; kidney disease and depression.
The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/26/2024, revealed Resident #10 had a Brief Interview for Mental Status score of 3 which indicated the resident had severe cognitive impairment. Resident #10 required substantial to maximal assistance with dressing, showering/bathing, sitting to lying and lying to sitting, from sitting to standing, transferring from chair to bed and bed to chair; required partial to moderate assistance for personal hygiene and to roll left to right; and required setup/cleanup assistance with oral hygiene and eating.
A review of Resident #10's care plan, revised date of 08/14/2023, revealed the resident had an Activities of Daily Living (ADLs) self-care performance deficit related to muscle wasting and atrophy; and had a moderate risk for falls related to dementia. Interventions included being able to move and turn in bed by self with limited assistance of one staff; be sure call light was in reach; follow fall protocol.
A review of Order Summary Report, revealed Resident #10 had an order for bed rails as an enabler, with a start date of 01/31/2024.
A review of Bed Rail Assessment, dated 10/08/2024 at 3:46 PM, indicated Resident #10 is non ambulatory, level of consciousness fluctuates, has altered safety awareness due to cognitive decline, has no history of falls, has difficulty moving to a sitting position, poor balance, requested side rails and is visually challenged. No interventions were selected, recommendations were bilateral side rail placement to serve as an enabler to promote independence. The assessment was signed by the ADON.
During an observation on 10/07/2024 at 1:35 PM, Resident #10 was in bed, with eyes closed, breathing even, un-rousable with verbal and audible (knocking on door) stimulus. Two-half rails are in the up position, one on each side of the upper half of the resident's bed.
During an interview on 10/14/2024 at 10:23 AM, the Environmental Director stated he does not do assessments, evaluations, or measuring for bed rails, the nurses are responsible for completing those. I just put on the rails they ask for, quarter, half, or whatever. The Environmental Director stated the determination for the bed rails is made based on the bed frame and what rail fits it, no measurements are done. The surveyor requested the manufacturers book or instruction book for installing the bed rails.
During an interview on 10/14/2024 at 10:33 AM, Licensed Practical Nurse (LPN) #24 stated if there is a need for side rails for a resident, or safety issues, the Director of Nursing (DON) or the Assistant Director of Nursing (ADON) would be contacted and do a bed rail assessment. The DON or ADON must approve bedrails and would let Maintenance or housekeeping know to put them on. The rails are care planned. LPN #24 stated they have not done measurements for bedrails and stated it would be done by maintenance or housekeeping.
During an interview on 10/14/2024 at 11:39 AM, the DON stated the rails on Resident # 10's bed are half rails and Resident #10 cannot lower them. The DON stated the rails are used as an enabler to assist Resident #10 with turning and are padded for protection. The DON stated Resident #10 is unable to get out of bed without a lift and prefers to remain in bed. The DON stated the bed rails are placed by maintenance or housekeeping. Nurses are not responsible for assessment and measurements for safety, and maintenance would need to complete those.
During an interview on 10/14/2024 at 2:36 PM, the ADON stated Resident #10 uses the bedrails as enablers to turn and cannot lower the rails alone. The ADON stated if Resident #10 requested the rails, they are not considered a restraint, and I don't think they should be able to lower them. The ADON stated the RAI (Resident Assessment Instrument) is used to complete the MDS and the bedrails are not reflected on Resident #10's MDS in Section P and would only be reflected if used as a restraint. The ADON was asked to review the guidance for Section P in the RAI, and stated the bedrails are considered a restraint for this resident. The ADON stated Resident #10's BIMS score is a 3 and is cognitively impaired. The ADON stated the family was involved in the quarterly assessment, Resident #10 stopped using the overhead triangle for positioning, no restraint release was signed by the family.
On 10/15/2024 at 12:29 PM, the ADON provided a document titled, CMS's RAI Version 3.0 Manual October 2024, Page P-5 and P-6, with P-6 Bed rails used with residents who are immobile highlighted. The ADON stated this applies to the resident, because Resident #10 does not get out of bed. The ADON was asked to clarify immobile, and stated Immobile is that they cannot get out of bed by themselves. On page 6 it says if they are immobile and cannot get out of bed. The ADON was asked why she stated they were used as enablers in an earlier interview and the ADON stated because a CNA will guide Resident #10's hand over to the rail and the resident would be able to turn over. The ADON continued to state Resident #10 was immobile because Resident #10 required 2 staff with a gait belt for transfers and must be assisted by a CNA to sit up.
A review of the document provided by the ADON titled, CMS's RAI Version 3.0 Manual October 2024, Page P-5 and P-6, indicated the use of the restraint and the benefit of the restraint to the resident's medical symptom must be clear, must be documented in the medical record with a physician order and medical symptom being treated. The physician's order alone is not sufficient to employ the use of a physical restraint. CMS will hold the nursing home ultimately accountable for the appropriateness of the determination. Consideration during assessment must be given to the effect of the device on the resident and not the purpose or intent of the use as the effect may be a physical restraint.
During an interview on 10/15/2024 at 1:26 PM, the Head of Hospitality stated any housekeeper would put bedrails on a resident's bed if a nurse requested it. The Head of Hospitality stated they have different sizes of bedrails, and some are welded on. The rails are installed by removing the mattress, placing the grips to the top and bottom of the rail and tightening it with a knob. The mattress is placed back on the bed. The Head of Hospitality stated she had never been taught to take measurements and has never noticed a difference in the way the mattress fits.
During an observation on 10/15/2024 at 2:08 PM, Resident #10 was watching television, two-half rails were in the up position, one on each side of upper half of the resident's bed.
During an interview on 10/15/2024 at 3:12 PM, the Administrator stated there are no policies or procedures for restraints or bed-side rails, and no manufacturer information on installation or use of bedrails.
During an interview on 10/16/2024 at 4:28 PM, CNA #1 stated Resident #10 used the bed rails to pull herself over, and sitting up in the bed for lunch, but gets in pain and asks to lay back down.
Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure assessments, proper bedrail placement and safety precautions for 2 (Resident #1 and Resident #10) of 2 residents reviewed for bedrails. Specifically, at-risk residents were not properly assessed for risks associated with the use of bedrails, and the facility did not perform or maintain documentation of assessments, measurements, or inspections of entrapment zones.
Findings include:
1. A review of the admission Record, indicated the facility admitted Resident #1 on 08/11/2020 with diagnoses that included hemiplegia/hemiparesis, convulsions, restlessness/agitation, psychosis, and delusional disorder.
A review of Resident #1 Order Summary Report revealed, Resident #1 had an order for full bedrails, to enable repositioning in bed, make sure they are up and tightly secured every shift, dated 05/17/2023.
On 10/15/2024 at 3:12 PM, the Administrator stated the facility did not have a policy for side rails/bedrails/full rails, restraints, or a manufacturers booklet for the bedrails.
A review of the document titled, CMS's [Centers for Medicare & Medicaid Services] RAI [Resident Assessment Instrument] Version 3.0 Manual, Page P-5 and Page P-6 provided by the Assistant Director of Nursing (ADON) stated, the use of bedrails even if they improve the resident's bed mobility must be coded by the facility as a restraint, specifically at P0100A. Also noted on Page P-6 was, if the resident is immobile and cannot voluntarily get out of bed because of a physical limitation or because proper assistive devices were not present, the bed rails do not meet the definition of a physical restraint.
The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/29/2024, revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 9 which indicated the resident was had moderate cognitive impairment. Resident #1 was identified on Section GG Question GG 0170 as: A) Roll left and right as partial/moderate assistance defined as helper does less than half the effort, B) Sit to lying as substitutional/maximal assistance defined as helper does more than half the effort, C) Lying sitting on side of bed as substitutional/maximal assistance defined as helper does more than half the effort. Resident #1 bedrails were not identified by the facility in Section P Question P0100A. Physical restraints was defined at the top of Section P as; any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.
A review of Resident #1's Bed Rail Assessment dated 01/31/2024 revealed, question 3 side rail placement identified as bilateral and question 3a as side rails/assist bars are indicated and serve as an enabler to promote independence and the resident expressed a desire to have side rails/assist bars.
A review of Resident #1's Bed Rail Assessment dated 04/01/2024 revealed, question 3, side rail placement as bilateral and question 3a as, side rail/assist bars are indicated and serve as an enabler to promote independence.
A review of Resident #1's Bed Rail Assessment dated 07/10/2024 revealed, question 3, side rail placement identified as bilateral and question 3a as, side rails/assist bars are not indicated at this time.
A review of Resident #1's care plan revised, revealed the resident had a self-care performance deficit related to intercranial injury related to gunshot wound, seizure, muscle spasm, delusions, agitation, psychosis, hemiplegia-affecting dominate side. Interventions for bed mobility included the resident can move/turn in bed independently with the use of full rails.
During an observation on 10/07/2024 at 12:01 PM, Resident #1 was in bed with bilateral upper and lower half side rails up resulting in 2 full rails. Both right side half rails were wrapped in gray pipe insulation for padding. The left lower half rail was wrapped in gray pipe insulation for padding. Resident #1 was observed as mobile and used the bedrails for bed mobility to both pull themselves up in bed and reposition from side to side. An overhead trapeze was also installed on the bed but was not positioned for Resident 1's use.
During an observation on 10/09/2024 at 10:05 AM, Resident #1 was in bed with the right upper half rail up and bilateral lower rails up resulting in a full rail on the right side but only a half rail on the left lower side. Both right side half rails were wrapped in gray pipe insulation for padding. The left lower half rail was wrapped in gray pipe insulation for padding. Resident #1 was observed as mobile and used the bedrails for bed mobility to both pull themselves up in bed and reposition from side to side. An overhead trapeze was also installed on the bed but was not positioned for Resident 1's use.
During a concurrent interview and observation on 10/10/2024 at 2:14 PM, Resident #1 stated, no ability to move their right side but was able to pull and move in the bed with their left side. Resident #1 demonstrated and used bilateral upper rails and right lower rail to move up in the bed and turn side to side. Left lower rail was not utilized.
During an interview on 10/10/2024 at 2:23 PM, Certified Nursing Assistant (CNA) #20 stated Resident #1 used the bedrails for mobility in the bed and to assist during peri-care. Resident #1 was able to turn upon their side to assist the CNA's during care. CNA #20 stated no knowledge of the padding on the bedrails.
During as interview on 10/10/2024 at 2:31 PM, Licensed Practical Nurse (LPN) #6 stated Resident #1 rails were up so the resident could move in the bed, but did not know why the rails were padded, LPN #6 assumed for safety.
During an interview on 10/14/2024 at 10:23 AM, the Environmental Director stated bedrails are placed on the bed after nursing request them. The determination of the type quarter, half, or whatever is based on what will fit on the bed frame and no measurements are done.
During an interview on 10/14/2024 at 11:39 AM, the Director of Nursing (DON) stated, half rails are used as enablers to promote resident turning. The Environmental Director or Head of Hospitality would install bedrails. The DON was unaware who did assessments or measurements for bedrail safety and assumed the Environmental Director did.
During an interview on 10/15/2024 at 1:11 PM, Registered Nurse (RN) #12 stated, Resident #1 used the bedrails as an enabler to pull up in bed. RN #12 stated, yes, 4 half rails up (2 full rails) is still a restraint. RN #12 stated employment since 2017 and doesn't remember any previous interventions for Resident #1.
During an interview on 10/15/2024 at 1:26 PM, the Head of Hospitality stated the facility process was any housekeeper could place bedrails on a resident's bed if nursing had made the decision. The Head of Hospitality stated the only bedrails available are the ones which fit on the facility's beds. Once the resident was out of the bed the mattress was removed and the bedrail gripped to the top and bottom of the rail and tightened with a knob. The Head of Hospitality stated they have never been taught to do any types of measurements for bedrails.
During an interview on 10/15/2024 at 1:31 PM, the ADON stated Resident #1's annual or quarterly assessments do not identify bedrails under restraints because it's not required for enablers for bed mobility. The ADON stated the discrepancy on the 01/31/2024,04/01/2024, and 07/10/2024 was Bed Rail Assessments were just an error, and nothing has changed with the resident. The ADON also stated the resident was immobile and bed rails do not need to be identified on the assessment. The ADON stated, even though Resident #1 used all 4 attached bedrails for bed mobility since Resident #1 cannot get out of bed without a mechanical lift the resident was immobile. The ADON stated, yes, Resident #1 was being identified as both immobile and requiring bed rails for independent bed mobility.

Based on observations and interviews, it was determined that the facility failed to answer call bells/lights within a timely manner for 2 of 2 residents (Resident #36, and Resident #18), and the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain each resident's highest practicability.
Findings Include:
During the Resident Council Meeting on 10/10/2024 at 2:17 PM, Resident #18 and Resident #36 reported that it takes the Certified Nursing Assistants a long time to answer the call bells that were given to them. Resident #18 reported that especially right now the call bells were not being answered, the staff reports to them they can't hear them. Resident #18 stated they rang the bell for 45 minutes no one responded, so Resident #18 started yelling and was finally able to get help. Resident #36 said it takes a long time for the staff to answer the bells as well, unsure of exact time but it's a long time.
On 10/15/2024 at 02:22 PM, during an interview with Resident #18 it was revealed that the Certified Nursing Assistants (CNA) were still not answering the ringing bells in a timely manner, it took them 30 minutes to answer the bell just prior to going to the dining room. The CNA responded then left and then didn't return to them for another 15 minutes.
On 10/15/24 at 02:28 PM, during an interview Resident #36 revealed that it is taking about 20-30 minutes. Staff state they will come back, but they don't.
On 10/16/24 at 12:05 PM, during an interview with CNA #15 was completed and CNA #15 reported that call lights are answered as soon as they are seen. CNA #15 reports that a call light should not go off more than 5 to 10 minutes. Reported that if CNA #15 cannot do what is being asked, they will tell them they are going to get help or tell the resident they will be right back and will go right back to the resident. An acceptable time to wait for a resident that needs to go to the bathroom is 10 minutes.
On 10/16/24 at 12:16 PM, during an interview CNA #16 reported that call lights/bells should be answered immediately. Revealed that If CNA #16 hears the bell then it is answered. CNA #16 reports that if they are unable to address what the resident is needing at that moment, they tell them they will be back, but has never had to do so. There is always staff to answer the bells or call lights.
Based on observation, interview, and record review the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain each resident's highest practicability.
The findings include:
During an interview on 10/10/2024 at 9:34 AM, Licensed Practical Nurse (LPN) #24 stated that due to insufficient staffing, particularly on the 2:00 PM to 10:00 PM shift, Resident #49 had eloped from the facility on numerous occasions. LPN #24 stated that certified nursing assistant competencies were not completed, and the certified nursing assistant staff did not have knowledge while working with dementia residents.
Review of the facility provided, Nurse Aides Skills Yearly Reviews, revealed certified nursing assistants signed off on skills verifying they were competent in the skill set. Several forms were not completed in their entirety, several skills remained unverified including dementia care and activities of daily living such as brushing teeth.
During an interview on 10/11/2024 at 9:00 AM, the Human Resource Director stated that competencies were reviewed upon hiring and that a skills carnival had been scheduled for the facility staff. The Human Resource Director denied knowing why the competency skill sets were not fully completed.
During an interview on 10/16/2024 at 3:00 PM, Certified Nursing Assistant (CNA) #1 stated that she felt sort of competent when providing care to residents within the facility. CNA #1 denied knowing when her skill competency was evaluated or by whom. She stated that some residents had to wait for long periods of time for assistance when staff were assisting others as there is one certified nursing assistant per hall with a float certified nursing assistant that works between halls.
During an interview on 10/14/2024 at 11:00 AM, the Director of Nursing (DON) stated the certified nursing staff and nursing staff demonstrated competency by completing the items on the skill competency list. The DON stated there was no way to verify if the certified nursing aids or nursing staff were competent in a skill if the skill was not verified and marked as completed. The DON stated she did not know what to say regarding staff competencies when the forms were not completed.
During an interview on 10/14/2023 at 12:03 PM, the Administrator stated the certification of the nursing staff provides initial competency. The Administrator stated competencies should be maintained, reviewed, and renewed yearly. The Administrator denied having a system in place to verify staff competency. The Administrator stated that having one aid per hall with a float aid in-between halls is not ideal as some residents would have to wait long periods of time for care.

Based on observation, interview, and record review, the facility failed to have nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain each resident's highest practicability.
The findings include:
During an interview on 10/10/2024 at 9:34 AM, Licensed Practical Nurse (LPN) #24 stated that the certified nursing assistant competencies were not completed, and the certified nursing assistant staff did not have knowledge while working with dementia residents.
Review of the facility provided, undated, Nurse Aides Skills Yearly Review, forms revealed that certified nursing assistants signed off on skills verifying they were competent in the skill set. Several forms were not completed in their entirety, several skills remained unverified, including dementia care and activities of daily living, such as brushing teeth.
During an interview on 10/11/2024 at 9:00 AM, the Human Resource Director stated that competencies were reviewed upon hiring and that a skills carnival had been scheduled for the facility staff. The Human Resource Director denied knowing why the competency skill sets were not fully completed.
During an interview on 10/16/2024 at 3:00 PM, Certified Nursing Assistant (CNA) #1 stated that she felt sort of competent when providing care to the residents within the facility. CNA #1 denied knowing when her skill competency was evaluated or by whom.
During an interview on 10/14/2024 at 11:00 AM, the Director of Nursing (DON) stated the certified nursing staff and nursing staff demonstrated competency by completing the items on the skill competency list. The DON stated there was no way to verify if the certified nursing aids or nursing staff were competent in a skill if the skill was not verified and marked as completed. The DON stated she did not know what to say regarding staff competencies when the forms were not completed.
During an interview on 10/14/2023 at 12:03 PM, the Administrator stated the certification of the nursing staff provides initial competency. The Administrator stated competencies should be maintained, reviewed, and renewed yearly. The Administrator denied having a system in place to verify staff competency.

Based on observation, interview, and record review, the facility failed to post nurse staffing information, including but not limited to: facility name, the current date, resident census, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: A) registered nurses, B) licensed practical nurses, C) certified nursing assistants.
The findings include:
A review of the facility Daily Staffing Log, dated 10/10/2024 for the day shift employees, listed 1 registered nurse, and 4 certified nursing assistants.
A review of the facility Daily Staffing Log, dated 10/10/2024 for evening shift employees, listed 3 certified nursing assistants.
During a concurrent observation and interview on 10/11/2024 at 11:00 AM, the Director of Nursing (DON) stated that the Daily Staffing Log is how employee staffing is accounted for. The DON denied staffing information being located anywhere else.
During an interview on 10/14/2024 at 11:27 AM, the Administrator stated that the staffing is kept at the nurse's station. The Administrator stated that some staff will sign the staffing sheet at the nurse's station, while other staff members will do a verbal check-in at the beginning of their shift. The Administrator denied having any staff posting that included the facility name, consistent dating with current date, resident census, or total number and actual hours of licensed and unlicensed nursing staff directly responsible for resident care per shift.

Based on observations, interviews, facility document review, and facility policy review, it was determined that the facility failed to prepare and serve food in a way to reduce food borne illnesses and ensure dishes were washed and stored in a sanitary manner with the potential to effect 48 residents served from the 1 of 1 kitchen reviewed for food preparation and service. Specifically, the facility left uncooked breaded chicken strips uncovered sitting on top of the commercial oven for one hour and fifteen minutes, failed to perform and maintain good hand hygiene during food service and preparation, failed to maintain safe food temperatures for pureed foods during preparation time, did not use soap/detergent to wash utensils during food preparation and allow for proper sanitation time, or store the ice scoop in a clean, dry container.
Findings include:
A review of a facility policy titled, Self Survey Module revised in September of 2007 stated, the intent was to prevent food borne illnesses and reduce practices that result in food contamination and compromised food safety to all residents. These practices included, foods should be covered until served, hot foods maintained at 140°F or above, hands should be washed before and after handling food, manual dishwashing should include correct submersion time in the chemical sanitizer.
A review of the facility's undated policy titled, Handwashing Policy and Procedure stated, rinse hands in running warm water, apply soap or alternate cleaning compounds, rub together vigorously for 20 seconds, rinse thoroughly from forearms down with clean warm water, and immediately dry hands.
During an observation on 10/07/2024 at 10:55 AM, eleven breaded chicken strips were laying on a cooking sheet uncovered. The cooking sheet was sitting on top of the counter-height free standing double-doored oven. The oven was turned on at 350° Fahrenheit (F) and was warming the bottom of the cooking sheet.
During an interview on 10/07/2024 at 11:15 AM, the Kitchen Manager (KM) stated, the breaded chicken strips had been out on the cooking sheet since 10:00 AM. Calculation revealed the breaded chicken strips were sitting out at room temperature for one hour and fifteen minutes. The KM stated sometimes they leave food there prior to cooking and the breaded chicken strips were not cooked. The KM temped them and stated she was not going to cook them now.
On 10/07/2024, observations of the lunch service line revealed; 12:29 PM, the KM left the serving line opened the reach-in cooler with her gloves on and retrieved a bowl for a resident tray then returned to the service line and plated food without a glove change or performing hand hygiene. At 12:35 PM, the KM left the line and made oatmeal for a resident then returned to plating food without a glove change or performing hand hygiene. At 12:40 PM, the KM reached on a lower shelf of a cart and retrieved a tray of bowls. She then picked up the bowls from the underneath side with contaminated gloves and sat the underneath side of the bowls directly on the plates and continued to add ham and squash to the plates. At 12:46 PM, the KM left the line and removed her gloves and performed hand hygiene for the first time since starting lunch service.
During an interview on 10/07/2027 at 1:15 PM, the KM stated, glove change and hand hygiene should have been performed prior to serving food after leaving the service line and touching the cooler and supplies.
During an observation on 10/10/2024 at 10:42 AM, [NAME] #23 pureed lunch then covered the pureed sweet potatoes, pureed pork loin, and pureed carrots with foil and set them in a container at room temperature and not on the steam table.
A review of the quantified recipe 760 for pureed Herbed Pork Loin stated, follow hot holding temperature of 135°F-140°F based on facility policy.
During a concurrent observation and interview on 10/10/2024 at 11:30 AM, [NAME] #23 went to place the covered pureed food on the stem table. Upon request, the KM temped the pureed food at pork loin 81.7°F, sweet potatoes 78°F, carrots 87.6°F. [NAME] #23 stated they always did it that way and it should be fine since it was just made. The KM stated all foods had entered the danger zone and would have to be remade. The KM pointed to a posted sign and stated the danger zone for food was less than 140°F for hot foods and greater than 40°F for cold foods.
During an observation on 10/10/2024 at 10:42 AM, [NAME] #23 sprayed off the food processor bowl, processor blades, processor lid, and spatula with hot water after pureeing sweet potatoes. The items were then dipped in the third compartment of the sink which contained sanitizer for less than five seconds and immediately returned to the food processor base for use in pureed pork loin preparation. No soap/detergent was used to wash the items. No hand hygiene was performed by [NAME] #23 after cleaning the bowl and utensils and prior to cooking preparation.
During an interview on 10/10/2024 at 11:10 AM, [NAME] #23 stated, spraying off the dishes and dipping them in sanitizer is how they always did the hand dishes, and no soap/detergent was necessary for this because of the chemical sanitizer. [NAME] #23 stated maybe hand hygiene should be performed from dirty to clean task, but it wasn't really necessary since their hands were in the sanitizer when the dishes were dipped.
During an interview on 10/10/2024 at 3:00 PM, Dietary Manager (DM) #14 stated [NAME] #23 was trained in the kitchen. DM #14 indicated, food in the danger zone temp should not be served to residents and hand hygiene should performed when moving from a dirty to clean task. DM #14 stated spraying and sanitizing was the facility's process for the food processor items because they were not allowed in the dishwasher, eighteen seconds was the correct sanitizing time for those items.
A review of the undated commercial food processor's cleaning and sanitizing instructions for food service application indicated, remove container from base and rinse container and lid, add washing solution to container scrub and flush, repeat using clean rinse water in place of washing solution. Washing solution based on non-sudsing detergents are recommended. No warning against dishwasher use was given.
During a concurrent observation and interview on 10/7/2024 at 12:00 PM, Kitchen Aide #22 was observed opening the ice machine, grabbing a scope that was in the ice, filling the scoop with ice and transferring the ice to a pitcher. Kitchen Aide #22 stated the ice in the pitcher would be used in serving the residents' beverages during lunch service. Kitchen Aide #22 stated that the ice scoop was always left in the ice machine.
During an observation on 10/7/2024 at 12:15 PM, Nursing Assistant (NA) #13 opened the ice machine, used the ice scoop to get a few pieces of ice, and then put the ice in a resident's drinking glass. Nursing Assistant #13 then returned the ice scoop to the ice machine.
During a concurrent observation and interview on 10/7/2024 at 12:30 PM, Certified Nursing Assistant (CNA) #9 opened the ice machine, used the ice scoop to get a few pieces of ice and put the ice in a resident's drinking glass, then return the ice scoop to the ice machine. CNA #9 stated the ice scoop should not be kept in the ice machine due to risk of contamination.
During a concurrent observation and interview on 10/10/2024 at 9:44 AM, the Kitchen Manager stated that the ice scoop could be kept in the ice machine because the ice machine was a self-sanitizing machine.
During a review of the facility provided ice machine instruction manual the ice scoop is the most often source of contamination.
During an interview on 10/15/2024 at 5:13 PM, the Kitchen Manager stated that Dietary Manager #14 verified with the ice machine company and the ice scoop should not be kept in the ice machine due to contamination. The Kitchen Manager stated Dietary Manager #14 was working to have an ice scoop holder installed but no written documentation of the ice scoop holder purchase could be provided.

Based on observation, interview, and record review, the facility did not dispose of garbage or refuse properly.
The findings include:
An observation on 10/7/2024 at 6:59 PM, showed garbage spilt around facility dumpster behind the facility.
An observation on 10/8/2024 at 8:32 AM, showed garbage spilt around the facility dumpster behind the facility.
During a telephone interview on 10/10/2024 at 9:34 AM, Licensed Practical Nurse (LPN) #24 stated that garbage often piles up in and around the facility dumpster as the facility often lacks the resources to pay the garbage company to empty the dumpster.
During a telephone interview on 10/11/2024 at 1:16 PM, the waste disposable company stated the facilities account had been locked numerous times for failure to pay. The waste management company stated that if an account goes 30 days past due the account would be locked, and the facility dumpster would not be emptied. The waste disposable company stated that the facilities account had been locked approximately 4 times in the past 6 months due to failure to pay.
During an interview on 10/14/2024 at 10:59 AM, the Environmental Director stated that the previous garage company had picked up the garbage around the facility dumpster. The Environmental Director stated that when the new company took over the facilities waste management, the Environmental Director assumed the new company would also pick up the garbage around the facility dumpster. The Environmental Director stated that the facility would be looking into changing the facilities waste management account to a different waste management company. The Environmental Director stated that the garbage that is not properly disposed of posed a risk of attracting pests and rodents to the facility.
During an interview on 10/14/2024 at 11:27 AM, the
Administrator stated that the facility was looking into changing waste management companies. The Administrator was unable to provide documentation of quotes or estimates from different waste management companies. The Administrator stated that the garbage that was not properly disposed of posed a risk of attracting pests and rodents to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, document review, and interviews, the administration failed to provide training and oversight to ensure the facility was free from the potential for injury related to identified concerns regarding elevated hot water temperatures. During the survey, the survey team identified hot water temperatures throughout all residential units / wings of the facility. Temperatures were found to be as high as 151 degrees Fahrenheit (F) in resident bathroom sinks, as well as resident shower rooms. Furthermore, the facility failed to ensure call light system was effectively working for 200 and 300 halls; and failed to implement an emergency backup system. The facility also failed to ensure a resident was free from physical abuse for 1 resident, Resident #21, who was heard yelling out at the contract lab technician to not draw the resident's blood. CNA #1 physically restrained Resident #21 while the resident's blood was drawn. These failures all resulted in Immediate Jeopardy for F600, F689, and F919.
This failed practice resulted in Resident #18 and #20 complaining of being burned by the hot water on 10/07/2024 and 10/04/2024. Resident #30 indicated they were scared to use the water in their bathroom since February 2024 due to the hot water temperature. Resident #21 complained of water in their bathroom being too hot to use. Lack of an effective call light system has resulted in residents having to call out for assistance and or have a delay in assistance resulting in care not being received. Resident #21 reported a fear of needles, feeling terrible after the incident, and due to psychosocial harm, refused to take a shower today. Resident #21 was visibly upset as evidence by writhing hands, rubbing legs, and wiping tears from his/her cheek. The Administrator was notified of the IJ on 10/11/2024 at 11:51 AM. Before ending the survey, the survey team offered the facility the opportunity to provide a plan to remove the Immediate Jeopardy and ensure serious harm would not occur or recur. An Immediate Jeopardy removal plan must include all the actions the facility has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely. The State Agency accepted a plan of removal on 10/13/2024 at 1:07 PM. The IJ was not removed prior to the exit from the facility on 10/16/2024 at 6:00 PM
The findings include:
A review of Administrator's job description revealed that they were responsible for managing and directing day to day operations for the facility in an effective and efficient manner.
On 10/06/2024 at 6:00 AM shift change, when night shift staff notified day shift staff that the call lights were not working. Administrator and was notified and Administrator reported that he did not have a backup plan and attempted to call other nursing homes and was unable to borrow any bells. A review of an online shopping platform invoice, dated 10/06/2024, indicated the facility ordered 3 Jingle Bells, 24 wrist band jingle bells, 12 musical instruments, and 50 hand bells. A review of an invoice from (Business Name), dated 10/08/2024 indicated an order for a Central Unit NC 110/150/200. A hand notation at the bottom of the invoice indicated Call light part. On 10/9/2024 hand and wrist bells came in and were distributed to the residents. On 10/15/2024 (Business Name) arrived at facility and call light system was repaired.
On 10/6/2024 it was observed by surveyors that the water temperatures coming from residents' bathrooms and common areas were extremely hot. Temperatures were observed with a staff member obtaining temperatures as high as 151 F in resident bathroom faucet. Report of Resident #18 and Resident #20 sustaining burns from hot water. A review of maintenance log dated 10/5/2024 had revealed an entry that indicated the bathroom water in room [ROOM NUMBER] gets too hot.
During an observation on 10/07/2024 at 1:24 PM, revealed a white paper with all capital, black letters, hanging in the shower room, that indicated, Caution: do not turn on straight hot water. you must adjust the temperature with cold water to prevent burns.
On 10/07/2024 at 5:15 PM , the Environmental Director stated the last time the mixing valve was adjusted was on Tuesday (10/01/2024) due to a CNA reporting there was no hot water to provide a shower, so the mixing valve was adjusted. The Environmental Director stated changes were not documented and was not aware changes needed to be documented. Also reported that mixing valve for hot water heater has problems getting it to work. 10/07/2024 after 6:01 PM on shower room doors that residents are not to receive showers/baths. Photos taken by surveyor. Signs were posted at 6:23PM. DON stated signs were posted because the facility was told they could not give showers until further notice. DON is unsure of why but thinks the temps were too high. No in-services were conducted.
On 10/07/2024 at 1:52 PM, when Resident #21 was heard by yelling, crying, and begging, from room [ROOM NUMBER], by surveyor and facility staff. A surveyor and a facility staff member entered room [ROOM NUMBER] and observed a contracted laboratory technician standing next to Resident #21 drawing blood despite Resident #21 stating no. DON/Administrator was notified. On 10/08/2024 the contracted laboratory technician returned and had contact with seven residents. During an interview with a surveyor on 10/14/2024 at 10:10 AM, the Administrator stated the first incident of abuse was reported to the State Agency on 10/08/2024 at 10:54 AM but should have been reported 2 hours after the notification to them was made. The Administrator stated a pre-investigation was being done to see if there was a miscommunication to do a soft file, but there was no miscommunication.
On 10/14/2024 at 2:51 PM, an interview with Administrator was completed and it revealed that there was no sitting administrator upon hire of the current Administrator. So, the Administrator felt like they were self-trained. The Administrator revealed that they educate themselves by googling it, phoning a friend, consult with the Interdisciplinary team, and looking at regulations. The Administrator stated the facility did not have any consultants and felt like the administrator needed more training. The Administrator stated the facility had a person that comes in on weekends and assists the administrator in areas that they are lacking in knowledge about. The Administrator stated the person was not a consultant but was just a friend from the industry. The Administrator reported that he just found out about the State Operations Manual Appendix PP within the last week. The Administrator stated he reviewed PP over the weekend to update himself on the regulations and felt it would increase their knowledge.
Removal Plan:
On 10/11/2024, upon notification of deficient practice of administration failing to perform education and training to ensure the facility was free from the potential for injury the facility completed the following:
On 10/11/2024 at approximately 2:00 PM, the Board President and Medical Director met with DON and administrator to complete the following:
Full review of job descriptions and expectations
Full review of expectations of administration as held by the board of directors
Education on regulations regarding reporting abuse and neglect allegations
Education on ensuring emergency backup planning in the event of system failures such as call light systems.
Education on follow up regarding tasks performed by interdisciplinary teams.
This review and education will be placed on and reviewed at next board meeting currently scheduled for 10/16/2024 at 7:00 AM.
Administrator/Designee will monitor resident areas for potential for injury through rounding twice daily and documentation five times per week for 8 weeks or until compliance is confirmed and verified with OLTC. Any negative findings will be reported to Admin, DON and Board President.
Onsite Verification:
The IJ was removed on 11/07/2024 at 12:00 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on 10/11/2024 when the Board of Directors President and the Medical Director met with the Director of Nursing and Administrator to review their job descriptions and expectations. The Board of Directors reviewed the DON and Administrators job descriptions and expectations, federal regulations were reviewed for reporting abuse and neglect allegations, education on the need for emergency backup systems in the event of failures, education on the follow-up regarding task assigned to the interdisciplinary team. A total of five staff interviews were conducted with staff to verify training had been completed. The staff interviewed included Head of Hospitality, Environmental Service Director, Assistant Director of Nursing, Director of Nurse and the Administrator. The staff interviewed verified they had been trained on follow-up of interdisciplinary task, emergency backup plans, reporting of abuse and neglect, job expectations. A review of in-service sheets provided indicated the Director of Nursing and the Administrator had received education on job duties and Board of Directors expectations.

Based on observation, interview, and record review, the facility failed to operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility
The findings include:
Review of Resident #23 Medical Diagnosis, reported the resident had diagnoses to include: multiple sclerosis, weakness, other motor neuron disease, a condition that causes sudden and uncontrollable laughing or crying, wheelchair dependence, dementia, anxiety, insomnia, and depression.
A review of Resident #23's Order Summary Report on 10/9/2024 at 3:00 PM, reported THC Gummies 25mg 1 gummy every 2 hours as needed, not to exceed 5 gummies in 24 hours verbal order per Medical Director order dated 9/2/2024. Previous orders include 15 mg/1000 mg may have 1-2 gummies every 2 hours as needed up to 10 per day on 8/11/24. THC gummies 600mg THC/15 mg delta may have two gummies each shift if 25 mg not available, every 8 hours for pain/anxiety, not to exceed 6 gummies per day on 8/1/24.
During a concurrent observation and interview on 10/9/2024 at 3:30 PM, THC gummies were observed in Licensed Practical Nurse (LPN) #6's medicine cart. LPN #6 stated that the THC gummies belonged to Resident #23. LPN #6 stated that the THC gummies are counted each shift, such as one would a narcotic. LPN #6 stated that at times the bag of THC gummies indicates there are 20 individual gummies per bag but upon opening bag less than 20 THC gummies are counted. LPN #6 stated that two nurses log the THC gummies in the narcotic book and correct the count.
During a telephone interview on 10/9/2024 at 4:41 PM, the Medical Director stated that Resident #23 had an active state medical marijuana card, and that Resident #23's healthcare proxy procures the THC gummies for Resident #23. The Medical Director stated that Resident #23 uses the THC gummies for anxiety and pain relief. The Medical Director denied any knowledge of how Resident #23's healthcare proxy obtained the THC gummies. The Medical Director stated that orders for the THC gummies are provided based on the facilities communication of what the concentration of the THC gummies Resident #23's healthcare proxy was able to obtain. The Medical Director stated the order for Resident #23's THC gummies were titrated based off reported pain and/or anxiety levels. The Medical Director denied being aware of what signs or symptoms the facility staff should monitor for. The Medical Director stated Resident #23 knows when the THC gummies are needed. The Medical Director stated that due to no FDA (Federal Drug Administration) oversight, no set dosing recommendations or guidelines were available for THC gummies. The Medical Director denied having licensure to prescribe medical marijuana, THC gummies, or fill out paperwork related to medical marijuana due to working for federally funded facility where Resident #23 resides.
During a telephone interview on 10/10/2024 at 8:57 AM, Resident #23's healthcare proxy stated that the THC gummies were procured from the manufacturer in [two nearby states], either through direct pick up or mail delivery. Resident #23's healthcare proxy stated the bags of THC gummies were brought into the nursing facility and handed to the nursing staff. Resident #23's healthcare proxy stated that the dosage provided to Resident #23 was determined by the Medical Director. Resident #23's healthcare proxy stated that while Resident #23 did have a medical marijuana card, the card was only active for [State]. Resident #23's healthcare proxy denied having caregiver marijuana card. Resident #23's healthcare proxy stated that it was not necessary to have a medical marijuana card for states of [two nearby states].
During a telephone interview on 10/10/2024 at 9:34 AM, Licensed Practical Nurse (LPN) #24 stated Resident #23's healthcare proxy brought the THC gummies to the facility. LPN #24 stated no training was provided, either by administration or the Medical Director, with regards to administering the THC gummies or the monitoring of side effects. LPN #24 stated that the nursing staff looked up THC gummy administration information on the search engines. LPN #24 denied knowing if the THC gummies were on Resident #23's care plan or minimum data set. LPN #24 stated that Resident #23 requested the THC gummies when the resident received narcotic medications during medication pass.
During an interview on 10/14/2024 at 11:27 AM, the Director of Nursing (DON) stated that no formal education had been provided to the staff concerning administration or monitoring of the THC gummies.
During an interview on 10/14/2024 at 11:30 AM, the Administrator stated that no formal education had been provided to the staff concerning the administration or monitoring of the THC gummies. The Administrator denied knowledge of how the THC gummies were obtained. The Administrator stated that the Medical Director prescribed the THC gummies. The Administrator denied knowledge of what class or schedule of medication the Medical Director was licensed to prescribe. The Administrator stated that the THC gummies that were within the facility for Resident #23 were removed from the facility and returned to the healthcare proxy.

Based on interviews, record review, and facility policy review, it was determined the facility's Governing Body failed to ensure facility policies were implemented regarding management and operation of the facility. The Governing Body failed to ensure compliance with Freedom from Abuse, Neglect, and Exploitation during Survey. Immediate Jeopardy and Substandard Quality of Care (SQC) was cited at F600 at a S/S of a J. Additionally, Administration, F835 was cited at a S/S of a J; Quality Assurance and Quality Improvement, F867 was cited at a S/S of a J. Resident Call Systems, F919 was cited at a S/S of K. Supervision to Prevent Accidents, F689 was cited at a S/S of K.
It was determined the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.70 - Administration at a scope and severity of L. The Administrator was notified of the IJ on 10/11/2024 11:51 AM. Before ending the survey, the survey team offered the facility the opportunity to provide a plan to remove the Immediate Jeopardy and ensure serious harm would not occur or recur. An Immediate Jeopardy removal plan must include all the actions the facility has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely. The State Agency accepted a plan of removal on 10/14/2024 at 7:51 AM. The IJ was not removed prior to the exit from the facility on 10/16/2024 at 6:00 PM
The findings include:
On 10/11/2024 at 10:45 AM, the Administrator stated the facility did not have a governing body policy. A review of a document titled, Meadowview Healthcare and Rehab Board Members documented members as the Board President, Governing Body Member (GBM) #13, GBM #18 and GMB #19.
On 10/12/2024 at 2:51 PM, an interview with the Administrator revealed that the facility was a non-profit facility and did not have a governing body, but they had a Board of Directors that met once a month. The Administrator and the Board of Directors go over the current census, bank account balances, and from May to August 2024 their Medicaid funds were cut off due to not receiving non-profit paperwork. The Administrator reported to Surveyor that they request from the Board of Directors things such as trainings, to have consultants come in and assist the Administrator, update policies/procedures and the requests are always denied. The Administrator reports that the Board of Directors reply with that there is no reason to change or update anything due to the way things are handled have been the same way for a long time. The Administrator reported that anytime he asks the Board of Directors for anything, the Administrator does not get it. The Board of Directors will be identified as the Governing Body.
On 10/15/2024 at 3:07 PM, a telephone interview with survey team with Governing Body Member (GBM) #13 revealed that the governing board met monthly. But GBM #13 did not attend the meeting in September and then revealed that they have not been to a meeting in a couple of months. It was revealed that there were four board members. GMB #13 reported that there had been some financial problems, but they were addressed and fixed. No further financial problems that GBM #13 was aware of. GBM #13 revealed that resident funds had not been addressed with the governing body. GBM #13 was not aware of the call lights being out or that the hot water burnt a resident. GBM #13 reported that GBM #13 had not had a recent meeting with the governing board since state surveyors had been in the building. The GBM #13 disclosed that they had worked on roof damage and few other building issues. GBM #13 reported that they were not aware of a pest problem or trash problem. Also, as far as GBM #13 knowledge, the Administrator had not asked for any trainings, or any other items related to training assistance.
During an interview on 10/15/2024 at 3:28 PM, he Board President stated the board met monthly at the nursing facility. There are four board members, and the administrator was present during the meetings, and sometimes the Director of Nursing (DON) is present. The Board President revealed that they are short a member at this time. They have tried finding another member but have not been successful. The Board President revealed that they did not receive Medicaid funds from March to August due being frozen because they had to get all the paperwork submitted proving they were non-profit. They were unable to do so themselves, so they hired some Certified Payroll Accountants to assist them with the process. Also, the Board President revealed that the facility had to terminate a staff member that worked for the facility for using the facility credit cards and checks. The staff member was let go in February. It was reported that the board was aware of the pest problem and the administrator was told to fix it and the board members were under the assumption that it was taken care of. They were not aware that there continued to be a problem. The Board President revealed that the board was aware of the trash problem, revealed that the company that they were using was not picking up the trash routinely and the Administrator had changed companies to resolve the problem. They were not aware that there was an ongoing problem. The Board President reported that the Administrator had not asked for any more training. The board had provided a consultant to help the Administrator, but unsure of when or what the consultant helped with. The board was not aware of the federal rules and regulations for the nursing home. The board also did not review the bank statements or any financial papers of the nursing facility.
On 10/16/2024 at 2:38 PM, an interview with the Administrator revealed that the governing body met that morning at 7:00 AM. The Administrator revealed that the governing body and himself realized there was a systemic failure and criteria for the nursing facility had not changed in thirty years. The Administrator stated federal rules and regulations were reviewed at the meeting.
Removal Plan:
On 10/11/2024, upon notification of deficient practice of ensuring a governing bodies implementation of policy and procedure regarding management and operations of facility the facility completed the following:
On 10/11/2024 at approximately 2:00 PM, immediate board members- Board President and Physician- met with Administrator and Director of Nursing (DON). Review of current facility bylaws- such as Interdisciplinary team job descriptions and general day to day policy and operations- occurred.
Board president and Physician reviewed job descriptions and expectations with Administrator and DON at this time. Board of directors to review and implement policy and procedures regarding management, operations and implementation of further policies.
Additional policies- such as assignment and allocation to additional over viewers, appointment of additional board members, and expectations of the sitting board- to be reviewed and further discussed at scheduled board meeting currently scheduled for 10/16/2024 at 7:00 AM. Review and further implementation to be documented in board meeting minutes.
Administrator/Designee will monitor implementation of board policy and procedures 2 times weekly through review and documentation with report to be provided to board president weekly on Fridays before end of business day for 8 weeks or until compliance is confirmed and verified with OLTC.
All corrections were completed on 10/11/2024.
Onsite Verification:
The IJ was removed on 11/07/2024 at 12:00 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on 10/11/2024 at 2:00 PM when the Board of Directors President, Medical Director, Director of Nursing, and Administrator met to review the facility ' s current by-laws for interdisciplinary team job descriptions, and the facility ' s general day to day policy and operations. The Board of Directors President, Medical Director, Director of Nursing, and Administrator met to review the facility ' s current by-laws for interdisciplinary team job descriptions, and the facility ' s general day to day policy and operations, Director of Nursing and Administrator job descriptions and expectations were reviewed, new board members were appointed and assignments were allocated, by-laws were updated, and the Administrator monitored new implementations and reported to the Board of Directors President every Friday. A total of 2 staff interviews were conducted to verify training had been completed. The staff interviewed included the Director of Nursing and the Administrator. The staff interviewed verified they had been trained on new bylaws, job descriptions, and expectations of the board. A review of in-service sheets provided indicated both had been provided training.

Based on document review and interviews, the facility failed to ensure the facility assessment included pertinent information to assure the necessary care and resources were allocated to meet the needs of the residents. This deficient practice had the potential to affect all residents of the facility. The total census was 48 residents.
The findings are:
Upon request for a Facility Assessment policy on 10/15/2024 at 10:55 AM, the surveyor was informed that the facility did not have a policy.
A review of the facility's Facility Assessment Tool revealed a typed date at the bottom of the pages of 09/05/2024.
The facility-wide assessment did not include the following:
-Date of assessment or update
-Date of assessment reviewed with QAA/QAPI committee
- Name of the administrator
- Accurate acuity levels to help the facility understand the potential implications regarding the intensity of care and services needed
- Review of staff assignments for coordination and continuity of care
- Staffing plan to evaluate the overall number of facility staff needed to ensure available and sufficient number of qualified staff are available to meet each resident's needs based on the facility census
- Competency-based approach to determine the knowledge and skills required among staff to ensure residents are able to maintain or attain their highest practicable physical, functional, mental, and psychosocial well-being and meet current professional standards of practice
- Assessment of resident's ethnic, cultural, or religious factors that may need to be considered to meet resident needs, such as activities, food preferences, and any other aspect of care identified
- An evaluation of what policies and procedures may be required in the provision of care and how the facility would meet the current professional standards of practice.
- Plan to recruit and retain enough medical personnel who are adequately trained and knowledgeable in the care of residents and/or how management expectations of medical personnel.
- The facility's resources which included supplies, equipment, or other services necessary to provide for the needs of residents
- An evaluation of any contracts, memorandums of understanding including third-party agreements for the provision of goods, services or equipment to the facility during both normal operations and emergencies
- Heath information technology resources for managing resident records and sharing information with other organizations.
- Description of how the facility would evaluate their infection prevention and control program that included systems for preventing, identifying, reporting, investigating, and controlling infections.
- Evaluation of the physical environment necessary to meet the needs of the residents.
-Description of other pertinent facts or descriptions of the resident population.
-Identifying the type of staff members, other health care professionals, and medical practitioners that are needed to support and care for residents.
-The building description and other structural buildings.
On 10/15/2024 at 10:55 AM, during an interview the Administrator continued by saying that the facility assessment was started after the fall conference, but it was not completed. The Administrator reported that he gave the surveyor the guidelines that they found and filled it in with the numbers. The Administrator reported that the facility assessment would be brought to the Governing Body meeting set for 10/16/2024 at 7:00 AM. The facility assessment is important because it shows us how the facility is run.

Based on interviews, and record review, it was determined that the facility failed to submit required Centers for Medicare & Medicaid Services (CMS) quarterly staffing information for the third quarter of 2024.
Findings include:
A review of the CMS Payroll Based Journal (PBJ) Staffing Data Report for the third quarter of 2024, defined as April 1 to June 30, 2024, revealed the facility failed to submit data for the quarter.
A review of CMS's Center for Clinical Standards and Quality/Survey & Certification Group Memorandum S&C: 17-45-NH revealed the requirements for participation in Medicare and Medicaid Services were amended to include submission of data related to staffing as staffing significantly affects the care delivered to residents. The memorandum further provides email contact information for questions and provides a link to the policy manual.
During an interview on 10/16/2024 at 5:05 PM, the Administrator stated the previous Business Office Manager did the PBJ reporting, has not been employed since February, and does not know when the last reporting was done. The Administrator stated, I don't know how to do it, and I went to a conference and met someone that will be able to assist me. The Administrator stated the training assistance has not been scheduled and has not reached out to CMS or the state agency for assistance.

The facility's Quality Assurance Performance Improvement Program (QAPI) failed to maintain a program that developed and implemented effective improvement plans to correct identified areas of concern. After identifying Immediate Jeopardy at F600, F689, F835, F837, and F919, the facility's QAPI plan was requested. The Administrator was unable to locate the facility QAPI plan.
It was determined the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.75 - Quality Assurance and Performance Improvement at a scope and severity of L. The Administrator was notified of the IJ on 10/11/2024 at 11:51 AM. Before ending the survey, the survey team offered the facility the opportunity to provide a plan to remove the Immediate Jeopardy and ensure serious harm would not occur or recur. An Immediate Jeopardy removal plan must include all the actions the facility has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely. The State Agency accepted a plan of removal on 10/14/2024 at 7:51 AM. The IJ was not removed prior to the exit from the facility on 10/16/2024 at 6:00 PM.
Findings include:
A review of an undated policy titled Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) Policy & Procedure revealed that the facility would develop a QAPI plan in accordance with federal guidelines. The facility would address clinical care, resident quality of life and residents' choice.
During an interview on 10/11/2024 at 2:30 PM, the Administrator stated that the QAPI binder was unable to be located. The Administrator stated that the QAPI binder was not up to par and he would no longer look for the binder. The Administrator stated the QAPI team was going to meet the second Tuesday of the month. The Administrator also stated the facility would like to add a resident to the QAA/QAPI team because he felt it would help identify systemic issues. The Administrator stated the QAPI program would help with better documentation and current policies. The Administrator stated that some of the facilities' current policies were from 1991 and need to be updated to current standards. The Administrator reported that a new QAPI binder had been started. The Administrator reported that it was important to have a QAPI program to help find issues within the facility and be able to fix them quickly. The Administrator stated he felt like his employees came to him a lot with problems. He did not think the QAPI program would bring any more problems up that his staff did not already bring to him, however, the Administrator stated he realized during the survey, he had a lot more problems than he knew about.
Removal Plan:
On 10/11/2024, upon notification of deficient practice to ensure an effective QAPI is in place, the facility completed the following:
On 10/11/2024, the Director of Nursing (DON) and Administrator reviewed current regulations revolving around a Quality Assurance Performance Initiative (QAPI) program ensuring further comprehension of program needs, placement, reasoning and requirements. Interdisciplinary team (IDT) met with DON & Administrator to review and increase knowledge and education on QAPI.
On 10/11/2024, DON and Administrator reviewed, adjusted and updated facility QAPI Policy & Procedure to include the following:
- Scheduled time of the month for QAPI to be held
- Reassignment of information to be provided from different members of IDT.
- Requesting for resident president to be a part of QAPI meetings and information gathering
Requesting that a floor staff member be a part of QAPI meetings and information gathering
- Review on providing in-service education to all staff pertaining to QAPI, it's reasoning and methodology.
Administrator/designee will oversee the implementation of comprehensive QAPI program through documentation 1 time per week for 8 weeks or until compliance is verified by OLTC.
All corrections were completed on 10/11/2024.
Onsite Verification:
The IJ was removed on 11/06/2024 at 2:49 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on 10/11/2024 when the Director of Nursing (DON) and Administrator reviewed current regulations for Quality Assurance Performance Initiative (QAPI) program. The Interdisciplinary Team (IDT) met with the DON and Administrator reviewed and increased their knowledge on QAPI, monthly QAPI meetings were scheduled for the 2nd Tuesday of every month at 2:00 PM, QAPI responsibilities were assigned to each IDT member, the resident council present was asked to take part in the monthly meetings, the Activities Director met with residents from resident council for input on needed improvements, a Licensed Practical Nurse (LPN) who works the floor was asked and accepted to join QAPI committee, all staff were educated on QAPI, and the administrator provided his weekly documentation of QAPI oversite. A total of 9 staff interviews were conducted with staff from all shifts to verify training had been completed. The staff interviewed included Certified Nursing Assistants, Licensed Practical Nurses, Registered Nurse. The staff interviewed verified they had been trained on QAPI. A review of in-service sheets provided indicated 54 of 69 had been provided training. Those staff who were not physically present to receive the in-services were provided the power point on paper by the night shift charge nurse and signed the acknowledgement sheet which was returned
to Human Resources.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. A review of a facility policy titled, Hand Washing Policy & Procedure undated indicated, staff are educated to industry standards upon hire and included the procedure steps 1-6 on washing with soap and water. Step 2 indicated, Apply soap or alternate cleaning compound.
7. A review of the Employee Handbook, contained a document titled, Inservice Instructor Video, Handout or Review, that included a list of in-services that included, Hand Hygiene competence Assessment and Monitoring Tool, and a signature line for the employee attending the in-service.
8. A review of the admission Record, indicated the facility admitted Resident #8 with diagnoses that included hydrocephalus and seizures.
The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/12/2024, revealed Resident #8 had a Staff Assessment of Mental Status (SAMS) score of 3 which indicated the resident had severe cognitive impairment. Resident #8 was dependent on staff for all activities of daily living (ADL), including eating; had a swallowing disorder that included loss of food and liquids from mouth, coughing or choking during meals; and required a mechanically altered diet.
A review of Resident #8's care plan, with a revised date of 08/14/2023, revealed the resident had an ADL self-care performance deficit related to organic brain syndrome and seizure disorder. Interventions included pudding thick liquids and puree textured food and dependent on assistance of 1 staff for eating.
A review of Order Summary Report, revealed Resident #8 had a regular diet, pudding consistency, and fortified foods.
9. A review of the admission Record, indicated the facility admitted Resident #25 with diagnoses that included dementia, anxiety disorder, and cataracts.
The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/25/2024, revealed Resident #25 had a Staff Assessment of Mental Status (SAMS) score of 3 which indicated the resident had severe cognitive impairment. Resident #25 required supervision and touch assistance with eating.
A review of Resident #25's care plan, with an initiated date of 08/15/2023, revealed Resident #25 had an ADL self-care performance deficit related to dementia and mobility limitations. Interventions included limited assistance and placing food in bowls to maximize independence with eating.
A review of Order Summary Report, revealed Resident #25 had a regular diet, mechanical soft texture, and thin consistency of fluids.
During an observation on 10/07/2024 at 12:54 PM, Certified Nursing Assistant (CNA) #1 was seated at the half round assist table to the left of Resident #8. CNA #1 placed their hands, palm sides down, in their lap, brought both hands back to the top of the table, picked up a spoon and placed food in Resident #8's mouth. CNA #1 repeated this action twice with no hand hygiene being performed.
During an observation on 10/07/2024 at 12:55 PM, CNA #9 touched the meal tray paper of Resident #8 when CNA #1 asked CNA #9 to identify the beverages in Resident #8's clear plastic cups. CNA #9 assisted Resident #25 by picking up a fork and placing food in Resident 25's mouth. CNA #9, using their index and middle finger to stabilize a straw, with palm facing downward over the top of the container of a (Brand Name) vanilla shake, provided Resident #25 a drink. No hand hygiene was performed.
During an interview on 10/16/2024 at 10:23 AM, CNA #9 stated hand sanitation should have been done after touching the meal tray paper and when touching Resident #25's fork and straw because of the spreading of one resident's germs to another by placing hands close to another resident's mouth by touching another resident's straw and fork.
During an interview on 10/14/2024 at 10:43 AM, the Director of Nursing (DON) stated hands should be sanitized between each resident, and after placing hands in lap or any other area because of transmission of diseases and any bodily fluids or bacteria that may be on their hands can be spread to the residents.
During an interview on 10/15/2024 at 1:17 PM, the Infection Preventionist (IP) stated hand hygiene should be performed every time the CNAs get a meal tray, and use hand sanitizer between meal tray set up, and after touching their hair or their face. If CNAs are feeding residents and touch their hands, clothes, or a resident's hands or clothes, CNAs should use the sanitizer because they are spreading germs to residents and other employees, each time they touch something.
During an interview on 10/16/2024 at 12:38 PM, CNA #1 stated hand hygiene should have been performed due to germs and bacteria from their clothing could have touched Resident #8's food and been ingested causing Resident #8 to become ill.
During an interview on 10/16/2024 at 2:45 PM, the Administrator stated hand sanitation should have been performed by CNAs in between trays, after touching their face, hands, or other objects, before feeding a resident, touching the resident's cups, or utensils. The Administrator stated germs would be spread and cross contamination could occur causing a resident to be ill if hand sanitation was not performed.
10. On 10/10/2024 at 12:32 PM, the Surveyor observed the documents, Legionella Water Management Program brought in by the Director of Nursing (DON). The documents were an instructional guide on how to set up a Legionella Water Management Program. The documents that were supposed to be filled in were blank. Also received informational handouts on Legionnaires Disease.
On 10/10/2024 at 11:00 AM, the Surveyor interviewed the Environmental Director who reported that he flushed one room on each side of the hallway on the 100 Hall weekly, because the 100 Hall is not occupied. The Environmental Director reported that on the occupied halls he flushes at least one room on each hall weekly. He also revealed that it is not documented anywhere. The Environmental Director revealed that he does the flushing when he checks the water temperatures on the hallways. When asked about the Legionella plan, he did not know anything about it. The Environmental Director reported that he does not do any testing and that the local water department does not either. Asked if there had been any outbreaks of Legionella in the building that he knew of and he did not know.
On 10/10/24 at 01:23 PM, during an interview the Surveyor asked the DON about the blank Legionella Water Management Plan and the DON revealed that what was given to me is all she has. There is no specific Legionella Water Management Plan.
On 10/14/24 at 01:13 PM, during an interview the Infection Preventionist (IP) revealed that all the facility had on legionella was what the Surveyor had already received. When asked what the facility plan was if there was legionella in the building, the IP replied that that is a good question. The IP reported maintenance flushes the water but did not know how often or if it was documented.
A review of the Antibiotic Stewardship Policy and Procedure revealed that the facility would utilize Suspected Urinary Tract Infection (UTI) Situation, Background, Assessment, and Recommendation (SBAR) tool when communicating with the physician and using the Medical Care Referral Form for other infections.
A review of Resident #49's Progress Notes dated 8/1/2024 at 4:31 PM revealed that Resident #49 had complained of pain upon urination and an urin alysis was performed and the nurse documented that the results was positive for Urinary Tract Infection (UTI). The Physician was notified and Bactrim double strength was ordered at 7:21 PM. No UTI SBAR was observed to be filled out in electronic medical record.
On 10/16/2024 at 1:25 PM, during an interview with Licensed Practical Nurse (LPN) #25 who had notified the physician about Resident #49's UTI symptoms and received the antibiotic order, revealed that she does not know anything about the guidelines used to identify infections in long-term care facilities, or what an Infection Preventative form is. Also reported there is no forms or anything she reviews prior to calling the physician. LPN #25 also stated that she knows what Antibiotic Stewardship is, indicated they use it at hospitals and clinics, but does not use it at this facility.
On 10/16/24 at 01:47 PM, an interview with LPN #11 is not aware of what guidelines are used to identify infections in long-term care facilities or when an infection prevention evaluation is to be completed. Also reported that she was unaware of what an antibiotic stewardship program is.
A review of the Infection Control Policy/Procedure did not address wearing Personal Protective Equipment.
On 10/10/2024 at 10:30 AM, the surveyor observed the Environmental Director walking down the hall pushing a laundry bucket with an apron and gloves on. During an interview the Environmental Director was asked if he should be walking down the hall with an apron and gloves on. He replied with that he was not going to pick up dirty laundry without them on. The surveyor then asked if it was an infection control problem walking down the hall with the PPE on. The Environmental Director did not respond, just stared at the surveyor and then walked off. Observed the Environmental Director emptying the laundry bucket with PPE on and then walk back up the hall.
On 10/14/2024 at 01:10 PM, during an interview with the Infection Preventionist (IP) she reported that there were concerns with the Environmental Director wearing gloves and going down the hall. The IP reported that the Environmental Director should not be doing that, because he is spreading germs by doing so. The laundry personnel should be putting their gloves on prior to picking up the laundry and then taking the gloves off after picking up the laundry.
On 10/16/2024 at 10:26 AM, during an interview with the Director of Nursing (DON) she revealed that it was ok for the laundry employees to wear their Personal Protective Equipment (PPE) down the hall if they are not touching anything dirty. Then reported that it's ok if the laundry employees wear gloves going down hall to empty but should not be wearing gloves down hall back to laundry. The DON reported that it is an infection control issue wearing gloves and touching doorknobs and anything afterwards.
Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to ensure staff performed hand hygiene; after touching clothing and meal tray paper and providing food for 2 (Resident #8 and Resident #25) residents during dining observation of 1 dining room reviewed for infection control; when going from dirty to clean task during wound care for 1 Resident (Resident #29) for 1 resident reviewed for infection control during wound care; during blood draws for 1 laboratory technician review for infection control; failed to develop a Legionella Water Management Program/Plan; failed to have an effective Antibiotic Stewardship program; and failed to implement infection control practices for 1 of 1 facility reviewed for infection control.
Findings include:
1. A review of the facility's undated policy titled; Hand Washing Policy & Procedure indicated the facility policy was to ensure all staff are educated/trained on hand washing and hand hygiene upon hire and as needed to industry standards. Staff are educated to industry standards upon hire and included the procedure steps 1-6 on washing with soap and water. Step 2 indicated, Apply soap or alternate cleaning compound.
2. A review of the facility's Infection Control Policy and Procedure dated 04/21/2021 stated, infection control coordinator/designee will in-service each new employee on infection control and provide periodic in-services.
3. A review of the facility's Infection Control Inservice dated both 05/22/2024 and 07/24/2024 stated, pathogens can be transmitted from person to person via hands. Hand hygiene is to be done before and after resident contact including contact with residents' intact skin, before and after dressing changes, before and after an invasive procedure, and after removing gloves. Inservice was signed by LPN #11.
4. A review of the admission Record indicated the facility admitted Resident #29 with diagnoses that included diabetes mellitus type 2, pressure-induced deep tissue damage of the left heel, and severe sepsis with septic shock.
The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/12/2024, revealed Resident #29 had a Brief Interview of Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. Resident #29 had added diagnoses of peripheral vascular disease and malnutrition and received wound care treatments of ointments and dressings changed to feet.
A review of Resident #29's care plan, revised on 09/20/2024, revealed an ulcer to the left heal with a goal to show signs of healing and remain infection free. Interventions included monitor and report signs of infection.
A review of Order Summary Report revealed Resident #29 had an order for daily wound changes to the left heal including application of an antibiotic ointment and rolled gauze.
During an observation and interview on 10/07/2024 at 9:40 AM, LPN #11 removed Resident #29's dirty dressing and removed dirty gloves then immediately put on clean gloves without performing hand hygiene. LPN #11 reported no awareness about hand hygiene between removing dirty gloves and [NAME] clean gloves.
During a concurrent interview observation on 10/09/2024 at 10:00 AM, a phlebotomist was in room [ROOM NUMBER] attempting to perform a lab draw for blood. Phlebotomist put on gloves with no hand hygiene, walking in and out of the resident's room looking for assistance, reaching in and out of the supply backpack, touching resident's light cord, recliner, bed, table, then sticking the resident twice first in the right forearm and then in the left forearm. Phlebotomist then filled the lab tube with the resident's blood, labeled it, and filled out paperwork. The phlebotomist repacked supplies in the supply backpack, then removed gloves at 10:23 AM. No hand hygiene was performed as the phlebotomist left room [ROOM NUMBER]. Phlebotomist then went into room [ROOM NUMBER] without performing hand hygiene where the resident arms were looked inspected, the nurses' station between 100-200 Halls, and then returned to room [ROOM NUMBER] with the Director of Nursing (DON). Phlebotomist and DON shared a pen and signed a paper. The phlebotomist stated lab draws were an aseptic technique. Phlebotomist stated their hand sanitizer was in their car, and they usually did not perform hand hygiene between resident interaction just changed gloves. Phlebotomist stated that would not be following aseptic technique.
A review of the facility's contract with the laboratory services company dated 10/04/2022 and signed by the facility's representative stated it the responsibility of the laboratory service provide to comply with all policy and procedures provided by the facility.
During an interview on 10/15/2024 at 3:12 PM the Administrator stated no policies or procedures were provided to the laboratory services company.
5. A review of the Employee Handbook, contained a document titled, Inservice Instructor Video, Handout or Review, that included a list of in-services that included, Hand Hygiene competence Assessment and Monitoring Tool, and a signature line for the employee attending the in-service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, it was determined that the facility failed to ensure the call light system was effectively working for 200 and 300 halls; and failed to implement an emergency backup system for 2 of 4 halls. The facility census was 48.
It was determined the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manul, Appendix PP, §483.90 (Physical Environment) at a scope and severity of K.
The IJ began on 10/06/2024 at 6:00 AM shift change, when night shift staff notified day shift staff that the call lights were not working.
The Administrator, Director of Nursing (DON), and Assistant Administrator /Business Office Manager (BOM) were notified of the IJ on 10/08/2024 at 5:13 PM. A Removal Plan was requested. The Removal Plan was accepted by the State Agency on 10/09/2024 at 1:19 PM. The IJ was removed on 10/16/2024 at 4:30 PM after the survey team performed onsite verification that the Removal Plan had been implemented. All call lights in the building functioned and bells were available for back-up system and plan for implementation.
Findings include:
A review of the Maintenance Log, revealed on 03/15/2024, call light outside room [ROOM NUMBER] was not working and initialed as completed; 04/08/2024, call light outside room [ROOM NUMBER] was not lighting up and initialed as working on 4/11/2024; 04/10/2024 call light room [ROOM NUMBER] not working and initialed as completed; on 04/15/2024 and 04/17/2024 call light outside room [ROOM NUMBER] not working and initialed as completed; 05/01/2024 call light room [ROOM NUMBER] not working, bed B and initialed as completed; 06/23/2024 emergency call light room [ROOM NUMBER] not working and initialed as completed; 06/27/2024 call light outside room [ROOM NUMBER] not working and initialed as completed; 10/06/2024 call light room [ROOM NUMBER] not working.
During an interview on 10/08/2024 at 4:00 PM, the Environmental Director confirmed the initials under the completed column were his and that the work was completed.
A review of a facility policy titled, Facility Assessment Tool, undated, did not address an emergency backup plan for the facility call system.
A review of an online shopping platform invoice, dated 10/06/2024, indicated the facility ordered 3 Jingle Bells, 24 wrist band jingle bells, 12 musical instruments, and 50 hand bells.
A review of an invoice from (Business Name), dated 10/08/2024 indicated an order for a Central Unit NC 110/150/200. A hand notation at the bottom of the invoice indicated Call light part.
During an interview on 10/07/2024 at 11:27 AM, Resident # 18 requested assistant related to soiling of a brief. Resident #18 picked up the call button from the bed and pressed the button to activate the call light. Resident #18 stated they felt like the call light was not activating. The surveyor stepped into the hallway and the light above Resident #18's door was not lit, and no sound was coming from the nursing area where the call system makes an audible beeping sound. Resident #18 stated the call lights on 200 and 300 halls had not worked for at least one week and believed the facility ordered bells to go off. Resident #18 stated if staff take too long, Resident #18 would roll their wheelchair into hallway so they see me and if it took too long, I yell, and they come.
During an interview and observation on 10/07/2024 at 11:52 AM, Resident #16's family member did not know if call lights were working. Resident #16 pushed the call button lying on the bed. The surveyor stepped into the hallway and the light above Resident #16's door was not lit, and no sound was coming from the nursing area where the call system makes an audible beeping sound. Resident #16 stated they would wait until an aide was in the hallway to tell them assistance was needed.
During an interview on 10/07/2024 at 11:59 AM, Nursing Assistant (NA) #18 stated call lights had not been working for about 2 days and some residents holler for assistance, and other residents are checked every 2 hours.
During an observation and interview on 10/07/2024 at 1:46 PM, Resident #20 pushed the call button, needing assistance. The surveyor knocked on door just as the resident pushed the call button to activate the call light. Resident #20 asked if call light was working because it was not and has not since at least Saturday. The light above Resident #20's door was not lit, and no sound was coming from the nursing area where the call system makes an audible beeping sound.
During an interview on 10/07/2024 at 1:48 PM, Certified Nursing Assistant (CNA) #1 stated they work only Sunday and Monday, and was told on Sunday the call lights were not working. CNA #1 stated once residents were laid down, the aides walk the halls and see if anyone needed anything.
During an interview on 10/07/2024 at 4:00 PM, Resident #46's family members stated Resident #46 had to lay in feces all evening due to call light not functioning and staff not rounding.
During an interview on 10/08/2024 at 09:25 AM, the Environmental Director stated he was notified of the call light system on 200 and 300 halls not working on Sunday (10-06-2024) morning between 5 and 6 AM. Staff reported the call light stopped working at some point on Saturday night, unsure of the exact time. The Environmental Director stated he flipped the breaker on and off and the call light system still did not work. The Environmental Director telephoned a technician to have the call light system assessed and was told the transformer needed to be replaced, and was ordered from a company in North Carolina, however due to flooding on the east coast, the Environmental Director is unsure when the part will arrive. The Environmental Director stated a (Medical Business) from Louisiana will install the part once it is received, and the Administrator ordered bells, that are supposed to arrive today (10/08/2024), to be used until repairs are made.
During an interview on 10/08/2024 at 4:00 PM, the Administrator reported that bells, (bells on a stick and bracelet bells), were ordered and would be delivered tomorrow (10/09/2024). The Administrator stated he called other facilities and tried to borrow bells from them, however they would not loan any as that was part of their back up plan. The Administrator stated he ordered bells online and provided a copy of the invoice.
During an observation on 10/09/2024 at 9:29 AM, Resident #1 was yelling out from their room, asking for something to eat, and Resident #45 was yelling out for help. At 9:31 AM, an aide entered Resident #45's room and the resident stated they had been waiting to go the bathroom.
During an observation on 10/09/2024 at 9:53 AM, there was no CNA visibly present on the 200-hall.
During an interview on 10/09/2024 at 10:08 AM, CNA #8 stated rounds were normally made every 2 hours, however rounds were being done every 20 to 30 minutes because of call lights not working, and if the residents need the staff, they holler at us if we are not down there.
During an interview on 10/10/2024 at 2:25 PM, the Environmental Director stated the call light part was received, and the company performing the repairs would be in the facility on Friday (10/11/2024).
During an interview on 10/10/2024 at 2:59 PM, the Director of Nursing (DON) was notified that during resident council, several residents complained of the physical bells the facility ordered as a back-up system were not working because staff could not hear them, and staff were not coming to assist the residents.
During an interview on 10/11/2024 on12:03 PM, LPN #11 stated staff were educated on reporting hazards and risks and implementing procedures for call lights not working. Staff were informed to do paper charting of rounds, like progress notes for residents. LPN #11 stated call lights were not working on Sunday, 10/06/2024, the Administrator, DON and Environmental Director were notified. LPN #11 notified CNAs to do rounds at least every 20 minutes until repairs were made and the LPN felt like CNAs did that.
During an interview on 10/14/2024 at 11:51 AM, Registered Nurse (RN) #12 stated the bathroom on the main hall was usually used by staff and visitors. Residents did use it at times, and depending on the resident, they would be able to lock the door. RN #12 stated, if a resident fell in the main bathroom, hopefully someone would hear them fall and check on them because there is no call light in the bathroom.
During an interview on 10/14/2024 at 12:35 PM, the Administrator reported the company scheduled to complete the call light repairs could not come out because all the technicians had COVID. The Administrator reported another company was supposed to be in to repair the call lights, but because of the federal holiday, they were off and would be at the facility tomorrow (10/15/2024) to put the part in.
During an observation on 10/15/2024 at 1:45 PM, a bell was sounding down 200-hall, no staff were observed on 200-hall. The bell sounded again, and staff were at the nurse's station and no staff responded. At 1:50 PM, the bell sounded again as the Assistant Administrator walked onto 200-hall from the sub corridor and turned left toward nurse station. The Assistant Administrator asked if anyone heard ringing. Staff near the nurse's station denied hearing anything. The bell sounded again, and the Assistant Administrator responded to the bell on the 200 Hall and entered Resident #18's room.
During an observation on 10/16/2024 at 12:05 PM, call lights on 200 and 300-halls were tested and call lights in rooms/beds 204-B, 208-B, 308-B, and 312-A were not working in the hallway, nurses' station, or in room. The Administrator was notified.
During an interview on 10/16/2024 at 12:45 PM, CNA #1 stated if a hazard or risk was identified, CNA #1 would report it to the nurse, and the nurse would notify staff if there was a hazard and tell the staff what to do. CNA #1 gave the example of being notified of call lights and the use of bells. CNA #1 did not know if the bells were working due to not being on shift since implementation.
During an interview on 10/16/2024 at 12:40 PM, the Administrator stated, of the 4 call lights reported not functioning, 2 were replaced and all 4 were now functioning.
During an observation on 10/16/2024 at 1:00 PM, call lights in rooms/beds 204-B, 208-B, 308-B, and 312-A were rechecked and the call light in 308-B is not working. The Administrator accompanied the surveyor to 308-B to test the call light. The call light worked 2 out of 9 attempts. The Administrator stated the light would be replaced.
During an interview on 10/16/2024 at 2:51 PM, the Administrator stated notification of call lights not working was made on Sunday, (10/06/2024) and staff were instructed to increase rounds on halls to every 15 minutes and contacted other facilities to borrow bells until the system could be repaired, and the request was denied as it was part of the facility emergency plan. Residents, families and staff are notified of any risks or hazards using an automated communication system that includes telephone calling, text, and email communication, through the electronic charting system. The Administrator stated no emergency plan was in place for the facility and the automated notifications to staff, residents and families was not used, I just didn't think about it. The Administrator stated an order for bells was placed with an online shopping platform. The Administrator stated once received, the bells were distributed, and nurses and CNAs were told to increase rounding, notification were made on the 24-hour report.
During an interview on 10/11/2024 at 2:13 PM, the DON stated the process of implementing interventions once a hazard was identified, was checking in and following up to be sure it was working or if changes needed to be made. The DON used the example of the wrist bells not being heard by staff and residents were offered a bell with a handle.
Removal Plan:
On 10/8/2024, upon notification of deficient practice to report abuse allegations, the facility took the following measures:
On Sunday October 6th at 2:10 PM, upon notification of failed call light system, the Director of Nursing (DON) directed direct care staff to increase rounding times to every 15 minutes in order to assist with call light failure on 200 and 300 Hall.
Charge nurses were then asked to verbalize this change to oncoming shifts before the start of the staffs shift.
Inservice education was created to be provided at all staff in-service held 10/9/2024 at 1400 [2:00 PM] pertaining to failure to document 15 minute checks. Any staff unable to attend all staff in-service will be provided 1 on 1 in-service by human resource director upon collection of their check. 15 minute check form created and placed at nurse's station.
Confirmation of specialized repair parts provided via email and shown to be enroute and scheduled to be delivered 10/9/2024.
Replacement parts ordered on 10/6/2024 after troubleshooting with the provider of our call system maintenance.
Facility to utilize bells as a backup call system. Upon arrival, the
Interdisciplinary Team (IDT) will converge and assist with dispersing back up call system. Confirmation via online tracking system shows that system will arrive at facility.
Upon correction, DON/Designee to test 4 rooms per hall 5 times per week for 8 weeks or until compliance is verified by OLTC. Any negative findings will be corrected and reported immediately to Admin.
All corrections were completed on 10/09/2024.
Onsite Verification:
The IJ was removed on 10/31/2024 at 12:00 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on 10/06/2024 at 2:10 PM when rounding of resident halls was increased to every 15 minutes and a 15-minute check form was created. Repair company was contacted, replacement parts were ordered, an in-service was held on 10/09/2024 at 2:00 PM, bells were purchased for resident use and handed out on 10/10/2024. A total of 15 staff interviews were conducted with staff from all shifts to verify training had been completed. The staff interviewed included Certified Nursing Assistants, Licensed Practical Nurses, Registered Nurses, Kitchen Aide, Hospitality Services, and Environmental Services. The staff interviewed verified they had been trained on bells as a back-up call system and 15-minute rounding. A review of in-service sheets provided indicated 67 of 71 had been provided training. Those staff who were not physically present to receive the in-services were given one on one education, with the in-service information provided and the employee completing and returning a post quiz.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility is free of pests and rodents.
The findings include:
Review of the facility provided Maintenance Log, dated 05/2/2024, reported a resident in room [ROOM NUMBER] had a rat in their room per resident, rat trap in need.
Review of facility provided Maintenance Log, dated 05/5/2024, reported a resident in room [ROOM NUMBER] had a mouse in their room.
During initial rounds on 10/7/2024 at 12:01 PM, Resident #43 stated that the facility had mice. Resident #23 confirmed that mice had been seen on multiple occasions.
During an interview on 10/7/2024 at 5:14 PM, Certified Nursing Assistant (CNA) #4 stated that mice are seen daily, and the last time she had seen a mouse was on 10/6/2024.
During an interview on 10/7/2024 at 5:34 PM, the Environmental Director stated that there was a mouse problem. The Environmental Director stated that live traps and sticky traps had been deployed around the facility. The Environmental Director stated that the Pest Control company could not spray for rodents inside of the facility due to risk to the residents health. The Environmental Director stated the Administrator was aware of the rodent issue.
An observation on 10/7/2024 at 6:59 PM, showed garbage and food spilt around the facility dumpster behind the facility.
An observation on 10/8/2024 at 8:32 AM, showed garbage and food spilt around the facility dumpster behind the facility.
During a telephone interview on 10/8/2024 at 2:30 PM, the facilities pest control company stated that they were responsible for maintaining the perimeter of the facility. The pest control company stated that they were never allowed inside of the facility. The pest control company stated that the Environmental Director reached out in November of 2023 for a quote on rodent control services. The pest control company stated that a quote was provided to the facility, but the facility did not move forward with the rodent control services.
During a telephone interview on 10/10/2024 at 9:34 AM, the Licensed Practical Nurse (LPN) #24 stated that there were mice in the facility, and that the mice were seen multiple times on a daily basis by staff, residents, and visitors. LPN #24 stated that the mice have been seen in common areas and in the resident rooms. LPN #24 stated that Administration was aware of the mice issue.
During a concurrent observation and interview on 10/10/2024 at 10:33 AM, the Kitchen Manager confirmed that the brown specks on the floor of the storage room in the kitchen area appeared to be mouse droppings. The Kitchen Manager stated that mice were an issue months ago in the kitchen area but had not been an issue recently. The Kitchen Manager stated that several bags of dried foods and bread had been wasted due to rodent infestation.
During an interview on 10/11/2024 at 8:00 AM, the Head of Hospitality stated that mice were common around the facility. She stated that what appeared to be mice droppings were often found in the resident closets. and that the droppings were removed, and the floors were cleaned with soap and water.
During an interview on 10/11/2024 at 1:00 PM, the Environmental Director stated that he had reached out to the pest control company for a quote on the rodent issue within the facility, and that the information was left with the Administrator for review and approval. The Environmental Director denied knowledge of any further action for pest or rodent control.
During an interview on 10/11/2024 at 1:17 PM, the pest control company stated that no facility representative had contacted the pest control company to move forward with rodent/pest control measures related to the mice issue within the facility. The pest control company stated that the company used chemicals that were state and federally approved for use within a long-term care facility.
During an interview on 10/11/2024 at 2:00 PM, the Administrator stated that he told the Environmental Director to move forward with the pest/rodent control quote from the pest control company. The Administrator denied any documentation of acceptance of the pest control company's quote or any other pest removal interventions for the mice.
During an interview on 10/14/2024 at 10:59 AM, the Environmental Director stated that garbage and food waste should be properly disposed of so as to not attract rodent and/or pests. The Environmental Director stated that the mouse issue was out of control and the pest control company should be contacted to handle rodent issues.
The following observations were made during onsite monitoring visit:
During observation in the Conference Room on 10/29/24 at 5:12 AM near the entrance of the building, the surveyor observed a live grey rodent underneath a chair in the room. When the surveyor moved, the rodent scurried outside of the room and was unable to be found.
During an interview on 10/30/2024 at 9:30 AM, the Low Voltage Technician (LVT) stated a live mouse was in the ceiling area while wiring was installed to correct the Immediate Jeopardy concern related to the call light system. The mouse was contained in a trash can and released outside the 200 Hall door by LVT.

Based on interviews and record review, the facility failed to establish a smoking policy in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also takes into account nonsmoking residents.
The findings include:
Per facility provided list of residents who smoke, undated, two residents within the facility smoke.
During an interview on 10/10/2024 at 11:00 AM, the Director of Nursing (DON) denied there was a facility smoking policy.
During an interview on 10/10/2024 at 11:30 AM, the Administrator denied there was a smoking policy.

Based on document review and interviews, the facility failed to provide required training to staff members for 1 of 1 facility.
The findings are:
Upon request of mandatory in-services, the surveyor received an Infection Control in-service and Resident Rights in-service.
Upon reviewing the facility assessment there were no required trainings and/or in-services addressed.
A review of an undated document titled, Required Annual State Inservices received by the Director of Nursing (DON), revealed that the in-services that the facility was going to provide were the following: Civil Rights, Disaster Preparedness, Fire Safety, Accident Prevention, Reporting Disaster/Outages, Utility Shut Off Demonstration, Oral and Dental Care, Restorative Nursing, Dignity, Death and Dying, Advanced Directives, Behavior Management, Assessments, Interventions, Medications, Documentation, Infection Control/Wound Management, Universal Precautions, Center of Disease Control, Tuberculosis Prevention, Nosocomial Infections, Treatments, Documentation, Abuse and Neglect, Types of Abuse and Neglect, Incident Reporting, Medication Administration and Resident Rights.
On 10/11/24 at 10:44 AM, during an interview with the Human Resource Director (HRD) it was revealed that the Administrator does all the administrative training, and it depends on what the in-service is about, on who does the in-services.
On 10/11/ 2024 at 2:30 PM, during an interview, the Administrator reported that they do not have all of the required training. And it was 100% his fault. He reported that the trainings were done, but the Administrator failed to document them.
On 10/16/24 at 11:04 AM, during an interview with the HRD it was revealed that the Administrator had the spreadsheet/calendar that keeps up with the in-services and when they were due. The HRD does not keep up with the in-services, the Administrator does. The HRD reported that just recently the in-services were given back to Administrator and there probably in the Administrator's new office. The HRD reported that they would go and look and see what could be found.
On 10/16/2024 at 2:00 PM, the HRD brought in two in-services that only had a cover sheet on them and pages of signatures with no information on what actually was covered in the in-services.

Based on document review, and interviews, the facility failed to conduct a compliance/ethics training for staff members.
The finds are:
Upon observation no compliance/ethics training was observed.
Om 10/11/24 at 10:44 AM, during an interview with the Human Resource Director (HRD) it was revealed that the Administrator does all the administrative training, and depending on what the in-service is about depends on who does the in-services.
On 10/11/ 2024 at 2:30 PM, during an interview the Administrator reported that they do not have all the required training. And it was 100% his fault. He reported that the training was done, but the Administrator failed to document them.
On 10/16/24 at 11:04 AM, during an interview with the HRD it was revealed that the Administrator has the spreadsheet/calendar that keeps up with the in-services and when they are due. The HRD does not keep up with the in-services, the Administrator does. The HRD reported that just recently the in-services were given back to the Administrator and there probably in the Administrator's new office. The HRD reported that she would go and look and see what could be found.
On 10/16/2024 at 2:00 PM, the HRD brought in two in-services that only had a cover sheet on them and pages of signatures with no information on what actually was covered in the in-services.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure staff was trained in behavioral health residents for 1 (Resident #49) of 2 residents reviewed for dementia care. Specifically, the facility had no formal dementia training for staff, this had the potential to affect 28 residents identified by the facility with an Alzheimer's/Dementia diagnosis.
Findings include:
A review of a certification titled, National Council of Certified Dementia Practitioners with a certification period of 08/08/2023 through 08/08/2025 revealed, Administrator had completed certification as a Certified Dementia Practitioner.
A review of the facility document titled, Required Annual State Inservices, revealed a Behavior Management category and a Cognitive Impairment category noting assessments, interventions, medications, and documentation. No specific dementia training was identified, and the last dates entered were 09/01/2022 for Behavior Management and 02/02/2022 for Cognitive Impairment
A review of the Resident Matrix dated 10/07/2024 revealed 28 residents identified by the facility with a diagnosis of Alzheimer's/Dementia.
A review of the admission Record, indicated the facility admitted Resident #49 with diagnoses that included dementia, generalized anxiety disorder, and delusional disorders.
The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/06/2024, revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated the resident was had severe cognitive impairment.
A review of Resident #49's care plan initiated on 07/30/2024 and revised on 08/31/2024, revealed the resident had cognitive or impaired thought processes related to dementia intervention included administer medication as ordered and ask yes/no questions, Relay Resident #49's capabilities to family and caregivers. Resident #49 was disoriented to place, had impaired safety awareness, wandering behaviors, a history of elopement from home, and an elopement from the facility on 08/30/2024. Interventions included distraction with structured activities, food, conversation, television, and books. Encourage placement of air tag watch per family. Identify patterns of wandering; purposeful, aimless, or escapist and intervene as appropriate.
During an interview on 10/11/2024 at 11:00 AM, the Administrator stated no formal dementia training was available for review. No records were kept, no training material and no in-services were signed by employees.
During an interview on 10/11/2024 at 2:10 PM, Administrator stated, yes, giving antipsychotics to keep Resident #49 from exit seeking was a chemical restraint and the front hallway was unoccupied on the weekends and was not in the line of sight of staff, making a more difficult area to monitor for elopement. Administrator stated, this was not the facility for Resident #49 and family had been approached about it in care plan meetings. The Administrator stated Resident #49's family was made aware the facility's interventions may not work and Resident #49 may have to be relocated to a facility with a memory care/dementia unit which is more secure.
During an interview on 10/15/2024 at 2:17 PM, Resident #49's family member stated they did not want to move Resident #49, but wanted to know why the facility accepted the resident if they could not handle the situation.
During an interview on 10/10/2024 at 9:34 AM, Licensed Practical Nurse (LPN) #24 stated that certified nursing assistant competencies were not completed, and the certified nursing assistant staff did not have knowledge while working with residents with behavioral health diagnoses.
Review of facility provided documents, undated, titled, Nurse Aides Skills Yearly Review, revealed certified nursing assistants signed off on skills verifying they were competent in the skill set. Several forms were not completed in their entirety, several skills remained unverified including dementia care and activities of daily living, such as brushing teeth.
During an interview on 10/11/2024 at 9:00 AM, the Human Resource Director stated that competencies were reviewed upon hiring and that a skills carnival had been scheduled for the facility staff. The Human Resource Director denied knowing why the competency skill sets were not fully completed.
During an interview on 10/16/2024 at 3:00 PM, Certified Nursing Assistant (CNA) #1 stated that she felt sort of competent when providing care to residents within the facility. CNA #1 denied knowing when her skills competency was evaluated or by whom.
During an interview on 10/14/2024 at 11:00 AM, the Director of Nursing (DON) stated the certified nursing staff and nursing staff demonstrated competency by completing the items on the skills competency list. The DON stated there was no way to verify if the certified nursing assistants or nursing staff were competent in a skill, if the skill was not verified and marked as completed. The DON stated she did not know what to say regarding staff competencies and why the forms were not completed.
During an interview on 10/14/2023 at 12:03 PM, the Administrator stated the certification of the nursing staff provides initial competency. The Administrator stated competencies should be maintained, reviewed, and renewed yearly. The Administrator denied having a system in place to verify staff competency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, it was determined that the facility failed to ensure a continent resident was able to call for toileting assistance to prevent incontinence for 1 (Resident #18) resident of 18 sampled residents; and the facility failed to ensure all residents were provided with similar dinnerware for 2 (Resident #25 and Resident #32) of 18 sampled residents. Specifically, residents requiring assistance with meals were served using (polystyrene foam) bowls.
Findings include:
A review of a facility document titled, Resident Rights, indicated residents have the right to be treated with dignity, privacy, respect, and to live in a safe, clean, and comfortable homelike environment.
1. A review of the admission Record, revealed the facility admitted Resident #18 with diagnoses that included blockage of blood flow to the brain, a decline in thinking skills due to condition that blocks blood flow to the [NAME] causing deprivation of oxygen, weakness on one side of the body, depression, urinary incontinence, and intestinal disorder with diarrhea.
A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/13/2024, revealed Resident #18 had a Brief Interview for Mental Status (BIMS) score of 15 that indicated the resident was cognitively intact. Resident #18 used a manual wheelchair for ambulation, required substantial to maximal assistance with toileting, was frequently incontinent of urine and was on a urinary toileting program, was occasionally incontinent of bowel, and was on a bowel toileting program.
A review of Resident #18's care plan, with a revision date of 03/15/2024, revealed resident had an Activities of Daily Living (ADLs) self-care performance deficit and required assistance of 1-2 staff for transfer and toileting.
A review of Order Summary Report, revealed Resident #18 was receiving a daily medication for overactive bladder and constipation, and an as needed antidiarrheal medication.
A review of bowel elimination history revealed Resident #18 had 21 continent bowel movements from 09/01/2024 to 10/11/2024, and 17 incontinent bowel episodes from 09/01/2024 to 10/11/2024. Resident #18 was continent of bowel on 10/4/2024 and 10/5/2024. Resident #18 was incontinent of bowel on 10/6/2024 and 10/7/2024. Resident #18 was continent on 10/8/2024. Resident #18 was incontinent on 10/09/2024. Resident #18 was continent on 10/10/24.
During an observation on 10/07/2024 at11:27 AM, Resident #18 requested assistance due to soiling of their brief. Apologized to the surveyor for odor. Resident #18 pressed the call button to turn on the call light, and the light did not activate. Resident #18 stated the call light has not been working on the 200 or 300 halls for at least a week and believed bells were ordered. Resident #18 stated staff do not come on a regular basis and goes into the hall so someone will know assistance is needed or will yell so someone will come.
During an interview on 10/11/2024 at 11:53 AM, Certified Nursing Assistant (CNA) #7 stated residents should be taken to the restroom every 2 hours or less. CNA #7 stated there is a standing order when residents come into the facility, they are automatically on a toileting program, and it is documented on their ADLs in the computer. CNA #7 stated since call lights have been out, if a resident is incontinent, because we don't get them to the toilet, it is a dignity issue and CNA #7 will try to calm them and notify the nurse.
During an interview on 10/11/2024 at 12:47 PM, Licensed Practical Nurse (LPN) #11 stated CNAs are expected to respond immediately to residents needing assistance. LPN #11 stated the toileting program is automatic, for all residents unless they have a catheter or ostomy, and it is for every 2 hours, before and after meals. LPN #11 stated Resident #18 is on a toileting program and had a bowel movement on Monday morning that was documented at 1:59 PM as incontinent. Resident #18 was able to tell us they needed to use the bathroom and was partially incontinent because we did not get there in time. Residents have a right to go to the bathroom and we need to provide that care.
During an interview on 10/14/2024 at 11:06 AM, the Director of Nursing (DON) stated staff should meet the resident's needs, as best they can. Staff should make rounds every two hours. The DON stated she was not aware of any resident on a toileting program and would need to speak to the Assistant Director of Nursing (ADON) who did the MDS evaluations.
During an interview on 10/14/2024 at 12:34 PM, the ADON stated staff are expected to care for residents within their scope of practice. Residents should push their call button if they want assistance, or now ring bells. The ADON stated staff were told to offer and assist with toileting before and after meals, before bed and as needed and residents every 2 hours, or sooner. The ADON believes Resident #18's inability to call someone for assistance with toileting, due to the call light not functioning, was psychosocially impacted because Resident #18 likes to remain continent and becomes upset and it would have affected their dignity.
During an interview on 10/16/2024 at 4:28 PM, CNA #1 stated Resident #18 was toileted regularly and was usually continent. CNA #1 stated Resident #18 had issues every 2 to 3 days when the call lights were out. CNA #1 stated, I would have felt embarrassed, because Monday, Resident #18 pushed the light, it did not work, and I did not get Resident #18 to the toilet in time.
2. A review of the admission Record, indicated the facility admitted Resident #25 with diagnoses that included dementia, anxiety disorder, and cataracts.
The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/25/2024, revealed Resident #25 had a Staff Assessment of Mental Status (SAMS) score of 3 which indicated the resident had severe cognitive impairment. Resident #25 and required supervision and touch assistance with eating.
A review of Resident #25's care plan, with an initiated date of 08/15/2023, revealed Resident #25 had Activities of Daily Living (ADLs) self-care performance deficit related to dementia and mobility limitations. Interventions included limited assistance and placing food in bowls to maximize independence with eating.
A review of Order Summary Report, revealed Resident #25 had a regular diet, mechanical soft texture, and liquids with thin consistency.
A review of Resident #25's meal tray paper indicated Resident #25 required food in small bowls.
3. A review of the admission Record, indicated the facility admitted Resident #32 with diagnoses
that included a progressive brain disorder affecting memory, and depression.
A review of the admission MDS, with an ARD of 08/08/2024, revealed Resident #32 had a BIMS score of 3 which indicated the resident had severe cognitive impairment. Resident #32 required partial to moderate assistance with eating and required a mechanically altered diet.
A review of Resident #32's care plan, with a revised date of 08/23/2024, revealed Resident #32 had an ADL self-care performance deficit related to decreased mobility. Interventions included providing encouragement and limited assistance from one staff member with eating.
A review of the Order Summary Report, revealed Resident #32 had a regular diet, mechanical soft texture and liquids with thin consistency.
During an observation on 10/07/2024 at 12:15 PM, a dining menu for lunch and dinner was posted to the left of the dining room entrance revealed lunch for 10/07/2024 was ham and beans, squash, cornbread, and peaches.
During an observation on 10/07/2024 at 12:48 PM, Resident #32 was sitting at a resident assist table on the left side of the dining room entrance, second from the left of CNA #9. Resident #32 had one (polystyrene foam) bowl containing ham and beans.
During an observation on 10/07/2024 at 12:49 PM, Resident #25 was sitting at a resident assist table on the left side of the dining room entrance, second from right of CNA #1. Resident #25 had 4 polystyrene foam bowls, one bowl containing peaches, one containing ham and beans, one containing crumbled cornbread and the fourth was empty, the CNA could not recall what was in the bowl.
During an interview on 10/07/2024 at 1:00 PM, CNA #9 stated they did not know why Residents #25 and #32 were served food in (polystyrene foam) bowls when others at the table had regular dinnerware.
During an interview on 10/07/2024 at 1:12 PM, Dietary Aide (DA) #10 stated the facility has a shortage of bowls because they keep disappearing, and was sure it was not acceptable to provide polystyrene foam bowls to assisted residents, but we did not have anything else.
During an interview on 10/07/2024 at 1:20 PM, the Kitchen Manager (KM) stated the facility runs out of bowls when serving meals, like beans, and that it is not fair to serve residents requiring assistance on (polystyrene foam) bowls, but the food that was being served could not be put on a plate. The KM stated dinnerware bowls ran out when assisted resident meals were prepared, because the assisted residents were served last. The KM stated dinnerware was to be ordered from (global food distributor) through a grant because the budget for the year was limited.
During an interview on 10/11/2024 at 2:08 PM, the Director of Nursing (DON) stated Resident #25 was served food in bowls because the resident was able to hold the bowls. The DON believed the kitchen ran out of bowls because of the ham and beans being served and the assist tables are served last and the kitchen ran out prior to serving. The DON believed bowls were on order and that assisted residents should not have been served in (polystyrene foam) bowls if dinnerware bowls would have been available.
During an interview on 10/15/2024 at 3:12 PM, the Administrator stated there is no policy and procedure for dining service.
During an interview on 10/16/2024 at 2:45 PM, the Administrator stated he did not know why the kitchen did not have bowls and residents should not be receiving food out of (polystyrene foam) bowls and an order would have been placed if he had been made aware because it was an issue of dignity to have assisted residents receiving the (polystyrene foam) bowls. Assisted residents are the last to be served and if the kitchen was short on bowls that is why they received (polystyrene foam) bowls.

Based on document review, and in-service reviews, the facility failed to provide communication training for staff members.
Findings include:
Upon review the surveyor did not observe a communication training/in-service to staff members.
On 10/16/24 at 11:18 AM, during an interview with the Human Resource Director (HRD) she stated she was unsure what communications in-services would be, but she would look for that as well.
On 10/16/2024 at 2:00 PM, the HRD brought in in-services, but there were no communication in-services and the HRD revealed that's all she could find.
On 10/16/24 at 11:48 AM, during an interview with the Assistant Administrator she reported that there was no communication in-services performed for new hires or existing employees.
On 10/16/24 at 11:49 AM, during an interview, the Administrator revealed that a communication in-service would be important to have one so that it would increase communication with staff.
On 10/11/2024 at 2:30 PM, during an interview the Administrator reported that the they do not have all the required trainings, and it was 100% his fault.

Based on document review, and interviews, the facility failed to provide Quality Assurance and Performance Improvement (QAPI ) training upon hire and in services to direct staff for 1 of 1 facility.
Findings include:
A review of the undated policy titled, Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) Policy, revealed that all staff would be educated on the QAPI plan and the role in development and implementation of interventions.
Upon record review there was no QAPI trainings or in services for new hire employees or current staff.
On 10/11/2024 at 2:30 PM, during an interview with the Administrator, he reported that there was no QAPI training or in-services, for newly hired staff or current staff. The Administrator reported that they did not know that it had to be done. He stated it would be important to do so, because they want the employees to know when and how to report problems and so that the QAPI team could address issues within the facility. The Administrator also reported that they do not have all the required trainings. And it was 100% their fault.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain written authorization from the residents or their legal representatives for 2 of 6 residents (Resident #9 and Resident #21) personal funds.
Findings include:
On 10/14/2024 at 10:55 AM, the Administrator stated the facility did not have a policy for resident funds.
A review of the admission Agreement in Resident #9's admission Packet 1 signed by Resident #9's representative on 02/16/2017, revealed a written request for the management of the resident's personal funds was required. For the question, Do you wish the facility to manage your funds, No was circled.
A review of Resident #9's Trust Transaction History for the dates 10/01/2023-10/09/2024 revealed a running balance with deposits and withdrawals entered by the facility. The current balance as of 10/09/2024 was $1,645.34.
A review of Resident #9's admission Packet Section 2 and electronically signed by the Medical Director on 09/24/2019 revealed Resident #9 had dementia and was usually confused.
During an interview on 10/14/2024 at 12:08 PM, Resident #9's representative stated they were not aware the facility managed funds for Resident #9 or an account containing $1,645.34 as of 10/9/2024.
2. A review of the admission Agreement in Resident #21's admission Packet Section 1, signed by Resident #21's representative on 07/16/2015, revealed a written request for the management of the resident's personal funds was required. For the question, Do you wish the facility to manage your funds, No was circled.
A review of Resident #21's Trust Transaction History for dates 10/01/2023-10/09/2024 revealed a running balance with deposits and withdrawals entered by the facility. The current balance as of 10/09/2024 was $1,891.15.
A review of Resident #21's admission Record revealed a diagnosis of dementia.
A review of Resident #21's quarterly Minimum Data Set (MDS) dated [DATE] stated the resident had Brief Interview for Mental Status (BIMS) of 12, indicating the resident had moderate cognitive impairment.
During an interview on 10/14/2024 at 12:08 PM, Resident #21's representative stated they were not aware the facility managed funds for Resident #21 or an account containing $1,891.15 as of 10/09/2024.
During an interview on 10/14/2024 at 10:55 AM, the Administrator stated, yes, the facility had running accounts for Resident #9 and Resident #21. The administrator stated, the financial accounts have been a mess due to the previous bookkeeping employee.
During a follow-up interview on 10/15/2024 at 4:00 PM, the Administrator stated, the former assistant administrator had been terminated for embezzlement of the facility's money from the general operating account .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide quarterly trust fund statements to the residents or their legal representatives for 2 of 6 residents (Resident #9 and Resident #21) and failed to ensure generally accepted accounting practices were followed for 2 of 6 residents (Resident #7 and Resident #28) reviewed for personal funds.
Findings include:
On [DATE] at 10:55 AM, the Administrator stated the facility did not have a policy for resident funds.
1. A review of the admission Agreement in Resident #9's admission Packet Section 1, signed by Resident #9's representative on [DATE], revealed the nursing facility agreed to maintain written records of all financial transactions with the resident or legal representative including quarterly statements.
A review of Resident #9's Trust Transaction History for the dates of [DATE]-[DATE] revealed a running balance with deposits and withdrawals entered by the facility. All deposits are either from Resident #9's federal benefits or interest paid. All withdrawals are the resident's liability to the facility except one, a cash withdrawal on [DATE] for $638.63. No documentation or notes explain the withdrawal. The current balance as of [DATE] was $1,645.34.
A review of Resident #9's admission Packet Section 2, electronically signed by the Medical Director on [DATE] revealed Resident #9 had dementia and was usually confused.
During an interview on [DATE] at 12:08 PM, Resident #9's representative stated, they were not aware the facility managed personal funds for Resident #9 and had not received any quarterly statements. Resident #9's representative did not authorize the [DATE] $638.63 withdrawal from Resident #9's account.
2. A review of the admission Agreement in Resident #21's admission Packet Section 1, signed by Resident #21's representative on [DATE], revealed the nursing facility agreed to maintain written records of all financial transactions with the resident or legal representative including quarterly statements.
A review of Resident #21's Trust Transaction History for the dates of [DATE]-[DATE] revealed a running balance with deposits and withdrawals entered by the facility. All deposits are either from Resident #21's federal benefits or interest paid. All withdrawals are the resident's liability to the facility except for two. A cash withdrawal on [DATE] of $8.09 was documented to the Resident #21's pharmacy and a cash withdrawal of $296.91 on [DATE] had no receipt or documentation by the facility. The current balance as of [DATE] was $1,891.15.
A review of Resident #21's admission Record revealed a diagnosis of dementia.
A review of Resident #21's quarterly Minimum Data Set (MDS) dated [DATE] stated the resident had a Brief Interview for Mental Status (BIMS) of 12, indicating the resident had moderate cognitive impairment.
During an interview on [DATE] at 12:08 PM, Resident #21's representative stated, they were not aware the facility managed personal funds for Resident #21 and had not received any quarterly statements.
3. A review of the facility's general operating account's bank statements from [DATE]-[DATE] showed monthly deposits for Resident #7 from [DATE]- [DATE], and for Resident #28's federal benefit incomes into the operating account.
During an interview on [DATE] at 3:28 PM, the Board President stated an employee had been terminated who used the facility money for personal use. The Board President stated law enforcement was not contacted.
During an interview on [DATE] at 10:55 AM, the Administrator stated quarterly statements were either given to the residents or mailed to their representatives, but not certified. Administrator stated the facility did not have any poof of mailed statements. No documentation of receipts was provided for 4 online shopping purchases shown on the bank statements labeled as Patients Account. The Administrator stated, no knowledge as to what the purchases were or what resident they could be for, it was not the practice of the facility to keep records of purchases or authorization for purchases. The Administrator stated, the financial accounts have been a mess due to the previous bookkeeping employee. The Administrator could not answer why the amounts on the resident ledgers did not add up to the amount in the resident trust fund account. The Administrator agreed it could be unallocated funds of an existing resident, funds from an expired resident which never got paid out, or seed money used to start the account.
During a follow-up interview on [DATE] at 4:00 PM, the Administrator stated the former Assistant Administrator had been terminated for embezzlement of the facility's money from the general operating account. The terminated employee was not reported to law enforcement or prosecuted. The Administrator again acknowledged resident federal income was deposited in that same account.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify residents or their legal representatives when their personal fund account balances approached limits for Medicaid eligibility for 2 of 6 residents (Resident #9 and Resident #21) for personal funds.
Findings include:
On 10/14/2024 at 10:55 AM, the Administrator stated the facility did not have a policy for resident funds.
A review of the admission Agreement in Resident #9's admission Packet Section 1 signed by Resident #9's representative on 02/16/2017, revealed the nursing facility agreed to maintain written records of all financial transactions with the resident or legal representative.
A review of Resident #9's Trust Transaction History for the dates 10/01/2023-10/09/2024 revealed, on 11/29/2023, a balance of $1,843.25, and remained above $1,800 until 02/02/2024. On 07/03/2024 a balance of $2,472.02 was posted and remained above $1,800 until 09/30/2024.
A review of Resident #9's admission Packet Section 2 and electronically signed by the Medical Director on 09/24/2019, revealed Resident #9 had dementia and was usually confused.
During an interview on 10/14/2024 at 12:08 PM, Resident #9's representative stated, they were not aware the facility managed personal funds for Resident #9 and had not received any statements about balance limits or made aware of ramifications when personal assets reach maintain above an $2,000 balance.
A review of the admission Agreement in Resident #21's admission Packet Section 1, signed by Resident #21's representative on 07/16/2015, revealed the nursing facility agreed to maintain written records of all financial transactions with the resident or legal representative.
A review of Resident #21's Trust Transaction History for the dates of 10/01/2023-10/09/2024 revealed; 01/03/2024, a balance of $2,551.44, and remained above $1,800 until 02/02/2024 then increased to $1,867.49 on 02/03/2024 and remained above $1,800 until 03/31/2024, 06/03/2024 a balance of $2,494.84, and remained above $1,800 until 06/30/2024, 07/03/2024 a balance of $2,494.84, and was still above $1,800 on 10/09/2024, the day the Trust Transaction was requested.
A review of Resident #21's admission Record revealed a diagnosis of dementia.
A review of Resident #21's quarterly Minimum Data Set (MDS), dated [DATE], stated the resident had Brief Interview for Mental Status (BIMS) of 12, indicating the resident had moderate cognitive impairment.
During an interview on 10/14/2024 at 12:08 PM, Resident #21's representative stated they were not aware the facility managed personal funds for Resident #21 and had not received any statements about balance limits or made aware of ramifications when personal assets reach and maintain above a $2,000 balance.
During an interview on 10/14/2024 at 10:55 AM, the Administrator stated that the financial accounts have been a mess due to the previous bookkeeping employee. The Administrator says the paperwork is either given to the resident, or mailed to the resident's legal representative, but they have no proof of it being mailed.
During a follow-up interview on 10/15/2024 at 4:00 PM, the Administrator stated that the former Assistant Administrator had been terminated related to embezzlement of the facility money from the general operating account.

Based on observations and interviews, it was determined that the facility failed to ensure that the most recent state survey was posted and accessible for 48 of 48 residents.
Findings include:
On 10/15/24 at 12:00 PM, the Surveyor observed the state survey book at the entrance of the building. The book was in a plastic file holder on the wall, located underneath a bulletin board connected to a chain with the 2021 state survey results inside. Also, a wooden bench on floor beneath the bulletin board was observed, which would prevent a resident in a wheelchair from being able to reach the book.
On 10/10/2024 at 2:00 PM, during a Resident Council meeting, it was revealed that the residents present did not know where the state survey book was located.
On 10/15/2024 at12:45 PM, during an interview the Administrator revealed that he was unsure if the state survey book was posted. The book was located, and the Administrator verified that inside the survey book was the 2021 state survey results. When asked if the most recent survey should be in the book, he responded that he would assume so. The Administrator also revealed that only some of the residents would be able to access the book due to the height and the wooden bench on the ground in front of the bulletin board.

Based on observation, interview, and record review, the facility failed to notify the medical provider of a significant change in Resident 14's dental health resulting in pain when dental care was provided.
The findings include:
During a concurrent observation and interview on 10/08/2024 at 9:00 AM, the Surveyor was speaking to Resident #14 in the facility common room. When Resident #14 smiled at the Surveyor, the Surveyor noted what appeared to be blood coming from Resident #14's upper gums. The Surveyor interviewed the Certified Nursing Aid (CNA) #4 who touched Resident #14's lip. Resident #14 pulled away and stated that it hurt. CNA #4 stated it appeared to be blood on Resident #14's gums.
During an interview on 10/09/2024 at 10:00 AM, Certified Nursing Aid (CNA) #9 stated Resident #14's gums bleed often, and dental care had become very painful for Resident #14. CNA #9 stated the blood and pain with dental hygiene had been reported to Registered Nurse (RN) #13.
During an interview on 10/09/2024 at 10:30 AM, Registered Nurse (RN) #12 stated no one had reported a change in Resident #14's dental condition including bleeding from the gums or pain with brushing.
During an interview on 10/10/2024 at 11:00 AM, Certified Nursing Aid (CNA) #19 stated Resident #14 bleeds a lot during dental care and usually pulls away from dental care stating it hurts. CNA #19 denied reporting the blood or pain with dental hygiene to a nurse.
During an interview on 10/10/2024 at 11:30 AM, Licensed Practical Nurse (LPN) #11 stated she usually worked the area of the facility where Resident #14 resided and typically took care of Resident #14. LPN #11 denied receiving reports of a change in Resident #14's dental condition including blood coming from the gum or pain with dental hygiene. LPN #11 reviewed Resident #14's medical record, including notes, and was unable to find documentation of the change in Resident #14's dental condition.
Review of Resident #14's Diagnosis Report reveal diagnoses of vitamin D deficiency, reflux, Alzheimer's disease, dementia, grinding of teeth, and multiple issues of the eyes.
Review of Resident #14's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/29/2024 revealed Resident #14 scored 1 (severely cognitively impaired) on a Brief Interview for Mental Status (BIMS). Section GG: Functional Abilities and Goals reported Resident #14 required partial/moderate assistance with oral hygiene.
Review of Resident #14's Care Plan listed Resident #14 has an activities of daily living performance deficit related to Alzheimer's Disease and has oral/dental health problems related to poor oral hygiene, broken/loose/missing teeth, diagnosis of grinding teeth. Interventions included an oral care routine in the morning and at night: brush teeth, clean gums with toothette as needed, rinse with mouth wash. Coordinate arrangements for dental care, transportation as needed/as ordered. Monitor/document/report as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function, any signs or symptoms of oral/dental problems needing attention: pain (gums, toothache, palate), abscess, debris in mouth, lips cracked or bleeding, teeth missing, loose, broken, eroded, decayed, tongue (black, coated, or inflamed, white, smooth), ulcers in mouth, lesions. Provide mouth care as per activities of daily living personal hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Resident #23 was free from unnecessary medications.
The findings include:
A review of Resident #23's care plan dated 07/10/2023, did not report any use of marijuana or THC products.
A review of Resident #23's Minimum Data Set, dated [DATE]; Section J reported no documentation of Resident #23's marijuana use.
A review of Resident #23's Medical Diagnosis, reported the resident had diagnoses to include multiple sclerosis, weakness, asthma, motor neuron disease, chest pain, dependence on wheelchair, dementia, anxiety, insomnia, and depression.
A review of Resident #23's Physician Orders, reported barbiturates, oxygen, muscle relaxers, narcotics, a mixed drink as needed, and tetrahydrocannabinol (THC).
During a concurrent observation and interview on 10/9/2024 at 3:30 PM, THC gummies were observed in the medicine cart for the 500 Hall. Licensed Practical Nurse (LPN) #6 stated the THC Gummies belonged to Resident #23 and were brought in by a friend. LPN #6 stated the Medical Director prescribes the THC gummies for Resident #23. LPN #6 stated she did not know if the THC gummies were on Resident #23's care plan.
During a telephone interview on 10/9/2024 at 4:41 PM, the Medical Director stated Resident #23 had a medical marijuana card and Resident #23 was provided with THC gummies via Resident #23's healthcare proxy. The Medical Director stated that Resident #23 used the THC gummies for anxiety and pain relief. The Medical Director stated he was unaware of how Resident #23's healthcare proxy obtained the THC gummies. The Medial Director stated the orders for the THC gummies are provided to the nurses based on the concentration of THC in the gummies the healthcare proxy was able to obtain. The Medical Director stated the concentration of THC in the gummies varies from one supply to the next and the nurses notify the Medical Director and the order is adjusted. The Medical Director stated there is no protocol for the THC dosing as THC gummies are not FDA (Federal Drug Administration) approved. The Medical Director stated that as an employee of a federally funded facility the Medical Director is not licensed to dispense THC products.

Based on observations and interviews, it was determined that the facility failed to provide food items as listed on the menu and follow the recipe during food preparation to meet the needs of the residents in 1 kitchen reviewed for food preparation and service. Specifically, the facility ran out of food on the designated menu due to serving staff meals prior to serving the residents; allowing food to cook down on the steam table for two hours and forty-five minutes for lunch on 10/07/2024; not following the menu for lunch on 10/10/2024, and not taking measurements verify serving size.
Findings include:
1. A review of the facility menu, Spring/Summer 2024, Week 4, for Monday, 22, the menu indicated the lunch meal was to include ham & beans, squash, cornbread, margarine, sour cream pound cake, chilled peaches, and coffee or tea.
During a concurrent observation and interview on 10/07/2027 at 10:55 AM, Dishwasher (DW) #21 was serving staff lunch from the steam table line including squash. DW #21 stated the staff lunch was served from 11:00 AM - 11:30 AM
During an observation on 10/07/2024 at 12:27 PM, the Kitchen Manager (KM) sent the first plated food tray out for resident lunch.
During an observation on 10/07/2024 at 12:58 PM, the KM ran out of squash on the serving line while plating mechanical soft diet trays and requested Kitchen Aide (KA) #22 to cut up two uncooked tomatoes which were then used as substitution for the cooked squash on three mechanical soft diet trays.
During an interview on 10/07/2024 at 1:05 PM, the KM stated five bags of squash were used in preparation for lunch but when it cooks so much, it turns to liquid. The KM stated the squash was put on the steam table at 10:15 AM, prior to staff lunch being served. It was calculated that the squash had been on the steam table for two hours and twelve minutes prior to the start of the first resident tray being served and two hours and forty-three minutes when the mechanical soft trays were made, and the facility ran out of squash.
During an interview on 10/08/2024 at 4:40 PM, Dietary Manager (DM) #14 stated, staff were served lunch prior to the residents, due to the staff break time was prior to the resident's lunch service. When asked if residents who pay to reside in the facility should be served before staff to ensure the residents receive the nutrition that the facility is being paid to provide, DM #14 stated the staff needed to eat as well. DM #14 stated food should only be on the steam table forty-five minutes prior to residents being served. DM #14 stated, when food is over cooked, it gets watered down it becomes unappetizing and loses nutritive value. DM #14 stated uncooked tomatoes were not adequate substitution for cooked squash intended for a mechanical soft diet.
2. A review of the facility menu, Spring/Summer 2024 Week 4, Wednesday 25, the menu indicated the lunch meal included herb pork loin, baked sweet potatoes, brussels sprouts, dinner roll, margarine, buttermilk pie, and coffee or tea. No brussels sprouts were served, instead carrots were prepared.
During a concurrent interview and observation on 10/10/2024 at 10:42 AM, [NAME] #23 prepared pureed foods for lunch and used a slotted spoon to get 2 scoops of already cooked sweet potatoes from a simmering pot on the stove. [NAME] #23 stated she did not use a measured scoop, but just eye-balled 8 ounces (oz). [NAME] #23 added the sweet potatoes with an unmeasured amount of milk to the food processor and stated it was 1/4 a cup. [NAME] #23 verified it was not measured, but eye balled. [NAME] #23 stated she had been cooking her entire adult life and did not need to measure, because she just knew. [NAME] #23 stated the sweet potatoes pot had 6.75 pounds of canned yams, 1 cup of milk and 1/2 cup of butter. [NAME] #23 then used a pair of tongs to retrieve pork loin from the steam table to a stainless-steel container, no measurement was done for serving size and [NAME] #23 eye balled for the pureed pork loin. [NAME] #23 stated 1.5 teaspoons of powdered pork base and 12oz. of hot water was mixed and added to the pork loin puree. A plastic disposable spoon was used to measure the powdered pork base, and no measurements were done on the water. After [NAME] #23 mixed the pureed pork loin, the mixture was runny, and thickener was added to thicken the mixture back up. No measurements were done. [NAME] #23 used a slotted spoon to transfer the carrots into stainless steel container without any measurements. [NAME] #23 stated the carrots had 1/2 cup of butter and 1/2 cup of brown sugar. No amount was given for the carrots.
3. A review of the Herbed Pork Loin Quantified Recipe-760 for puree, dated 03/26/2024 at 3:22 PM, indicated the serving size for five residents would be 15 oz of pork loin with 1/2 cup plus 2 tablespoons of water or stock. The surveyor was unable to verify the recipe due to [NAME] #23 not taking any measurements.
A review of the Whipped Sweet Potatoes Quantified Recipe-762 for puree, dated 03/26/2024 at 3:22 PM, indicated for pureed diet, to top whipped sweet potatoes with 1 tablespoon of butter. No milk was to be added only butter.
During an interview on 10/10/2024 at 3:00 PM, DM #14 stated that [NAME] #23 had received the same training as the other staff in the kitchen and it was not correct to leave ingredients out of recipes because it takes away from the nutritional value. DM #14 acknowledge when food was prepared for the residents' measurements should be done. No reason was given for the substitution of brussels sprouts with the carrots.

Based on observations and interviews, it was determined that the facility failed to provide privacy for 1 of 1 Resident (Resident #47).
Findings included:
After a request for a dignity policy. It was reported that the facility did not have a dignity policy.
A review of Resident #47's admission Record, revealed the resident's medical diagnoses included: dementia and generalized anxiety disorder.
On 10/11/2024 at 9:00 AM, this surveyor was standing beside the nurses' desk when the residents' main bathroom door was opened by Certified Nursing Assistant (CNA) #7 asking for the surveyor to get help. Upon opening the door wide, the resident was exposed with pants and brief pulled down standing in front of the toilet in eyesight of this surveyor. The CNA then shut the door.
On 10/11/24 at 10:25 AM, during an interview, the Environmental Director revealed that there had been a bell attached to the emergency call light, in the resident's bathroom. The surveyor then observed a bell attached to the string hanging from the call light string.
On 10/11/24 at 10:40 AM, during an interview CNA #7 revealed that the call light in the bathroom did not work and had no other way of calling anyone for help. CNA #7 reported that the resident was anxious, and she needed assistance. When asked if there was a bell in the bathroom she did not know if there was or not.
On 10/14/2024 at 1:30 PM, during an interview the Director Of Nursing (DON) revealed that the residents' bathroom by the nurses' desk had a bell in there for them to call for help. The DON also revealed that the CNA should have only cracked the door just enough to poke their head out or use the bell to signal for need for assistance.

Based on observation, interview, and record review, the facility failed to provide residents who used the shower hallway with a safe, clean, homelike environment.
The findings include:
Review of facility provided Maintenance Log, dated 03/04/2024 stated outside of the double shower, the floor is leaking.
During the initial facility rounding on 10/7/2024 at 11:05 AM, this Surveyor noted a section of the facility hallway that had the flooring removed exposing the concrete foundation with non-skid tracks laying down and three blankets rolled up and pressed to the far-right wall.
During an interview on 10/7/2024 at 5:00 PM, Certified Nursing Assistant (CNA) #9 stated the flooring had been removed due to a leak from the far-right wall. CNA #9 stated that it was difficult to get residents into the shower room due to the flooring being removed and stated staff had to remain vigilant when transporting residents into the shower rooms due to the holes in the door frames to the shower room.
During an interview on 10/7/2024 at 5:30 PM, the Environmental Director stated the flooring was removed in the hallway due to a leak in the far-right wall. The Environmental Director stated that blankets were placed against the far-right wall to absorb any water that drained from wall. The Environmental Director stated that the floor had been removed and the wall had been leaking for approximately five months. The Environmental Director stated he did not think about the hazards of the jagged door frames to the shower room presented to resident safety. The Environmental Director stated the facility had gotten verbal quotes to fix the floor and wall, but no copy was available.
During an interview on 10/9/2024 at 7:55 AM, the Assistant Administrator stated that the floor had been removed due to the walls leaking, and the issue had been ongoing for months. The Assistant Administrator stated that the door frames appeared to be rusted and that the holes appeared to be deep. The Assistant Administrator stated that this posed an issue for the residents who used the hallway and those that used the showers. The Assistant Administrator stated that quotes had been provided to fix the area, but no documentation of the quote or repair process was available.
During a concurrent record review and interview, on 10/16/2024 at 8:00 AM, review of the Estimate from the contracted repair company reported repair costs of $17,500. The owner of the contracted repair company was interviewed via phone, the owner stated the wall was not inspected for rust or any type of damage, estimate was provided off of the walk through only.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to ensure a resident was free from physical abuse for 1 (Resident #21) resident, who was heard yelling out at the contract lab technician to not draw the resident's blood. Specifically, Certified Nursing Assistant (CNA) #1 physically restrained Resident #21 while the resident's blood was drawn.
It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, §483.12 (Freedom from Abuse, Neglect, and Exploitation) at a scope and severity of K.
The IJ began on 10/07/2024 at 1:52 PM, when Resident #21 was heard yelling, crying, and begging, from room [ROOM NUMBER], by the surveyor and facility staff. The surveyor and a facility staff member entered room [ROOM NUMBER] and observed a contracted laboratory technician standing next to Resident #21 with lab supplies to perform a blood draw.
The Administrator, Director of Nursing, and Business Office Manager were notified of the IJ on 10/08/2024 at 5:31 PM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 10/13/2024 at 1:15 PM. The IJ was not removed prior to exit from the facility on 10/16/2024 at 6:00 PM.
Findings include:
A review of a facility policy titled, Patient Abuse/Neglect, dated 2017, outlined the policy and procedures for investigation and reporting of alleged violations that included abuse and neglect. The procedures included reporting alleged violations to the state agency, immediately performing an investigation, Protection: indicated the accused employee will be immediately sent home and immediately placed on suspension. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Training of employees includes appropriate interventions, examples of reportable incidents to assist staff in detection of such incidents, shall be done on admission and annually.
A review of an undated facility policy titled, Your Rights and Protections as a Nursing Home Resident revealed, residents have a right to be free from verbal, sexual, physical, and mental abuse.
A review of an undated facility document titled Resident Rights, revealed residents have rights that included being treated with dignity and to live in a safe, homelike environment.
A review of an undated facility document titled N.A./C.N.A. [Nursing Assistant/Certified Nursing Assistant] Job Description revealed CNAs perform care and related duties for disabled, physically ill, and geriatric residents. Duties and responsibilities included communicating with residents and the nurse and assisting with safety measures.
A review of the Employee Handbook, dated 2023, page 3 revealed Any allegation, suspicion or witnessed events of abused (sic), neglect, or theft must be reported immediately to: and listed individuals and agencies to be notified. Page 20 of the handbook indicated Grounds for Immediate Dismissal included verbal or physical abuse, speaking rude or disrespectful to anyone, disregard or violation of facility policies, or use of profanity. Page 21 of the handbook contained a Patient Abuse/Neglect policy, with a change effective date of 09/25/2017, number 15. §483.5 Definitions defined Abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Page 24 included a signature line and date for the abuse and neglect policy. A document titled Inservice Instructor Video, Handout or Review on Page 56 included a list of in-services, including Adult and Long-Term Care Facility Resident Maltreatment, and a signature line for the employee attending the in-service.
A review of in-services provided by the facility included Abuse, Neglect, & Misappropriation/Exploitation with signature pages. The In-service Education Report indicated it was an all-staff in-service, with dates of 12/06/23, 2/14, 6/12, and 8/9, and included the types of abuse with definitions and how to report abuse.
A review of Certified Nursing Assistant (CNA) #1's personnel file revealed on 05/29/2024, CNA #1 received abuse training, and signed a reporting and corrective action document that revealed, any employee shall immediately notify the Administrator regarding abuse. CNA #1 signed an attendance document titled, Inservice Instructor Video, Handout or Review, that included training on identifying and reporting abuse and neglect, on 05/29/2024.
A review of the [Contracted Lab Name] Services Agreement with an effective date of 10/04/2022, indicated the contracted laboratory company was the Provider, and shall comply with policies provided by the facility.
A review of the [Contracted Lab Name] Handbook for Policies and Procedures dated 06/7/2022 did not address abuse of residents or patients.
A review of the admission Record, indicated the facility admitted Resident #21 with diagnoses that included depressive disorders and anxiety disorder.
The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/09/2024, revealed Resident #21 had a Brief Interview for Mental Status score of 12 which indicated the resident had moderate cognitive impairment. No mood or behavior was indicated. Resident #21 required partial to moderate assistance with shower/bathing and toileting, required setup or clean-up assistance with eating and oral care and was independent with dressing and personal hygiene. Resident #21 used a manual wheelchair for ambulation.
A review of Resident #21's care plan initiated, 06/21/2023 revealed no focus or intervention for anxiety or fear of needles.
A review of Order Summary Report, revealed Resident #21 had laboratory orders for blood tests that included, Lipid panel every 6 months with an order date of 10/04/2024, CBC (complete blood count) every 91 days with an order date of 05/26/2023, CMP (comprehensive metabolic panel) every month with an order date of 10/04/2024, Dilantin every 91 days with an order date of 05/26/2023, Keppra, Lacosamide, Phenobarbital every 91 days with an order date of 05/26/2023, NH3 (Ammonia) level every 91 days with an order date of 05/26/2023, and a BMP (basic metabolic panel) on 10/10/2024.
A review of October Medication Administration Record, did not reveal Resident #21 had any laboratory draws done.
A review of the October Treatment Administration Record, did not reveal Resident #21 had any laboratory draws done.
During an observation on 10/07/2024 at 1:52 PM, the surveyor heard yelling, crying, and begging from a room on 200-hall. Resident #21 was sitting in a recliner, their legs were elevated and covered with a blanket. Resident #21 was pleading Please no, don't, not today. I don't want to, not today. Resident #21 repeatedly stated no to the man standing next to the recliner, while shanking head side to side, with voice raised, tears in eyes and on cheeks, arms crossed over chest and pulled blanket upward to cover arms. Resident was looking at a man in in blue scrubs, who identified himself as Phlebotomist with the contracted lab company, to draw blood for an Ammonia test.
At 2:03 PM, CNA #1 entered Resident #21's room and stated they heard yelling and came to see what was going on. Resident #21 grabbed CNA #1's left hand and tearfully said I just don't want this. Phlebotomist asked to look at Resident #21's arm and Resident #21 stated, I don't want this. Phlebotomist placed tourniquet on Resident #21's left arm, Resident #21 actively crying and looking at CNA repeating No. Resident #21's right arm remained under blanket. Phlebotomist removed the tourniquet from the left arm and moved to Resident #21's right side. CNA #21 moved to Resident #21's left side and held resident's left arm, while the Phlebotomist placed tourniquet on Resident #21's right arm. Resident #21 continued to cry stating they did not want the blood draw. CNA #1 let go of resident's left arm and moved to close door. The Phlebotomist stood up to gather supplies. The surveyor asked CNA #1 what Resident #21 was saying. CNA #1 stated, No, and did not want to have blood drawn. CNA #1 was asked if blood should be drawn if the resident says no. CNA #1 did not respond and left the room. Phlebotomist stated blood would not be drawn blood until the nurse returned. Resident #21 again stated they did not want to have blood drawn. CNA #1 reentered the room, moved to Resident #21's left side and held Resident #21's hand and arm. Phlebotomist placed tourniquet on Resident #21's right arm and began to move toward resident with the needle. Shaking their head side to side, Resident #21 repeated the word no. Surveyor asked Phlebotomist, If the resident is saying no, refusing, should you continue to draw the blood? Phlebotomist responded that is why the nurse is here because some people are apprehensive. The phlebotomist proceeded to insert the needle into Resident #21's right arm and obtain blood in vials. Resident #21 continued to cry looking at the CNA.
During an interview on 10/07/2024 at 2:09 PM, CNA #1 stated they do have a duty to care for and protect residents. If a resident says no then we should not do something. [Pronoun] grabbed my hand, so I stayed. Residents should be allowed to say no, and I probably should have gone to get my nurse. CNA #1 stated the residents should not be forced to have a procedure that they do not want and that is abuse. CNA #1 walked away and was observed with tears in eyes.
During an interview on 10/07/2024 at 2:12 PM, Resident #21 stated, If I say no, they do it anyway because the doctor needs it. I am scared of needles. I feel terrible and this was supposed to be my shower day and now I can't do it. I just can't. Resident observed writhing hands, rubbing legs, and wiping tears from right cheek.
During an interview on 10/07/2024 at 2:19 PM, the Director of Nursing (DON) was notified of the abuse. The DON stated Resident #21's refusal should have been accepted, and staff should have notified the nurse of the refusal. I will speak with the lab tech and the aide.
During an interview on 10/07/2024 at 4:10 PM, the DON stated the Administrator was notified of the situation with Resident #21 and Resident #21 was interviewed. CNA #1 and Phlebotomist were reeducated on what to do if a resident refuses blood work. The Phlebotomist finished blood draws and was not asked to leave the building. The DON stated she did not believe this was abuse, only a misunderstanding.
A review of the [Contracted Lab Name] Patient Service Log dated 10/07/2024, revealed Resident #21 had routine blood drawn at 2:00 PM, by Phlebotomist. The Phlebotomist drew blood on two (2) additional residents after leaving Resident #21's room.
A review of the [Contracted Lab Name] Patient Service Log dated 10/08/2024 revealed the Phlebotomist returned to the facility and had contact with 7 residents.
On 10/09/2024 at 10:53 AM, a policy and procedure on specimen collection for the contracted lab and the facility was requested from the DON. The DON stated the contracted lab would be contacted to obtain that information and did not believe the facility had a policy and procedure.
During an observation on 10/10/2024 at 11:45 AM, at the front entry, an employee of the (contract lab) was speaking with the DON and stated, They fired him referring to the Phlebotomist, and the DON replied, I heard.
During an interview on 10/14/2024 at 10:10 AM, the Administrator stated the first incident of abuse was reported to the State Agency on 10/08/2024 at 10:54 AM but should have been reported 2 hours after the notification to them was made. The Administrator stated a pre-investigation was being done to see if there was a miscommunication to do a soft file, but there was no miscommunication. The second incident was sent to the State Agency at 4:30 PM on Friday (10/11/2024). A soft file was described as an incident needing education. The Administrator stated he was not aware of another incident and reported two.
During an interview on 10/11/2024 at 11:49 AM, CNA #8 stated upon hire staff receive training on abuse and neglect and are paired with a skilled CNA for orientation on the hall. CNA #8 stated abuse and neglect are mentioned quite a bit, and are required to sign a form during the in-service, which includes the types of abuse and how to report it to the nurse, DON and the Administrator. CNA #8 stated after the in-service presentation, questions were answered if they have any, and forms are handed out on abuse.
During an interview on 10/11/2024 at 12:21 PM, Licensed Practical Nurse (LPN) #11 stated upon hire, in-services on Dementia, peri-care and proper transfer was received and training on the floor with a nurse was done. LPN #11 stated a packet including Resident Rights, including abuse and neglect, and Dementia training was also provided. LPN #11 stated the last in-service on abuse and neglect was on Wednesday (10/09/2024) and included a print off of Resident Rights that included types of abuse, how and who to notify, the CNA is to notify the nurse, and the nurse is to notify the Administrator and DON. LPN #11 stated they had to report abuse in the past, could not recall when, stated before January, and notified the Registered Nurse (RN) on duty, sent the person home after they wrote a statement, and the Administrator, police and state were notified. LPN #11 stated the resident involved would be monitored and the physician would be notified of changes. When asked how LPN #11 ensured staff understand and are able to identify abuse, LPN #11 stated it was like mouth care and if someone didn't know how to perform it, they would ask for assistance.
During an interview on 10/11/2024 at 2:22 PM, the DON stated initial training on abuse and neglect was done upon hire, by the Human Resource Director (HRD). The DON stated abuse and neglect training that includes the type of abuse, who and when to report to is done at least yearly by the DON or Administrator and is followed by a test to ensure staff understood the information. The DON stated CNA #1, CNA #2 and CNA#3 should have received training on abuse and neglect, in the hiring packet, in-services are done yearly, and follow-up should have been done. The DON stated the follow-up is asking questions and getting feedback. The DON stated that when made aware of the abuse involving Resident #21 and Resident #23, an investigation was done that included talking to all parties involved and reporting to the state agency, Medical Director, police, and families. Physician orders received for Resident #21 and Resident #23 were for vital signs every shift for 3 days. Resident #21 did not receive any medical evaluation or referral.
During an interview on 10/15/2024 at 12:02 PM, the Human Resources Director (HRD) stated new Staff training/orientation begins with Long Term Care Training videos viewed by the employee on an online video sharing platform. HRD stated the facility did not have a DVD player to show DVDs, so the online video sharing platform video for Abuse, Neglect, Exploitation, and Misappropriation Property, by NORC Ombudding, along with the video titled, Resident Rights in Action, from the Pennsylvania State Ombudsman, were used by the facility. The HRD stated personal stories are also used. Orientees were expected to watch the videos and attest that they have watched them by signing the Inservice Instructor Video, Handout or Review in the employee handbook. The HRD stated follow-up with staff is done during the video training and staff are told to call if they have a question on the new hire training. CNA #1 received training on abuse and neglect. The HRD stated CNA #1 sat down with the HRD and went through the employee handbook page by page together. The HRD stated CNA #2 and CNA #3 were employed prior to HRD taking position and both received in-services and updates with other staff. After abuse and neglect in-services staff sign they attendance and interact with questions and answers, We keep an open dialogue. HRD stated the last in-service on abuse and neglect was done by the Administrator last week.
During an interview on 10/16/2024 at 4:37 PM, CNA #1 stated new hire training included an assigned trainer watching tasks being performed and signing off on a competency list, and prior to hire did watch some videos but did not recall any training on abuse and neglect. CNA #1 stated no training, or in-service was received after Resident #21's abuse allegation, and stated they were not suspended because they were not scheduled to work the remainder of the week.
During an interview on 10/14/2024 at 12:10 PM, the Assistant Director of Nursing (ADON) stated information was received regarding Resident #21 and Resident #23 abuse allegations during the daily debrief. Discussion included care planning fear of needles for Resident #21, and unless there was a total refusal during the lookback period it would not be placed on the MDS. The ADON was not aware of any referral treatment for Resident #21.
During an interview on 10/16/2024 at 10:20 AM, CNA #9 stated training on abuse and neglect was received last week, and had not had anyone complain, and had not witnessed anyone being forced to do anything after saying no and had not witnessed abuse.
A review of an Inservice Education Report, dated 12/06/2023, 02/14/2024, 06/12/2024, and 08/09/2024, revealed the topic was Abuse, Neglect & Misappropriation/Exploitation, and included signature pages of staff attendance. CNA #1 and CNA #9 attended the in-services on 06/12/2024 and 08/09/2024.
During an interview on 10/16/2024 at 3:27 PM, the Administrator stated the abuse should have been immediately reported and was not as It did not register that it was abuse. The Administrator stated the CNA should have gotten a nurse, and the nurse should have intervened. The Phlebotomist should have been removed from the room, and the building. The Administrator stated it was not presented as abuse, it was presented in a calm way, by the DON, and that the CNA needed to be educated.
Removal Plan:
On 10/8/2024, upon notification of deficient practice to report abuse allegations, the facility took the following measures:
At approximately 10:30 PM, the Administrator notified DHS via portal of abuse allegation pertaining to Resident #21.
At approximately 12:15 PM, the Director of Nursing (DON) provided verbal education to Certified Nursing Assistant (CNA) #1 and contracted lab technician in question pertaining to resident's right to refusal, and types of abuse. CNA #1 out of facility on suspension at this time. Lab tech exited facility after verbal education with DON. DON contacted lab techs supervisor. Lab supervisor reported that lab company will provide education to employee, and are supposed to follow up with facility/DON the afternoon of 10/9/2024.
On 10/11/2024 at 4:32 PM, Administrator completed and submitted 7734, notification of abuse allegation to DHS, via portal.
The Administrator provided education at all staff in-service held 10/9/2024 at 2:00 PM about resident rights and types of abuse. Staff unable to attend scheduled in-service will be provided a handout by Human Resources then they come to facility to pick up checks. Any remaining staff will be contacted for one on one education prior to the start of their next shift.
On 10/11/2024, the Administrator provided immediate verbal in-service to staff currently in the facility. Witness statements provided to staff. DON educated nurses. Witness statements provided to nurses with notification placed on 24-hour report sheet.
The Social Services Director (SSD)/Designee to interview all residents with a Brief Interview for Mental Status (BIMS) of 13 or above pertaining to if they have ever felt or have any knowledge of abuse occurring within the facility.
Second shift charge nurse to perform body audit on all non-cognitive residents and those scoring a 12 or below on BIMS quarterly assessment to check for discoloration or bruising.
On 10/11/2024, DON interviewed all residents with a Brief Interview for Mental Status (BIMS) of 13 or above pertaining to if they have ever felt, or have any knowledge of abuse occurring within the facility. Second shift floor nurses- with the assistance of DON and additional nursing staff- to perform body audits on all residents-both cognizant and non-cognizant- as they will allow.
DON/Designee to monitor resident areas for possible abuse occurrences twice a day for 8 weeks or until compliance is confirmed and verified by OLTC. Any negative findings will be reported immediately to Admin.
All corrections were completed on 10/11/2024.
Onsite Verification:
The IJ was removed on 10/29/2024 after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on 10/09/2024 at 2:00 PM when a mandatory meeting providing in-service on resident rights and abuse was completed. Staff in-serviced on resident rights and types of abuse, Social Services Director interviewed all residents with Brief Interview Mental Status (BIMS) of 13 or greater, second shift charge nurse conducted body audits on all non-cognitive residents and those with a BIMS of 12 or less, and Director or Nursing (DON) monitored resident areas for possible abuse occurrences twice a day. A total of 12 staff interviews were conducted with staff from all shifts to verify training had been completed. The staff interviewed included Certified Nursing Assistants, Licensed Practical Nurses, Registered Nurses, Kitchen Aide, Hospitality Services, and Environmental Services. The staff interviewed verified they had been trained on resident rights an abuse. A review of in-service sheets provided indicated 65 of 71 had been provided training.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a cognitively impaired resident did not exit the facility without staff knowledge for 1 (Resident #1) of 3 (Residents #1, #2, #3) sampled residents who were at risk for elopement, as evidenced by failure to ensure the locking mechanism on a door was in proper working order allowing Resident #1 to exit the facility. Resident #1 was missing for approximately 30 minutes and was found lying on the ground adjacent to a facility parking lot. The resident sustained a hematoma. The facility failed to ensure all residents were accounted for; no residents were reassessed for risk of elopement; no education was provided to staff; no assessment or monitoring of the remaining facility door locking mechanisms were put in place to prevent lock failures; facility elopement policy lacked clearly defined mechanisms and procedures for assessing or identifying, monitoring, and managing residents at risk for elopement. The failed practice resulted in non-compliance at the level of Immediate Jeopardy and placed a risk to the resident's health and safety, and placed the resident at risk of weather exposure, other medical complications, and being struck by a motor vehicle. The failed practice had the potential to cause serious injury, serious harm, serious impairment, or death to 5 residents who were at risk for elopement, as documented on a list provided by the Administrator on 12/12/23. The Administrator was informed of the Immediate Jeopardy situation on 12/13/23 at 11:47 AM. The findings are:
Resident #1 had diagnoses of Depression, Alzheimer's disease, Dementia, Psychotic disturbance, Mood disorder and Anxiety. The Annual Minimum Data Set with an Assessment Reference Date of 9/28/23 documented the resident scored 4 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status; wandering occurred 1 to 3 days; ambulates independently with a walker.
An Elopement Risk assessment dated [DATE] noted a score of 3, indicating at risk for elopement. The assessment answered 'yes' to the following questions: Does the resident have a history of attempting to leave the facility without informing staff? Has the resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door? Does the resident wander? Is the wandering behavior a [NAME], goal-directed (i.e., specific destination in mind, going home, etc.)? Does the resident wander aimlessly or non-goal-directed (i.e., confused, moves without purpose, may enter other's rooms, and explore other's belongings)?
Documented in the Comprehensive Plan of Care with the date initiated on 9/28/23 and a revision date of 10/20/23 a focus problem of an elopement risk/wanderer related to Impaired safety awareness, Resident wanders aimlessly. The goal: the residents ' safety will be maintained through the review date. The following interventions were documented: Assess for fall risk. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Monitor for fatigue and weight loss. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. The resident's triggers for wandering/eloping are time of day, usually around 3-4. The resident's behaviors is de-escalated by reorienting resident to her room, talking on the phone with family. Additional problem initiated on 9/28/23 with a revision date of 10/20/23: the resident has impaired cognitive function/dementia or impaired thought process3es related to Alzheimer's; the resident will develop skills to cope with cognitive decline and maintain safety by the review date; with an intervention of cue, reorient and supervise as needed.
Progress notes reviewed for the past 120 days revealed Resident #1 was experiencing increased anxiety and exit seeking behaviors on 8/30/23, 9/25/23, 10/7/23, 10/20/23 and 10/21/23.
A Progress Note dated 12/8/23 documented, Resident noted to be missing from building at 1730 [5:30 P.M.]. All staff pulled to search for resident. Laundry room door open with resident's walker in doorway. Resident found lying in grass on right side outside laundry room door with feet towards curb. Large knot noted to right temple. MD [Medical Doctor] notified with new order received and noted may send to ER [emergency room] if shows signs of ICP [increased intracranial pressure]. Administrator notified. Family notified. [Local Police Department] notified.
On 12/12/23 at 1:44 PM, during an interview, the Administrator reported on 12/8/23 Resident #1 exited the building through service corridor that goes to dietary and laundry. The Administrator stated, The lock on it [the door going from 500 hall into the corridor/hall to the kitchen and laundry area] failed. [Resident #1] got through it and then to the laundry area, got to one of the doors and wedged her walker and that is when she got out. That is how they found her after they found her walker. Every door going out has a lock. So, I came up that night and replaced it with a keypad lock. We made sure the door pulls were adjusted appropriately. The Administrator confirmed Resident #1 had a history of wandering and exit seeking. He was asked to provide the facility elopement policy and procedure.
On 12/12/23 at 1:53 PM, the Administrator provided a copy of a completed facility reported incident of Resident #1's elopement that was submitted to the state agency on 12/12/23. The incident report contained the following information: Notifications: Administrator, Doctor, Family, Law Enforcement. Description of Incident: Resident opened service hall door and proceeded to laundry area. Resident was able to open laundry room door and exit out the rear of the building. All staff pulled to search for resident. Resident found lying in grass outside of laundry area, with a large knot noted to right temple. Resident's current medical condition: Bruising to resident face with knot noted. No noted changes in cognition. Nursing staff continue to monitor resident for any notable changes. Resident currently at baseline. Findings and Actions Taken: Resident ambulated to service hall door, lock had not engaged properly, and resident able to open door and exit towards laundry room. Admin [Administrator] immediately replace door mechanism with electronic keypad at 2000 [8:00 PM] on 12/8/2023 to ensure this did not recur. Maintenance then adjusted all doors in service hallway to ensure self-closing mechanism was effective.
On 12/12/23 at 3:14 PM, the Administrator provided a document titled, 'Elopement of Resident Policy. The policy outlined the search procedure when it became known a resident was missing. Preventive measures will be the responsibility of the Administrator and Director of Nursing. What we do to try to prevent an elopement: On admission and Elopement Risk Assessment will be completed. Talk to family about their usual routines. Report all elopement attempts immediately to supervisor. Involve them in activities that satisfy their needs. There were no other instructions.
On 12/12/23 at 3:33 PM, during an interview with Registered Nurse (RN) #1, the nurse caring for Resident #1 at the time of elopement. The Surveyor asked if she could describe the incident of Resident #1's elopement from the facility. She reported that the resident was up at the nursing station at approximately 5:30 PM and was crying. RN #1 stated, I was going to give her prn [as needed] pain meds, I thought she might be hurting. She paces a lot, frequently in the evenings. After I pulled her meds [medications], she was not there. I thought she had walked down the hall to her room. I asked the CNAs [Certified Nursing Assistant] if they had seen her. The CNAs searched up the halls and rooms, couldn't find her. I pulled everybody to look for her. I called the DON [Director of Nursing]. [Environmental Technician] went down toward laundry and saw her walker was in the door. He went out the back door. I called the cops when we couldn't find her. When they found her, we got her in the building. She had a hematoma on the right side of her head. Called the doctor, he said we needed to make sure we had some kind of security system on the door. He said to do neuro checks and 15 minute checks and if she had any problems to send her to the ER [emergency room]. [Environmental Technician] said she was laying by the vehicle out the back door. The Administrator came in and put a lock on the door. There was a locking mechanism, but it wasn't working. RN #1 denied knowing how long the lock on the door did not work. RN #1 confirmed Resident #1 had a history of exit seeking; confirms resident was missing approximately 30 minutes. When asked if she had resident elopement training, she stated, Yes, find the resident, if you can't find them, call the police, call the DON, Administrator, Physician. RN #1 was asked if she had checked on the other residents to confirm everyone was accounted for once Resident #1 was located. RN #1 said that the staff went in everybody's room to look for Resident #1 and her concern was with that patient. When asked again if she confirmed all other residents were accounted for, she stated, No.
On 12/12/23 at 3:48 PM, during an interview with the Environmental Technician, he was asked to describe what happened when Resident #1 was missing on 12/8/23. He stated, She came up missing, we all looked around here. I went down through the hall, both doors to laundry was locked. I seen her walker in the door, ran up the front to tell them she was probably outside. The CNA went and found her in the parking lot. It is scary, we are right by the road. When asked if he was aware if the resident had a history of exit seeking or trying the doors. He stated, She is always crying out, wanting to go home. When asked if she tries the doors. He stated, Oh, yes. The Environmental Technician confirmed the door locking mechanism did not work.
On 2/12/23 at 4:45 PM, the Administrator was asked if the staff are trained on elopement. He said it was in the hire packet, so they are trained on hire and quarterly. He was asked if the locks on the doors were checked for proper functioning. He said he was not sure. He was asked if the facility conducted emergency drills, and if they had an elopement drill. He said they had no elopement drills and stated, But we will now.
On 12/12/23 at 4:54 PM, the Administrator was asked to show the Surveyor the door that the lock failed on; the door the resident exited the building, and where the resident was found. The Administrator pointed out the door at the beginning of the 500 Hall with a keypad lock that went down a hall or corridor that led to the kitchen entrance and then 2 doors that lead into the laundry area. The resident's walker was found wedged at one door that led to the back of the building. Outside this door was a truck loading dock and an incline from the building. Another door exited to the side and is where the resident was found lying in the grass at the edge of a parking lot on the side of the building.
On 12/12/23 at 5:00 PM, the Surveyor asked the Environment Director if he was maintenance. He confirmed he did maintenance. He was asked if he checked the facility door locks functioning to make sure they were working. He said, Every time you go in and out. He was asked if he monitored the functioning of the doors on a regular basis. He stated, Just when someone says something is wrong.
On 12/13/23 at 8:58 AM, during an interview with the DON, she was asked to describe the process if a resident is missing in the facility. She said the nurse looks for the resident, then staff help look, then they call the DON, the Administrator and then they call the police and continue looking. She was then asked to explain what happened on 12/8/23 when Resident #1 eloped from the facility. She said the nurse called and said they could not find her. They looked for 15 minutes and called the police. They continued looking. The DON stated, I called them when I was on the way. By the time I got here they had found her. The DON confirmed Resident #1 had been missing approximately 30 minutes. The resident was found outside the laundry hall. Her walker was by the door by the dock, she was found outside the other door. She had an abrasion and bruise to the right side of her face. When asked what was done for the resident she said, Neuro checks and 15 minute checks. The DON said she did not think Resident #1 had ever gotten out and confirmed she is a wanderer and would exit seek. When asked if staff received training on resident elopement, she said she was not sure probably yearly. She was asked if she was aware of any other elopements. She said years ago. She was asked if the doors were monitored for functioning. She stated I don't know. If I notice it not locking, I notify someone. She was asked if risk assessments were completed on residents to include elopement risk. She said they are done quarterly. She was asked if a resident was at risk, what was done. She said they care plan it and educate the staff. She was asked if all residents were accounted for after Resident #1 had eloped on 12/8/23. She stated, I think that is part of looking for someone, but I don't think we did a check. She was asked if any resident was reassessed for risk of elopement. She stated, No.
On 12/13/23 at 11:47 AM, the Administrator was provided an IJ template and was notified the facility was in noncompliance and in Immediate Jeopardy for not providing adequate supervision to prevent a cognitively impaired resident who had a history of exit seeking from exiting the facility unknown to staff through a door with a failed locking mechanism. The resident was missing for approximately 30 minutes and was found lying on the ground adjacent to a facility parking lot. No residents were reassessed for risk of elopement, no education was provided to staff, no assessment of exits to ensure all exit locks were functioning properly, and no monitoring of exit locking devices were put in place to prevent future lock failures.
On 12/13/23 at 1:20 PM, the Administrator provided a Plan of Removal with the following measures:
On 12/11/2023, upon notification of deficient practice to provide adequate supervision to prevent a cognitively impaired resident from exiting the facility without their knowledge, facility took the following measures.
Immediate reassessment of elopement assessment on each individual. MDSC [Minimum Data Set Coordinator], IP [Infection Preventionist], and DON to review and complete new assessments on all 52 residents currently within the facility to ensure all assessments are correct, and any new resident at risk of elopement is identified.
Inservice education to staff. Inservice education to be presented to staff at all staff inserviced currently scheduled for 12/13/23 at 1400 [2:00 PM]. Inservice will review actions to be taken in the event a resident is missing or elopes from the facility.
Evaluation and review of all external door locks, and assistant shutting devices. Environmental department to complete and check off review of all locks withing the facility to ensure that they are working correctly. Environmental department to assess and ensure all external doors with an assistant shutting device is in proper working order, and seats door firmly in place.
On 12/13/23 at 1:15 PM, the DON provided a document that confirmed all 52 residents in the facility had an updated elopement risk assessment completed on 12/13/23.
On 12/13/23 at 1:20 PM, the Administrator provided a document that confirmed all external doors were checked to ensure the locking mechanism and assistive shutting devices were working correctly.
On 12/13/23 at 3:34 PM, the Administrator provided a document of inservice that was provided to staff related to resident elopement that included staff signatures of attendance.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled appropriately and disposed of past the expiration date when applicable. The findings are:
The following observations were made on 10/11/23 at 9:59 AM of the medication cart on 400 hall and 500 hall.
a. One box of nasal strips containing 19 strips with no resident ' s name.
b. A tube of topical anesthetic with no resident ' s name.
c. One tube of eye drops with no resident ' s name.
d. Two cups of a white powder with no label with the contents.
e. 1 tube of eye ointment with an expiration date of 7/2023.
During interview on 10/11/23 at 10:05 AM, Licensed Practical Nurse (LPN) #1 said, medications should be left on the cart in the original container or box and labeled.

Based on observation an interview the facility failed to ensure that the menu was followed for 2 sampled resident's (Resident #27 and #28) who receive a pureed diet. The findings are:
During observation on 10/10/23 at 12:30 PM, Resident #28 was served pureed ham, turnip greens, sweet potatoes, and a bowl of pureed cake. Resident #27 received a tray containing the exact foods at 12:31 PM.
Review of facility ' s pureed lunch menu for 10/10/23 showed baked ham, sweet potatoes, greens, cornbread, margarine spread, and plain white cake.
During interview on 10/10/23 at 12:38 PM, the Dietary Manager confirmed the cornbread was not served to Resident #27 and #28.

Based on observation, interview and record review, the facility failed to ensure foods were utilized prior to the use by date, stored in a manner to prevent cross contamination, hair coverings were worn when entering the kitchen and hand hygiene was performed to prevent cross contamination. The findings are:
During observation on 10/09/23 at12:36 PM, CNA #9 coughed used the gloved right hand to cover her mouth. CNA #9 removed the paper covering from a straw and placed the straw into Resident #25 ' s plastic mug. CNA #9 did not perform hand hygiene.
During interview on 10/09/23 12:49 PM, CNA #9 said hand hygiene should be performed before and after resident care, and confirmed she should have not used her gloved hand that covered her mouth to handle the resident ' s straw.
The following observations were made on 10/10/23:
a. At 11:59 AM, Certified Nursing Assistant (CNA) #5 served a meal tray from the tray cart to Resident #19. CNA #5 did not perform hand hygiene prior to removing the room tray from the tray cart and did not perform hand hygiene after exiting Resident #19 ' s room.
b. At 12:00 PM, CNA #5 removed a meal tray from the tray cart and entered Resident #48 ' s room and placed the meal tray on the resident ' s bedside table. Using her bare hands CNA #5 removed the straws from the paper and put one straw in the nutritional supplement and one straw in a glass of tea. CNA #5 did not perform hand hygiene.
c. At 12:13 PM, CNA #5 removed a meal tray from the meal cart and entered Resident #25 ' s room placed the meal tray on the bedside table and exited the room. CNA #5 did not perform hand hygiene before removing the meal tray from the meal cart or before entering the resident ' s room.
During interview on 10/10/23 at 2:06 PM, CNA #5 said hand hygiene should be performed before and after meal trays are delivered to residents.
During interview on 10/13/23 10:35 AM, the Director of Nursing (DON) said hand hygiene should be performed when passing meal trays to residents as part of infection control.
The following observations were made in the kitchen on 10/09/23.
a. At 10:10 AM Dietary Aide #1, entered the kitchen with hair not covered or contained, and walked through the kitchen approximately 50 feet to the back of the kitchen. There was food being cooked on the stove, and food on metal tables.
b. Dietary Aide #1 at 10:19 AM applied gloves to check the temperatures of the food on the stove and did not perform hand hygiene before applying gloves.
c. On 10/09/23 at 10:20 AM Dietary Aide #1 placed a temperature probe in cooked chicken. Dietary Aide #1 cleaned the probe with an alcohol prep pad and checked the mashed potatoes. Dietary #1 cleaned the probe with an alcohol pad and inserted the probe into the puree chicken sandwich.
d. Dietary Aide #2 at 10:27 AM was standing next to the stove with hands on hips then touched and leaned against the plate warmer. Dietary Aide #2 did not perform hand hygiene.
e. Dietary Aide #2 at 10:29 AM obtained an empty liquid pitcher, filled the pitcher with water from the sink, and poured the water into the pan on the stove. Dietary Aide #2 scratched head with bare hands.
f. At 10:43 AM, an opened bottle of water, an open can of soda, a clear cup containing a brown liquid, a personal cell phone, and 2 metal drink bottles were on a metal table in the kitchen.
g. Dietary Aide #2 at 10:58 AM removed a plate containing turkey from the refrigerator with gloved hands, removed gloves, and applied a new pair of gloves. Dietary Aide #2 did not perform hand hygiene after removing gloves and before applying the new gloves. Dietary Aide #2 placed the turkey in the mixer and mixed the turkey. Dietary Aide #2 removed the mixer lid and poured the turkey on a plate uncovered and placed the plate of turkey inside the microwave. Dietary Aide #2 removed gloves and did not perform hand hygiene. Dietary Aide #2 pulled the heated plate of turkey from the microwave with bare hands touching the inside of the plate with right thumb. Dietary Aide #2 at 11:02 AM without performing hand hygiene applied gloves and checked the temperature of chopped chicken and removed gloves.
The following observations were made on 10/09/23 in the kitchen:
a. At 10:15 AM, nectar thick drinks were on a tray in a 3-door refrigerator unlabeled and undated.
b. Ten small bowls of diced pears were on a tray uncovered. Dietary Aide #1 stated I was going to put a sheet of parchment paper over that.
c. At 10:24 AM, a container of onion powder was on the worktable with the lid open.
d. At 10:25 AM, a one-gallon clear plastic container 1/2 full of coconut was labeled as opened on 6/7/23.
e. At 10:39 AM, a case of Oatmeal containing 12 containers was on the floor of the dry storage area.
f. At 10:45 AM an opened 5-pound bag of vegetable medley half full was on the shelf of the walk-in freezer with no open date.
g. At 10:50 AM, 7 snack bags with a use by date of 9/26/23 was a box on a shelf under a worktable in the kitchen.
h. Dietary Aide #4 at11:28 AM, changed her gloves without washing her hands first.
i. At 11:33 AM, with gloved hands, Dietary Aide #2 obtained a bag of bread, opened the bag, removed 2 slices of bread, , buttered the bread, and placed in the skillet.
j. Dietary Aide #2 at 11:40 AM, put on gloves, opened a drawer, and withdrew a utensil. She walked into the dry storage area, removed a large box from the top shelf and obtained 1 bag of chips.
During observation on 10/10/23 at 11:40 AM, Dietary Aide #1 was taking the temperature of the lunch meal with hair hanging out of the hair covering on each side of her face.
Review on 10/11/23 at 9:55 AM, of the policy Handwashing and Hand Care Dietary Department showed handwashing is the most important step all employees can take to protect food.
On 10/13/24 at 9:05 AM the Dietary Manager (DM) said dietary employees should wash their hands all the time. When they leave the kitchen and return, change tasks, move from one food to the next, and if they touch something that is contaminated. DM said she expects dietary employees put a hair covering on at the door. DM described proper food storage as placing the item in a sealed container with a label containing the date and name of the item or name of the resident for whom the item was prepared.
Review of facility titled Meal Service/Tray Pass dated 06/29/20 showed between trays staff will sanitize hands with alcohol-based hand rub or soap and water.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure infection control precautions were followed during wound care for 2 (Resident #25 and #27) residents, failed to ensure that bed pans were stored properly when not in use for Resident #21, and clothing and linens were processed in a manner to minimize cross contamination. The findings are:
On 10/11/23 at 1:40 PM, Surveyor observed LPN #2 perform wound care on two of Resident #25 wounds. CNA #2 and CNA #10 assisted LPN #2. LPN #2, CNA #2, and CNA #10 did not perform hand hygiene or change gloves during the wound care process.
During observation on 10/11/23 1:54 PM, LPN #2 entered Resident #25's room donned in an isolation gown and gloves. LPN #2 lifted the Resident's heels off the bed and applied a heel protector to each heel. LPN #2 manually raised Resident #25 head of bed up, and pulled the sheets up to the Resident's chest and applied a cream to the Resident's shoulders. LPN #2 did not change gloves.
On 10/12/23 at 1:25 PM the Surveyor observed CNA #10 and CNA #2 perform personal care for Resident #27. During the care provided the personal care technique of wiping front to back was not used. The same disposable wipe was used to clean the area a second time. Hand hygiene was not performed, and gloves were not changed to prevent cross contamination.
During interview on 10/12/23 1:50 PM, CNA #2 said hand hygiene should be performed before you enter a resident's room and before you leave the room, and gloves should be changed when you go from a dirty area to a clean area. CNA #2 confirmed when performing incontinent care, you should wipe once front to back and throw away the wipe.
During interview on 10/12/23 1:57 PM, CNA #10 confirmed she should have changed her gloves after incontinent care, and before touching the clean brief.
During interview on10/13/23 10:35 AM, the Director of Nursing (DON) said gloves should be changed during wound care from a dirty to clean area.
Review of the facility policy titled Wound Care for all Wounds showed facility will provide wound care using clean techniques to promote healing.
On 10/10/23 08:54 AM, a bed pan was observed in the bathroom between rooms [ROOM NUMBERS]. The bed pan was positioned between the grab bar and the wall unlabeled to which resident the bed pan belonged to.
During interview on 10/12/23 3:30 PM, CNA #8 said a resident's bedpan should be labeled with resident's name and stored in a bag in the resident's drawer.
During interview on 10/12/23 3:34 PM, Licensed Practical Nurse (LPN) #4 said bed pans should be labeled and stored in a plastic bag.
During interview on 10/13/23 10:35 AM, the Director of Nursing (DON) said bed pans should be labeled and stored when not in use in a bag, and it shouldn't be sitting out.
On 10/10/23 at 12:42 PM, observed the dirty side of the laundry facility with laundry employee, #1. Laundry employee #1 said
he wears a disposable apron and gloves when he handles isolation laundry. The Surveyor asked how often the aprons are disposed of, he said the aprons are disposed of every 2 to 3 weeks if the apron becomes soiled with feces, for example then they would be cleaned with soap and water. The only time a mask or a shield is worn is when the facility has an outbreak.
On 10/10/23 at 12:48 PM laundry employee #2 was observed laying a t-shirt on his chest and abdomen for ease in folding. Upon completion, a second t-shirt and a pair of pajama pants were folded using the chest and abdomen as a folding surface.
During interview on 10/10/23 at12:52 PM Employee #2 said when he folds a sheet, he tries to fold it in a manner so that it, doesn't look like it just came off of someone's bed. When asked if there was anything about the floor employee stated, you are supposed to keep it off the floor. Employee #2 confirmed he laid clean resident clothing on his chest for ease of folding and stated, I guess I just forget, I have been doing it for so long.

Based on observations, record review, and interviews, the facility failed to ensure staff did not stand over the resident while assisting with meals to promote dignity for 1 (Resident #25) of 1 sampled resident who required assistance with meals; and the facility failed to ensure residents were not referred to as a feeder to promote dignity to residents who required assistance with meals. The findings are:
Resident #25 at 12:31PM was sitting up in bed, and Certified Nursing Assistant (CNA) #9 was standing next to the bed and gave Resident #25 a drink of tea.
At 12:36 PM and 12:34 PM, CNA #9 was standing next to Resident #25 while giving her a drink of tea from a glass using a straw.
During interview CNA #9 said she usually sits in a rolling chair if they are a feeder. The Surveyor asked CNA #9 was asked, what is a feeder? CNA #9 stated, Residents that have to be fed.
During interview on 10/13/23 10:02 AM, Licensed Practical #3 said a residen's dignity is maintained when assisting them with meal by talking with them and sitting eye level.
On 10/13/23 at 10:35 AM, the Surveyor asked the Director of Nursing (DON) what is a feeder? The DON stated, somebody we have to feed. The DON was asked, how do you ensure a resident's dignity is maintained when assisting residents with a meal? The DON said sitting down with the resident.
Review on 10/9/23 at 12:20 PM of facility policy titled Resident Rights showed residents have the right to be treated with dignity and respect.

Based on observation and interview the facility failed to ensure that a call light was within reach for one (Resident #4) of one sampled resident who requires a call light for assistance. The findings are:
On 10/09/23 at 2:48 PM, Resident #4 was observed lying in bed with the call light in the chair next to the bed out of the resident's reach. In the adjacent bed the call light was hanging over the headboard of the bed, out of reach of the resident. Resident #4 was asked do you ever use the call light for assistance? He nodded his head up and down and looked at each side rail.
On 10/09/23 at 2:51 PM, Certified Nursing Assistant (CNA) #1 confirmed Resident #4 ' s call light was on the chair and out of reach.
On 10/12/23 at 1:00 PM Licensed Practical Nurse (LPN) #2 confirmed Resident #4 had the ability to use his call light.

Based on interview and record review the facility failed to ensure that 1 (Resident #2) of one sampled resident had completed an Advance Directive upon entry. The findings are:
Review on 10/9/23 at 3:13 PM, of Resident #2's medical record revealed no information concerning an Advance Directive
10/13/23 at 2:05 P.M, the Administrator reported that Resident #2's Advance Directive could not be located and said the document might be located with the Resident's original admission record from 2013 in storage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure resident's environment was safe, free of hazards, and promoting a home like environment. The findings are:
The following observation were made:
On 10-9-23 at 12:12 PM, room [ROOM NUMBER]'s door protector was loose with a hard plastic cover on the lower half of the door and splinters.
During observation on 10/12/23 at 2:03 PM, room [ROOM NUMBER] ' s door had a loose protector gaping open with sharp screws.
On 10/09/23 at 12:20 PM, the baseboard approximately 12 inches in length in room [ROOM NUMBER] was pulled away from the wall and protruded outward. A hole approximately 3 inches deep was in the wall with sheet rock and insulation exposed behind the baseboard.
On 10/10/23 at 12:17 PM, a hole in the wall of room [ROOM NUMBER] had approximately 12 inches of base board detached from the wall and protruding outward.
On 10/12/23 11:48 AM, a hole in the wall approximately 3 inches deep and approximately 12 inches of base board was detached from the wall and protruding outward in room [ROOM NUMBER].
On 10/09/23 at 1:27 PM and 10/10/23 at 11:55 AM in the day room, a recline's handle covered with a plastic pipe and secured with 2 screws protruding out 2 inches was observed.
On 10/10/23 at 2:28 PM, the following rooms had loose door protectors with splinters; when room [ROOM NUMBER], #312, #401, #403, #406, #501, #503,
#505, #506, #508, #509, # 510, #511, and #512.
During observation on 10/11/23 at 11:43 AM, hall's 300, 400, and 500 door protectors were loose.
Review on 10/12/23 of the maintenance log showed the following.
a. Dated 9/28/23 a request for the door in room [ROOM NUMBER] to be glued back.
b. Dated 10/9/23 a request for door protector on room [ROOM NUMBER] to be glued back on the bottom half.
c. Dated 1/9/23 through 10/9/23 no documentation entry was noted for repair of the recliner handle or the hole in the wall and baseboard protruding outward in room [ROOM NUMBER].
During interview on 10/12/23 10:13 AM, the Administrator confirmed the recliner handle had a plastic pipe with two screws sticking out.
During interview on 10-13-23 at 9:01 AM, the Director of Nursing (DON) said when something needs repaired the employees inform maintenance by adding it to the maintenance log in the charting room or verbally informing the Maintenance Supervisor.
During interview on 10/13/23 10:35 AM, the DON said, a resident ' s environment should be safe and free of hazards, so they are not injured.

Based on observation, record review and interview, the facility failed to ensure facial hair was removed in a timely manner to maintain dignity for 2 (Resident #25 and #42) of 2 sampled who required assistance for personal hygiene. The findings are:
Review of Resident #25's care plan with a revision date of 8/14/23 showed Resident is totally dependent of 1 staff to provide a bath/shower.
Review of the activities of daily living self-care performance bathing task showed Resident #25 was provided a bath/shower on 10/9/23, 10/5/23, and 10/2/23.
On 10/10/23 at 8:54 AM, Resident #25 was observed lying in bed with facial hair/whiskers approximately 0.25 in to 0.5 inches in length on/under chin and on neck.
On 10/10/23 at 2:49 PM Resident #25 was observed lying in bed with facial hair/whiskers approximately 0.25 inches to 0.5 inches in length on/under chin and neck.
On 10/11/23 at 8:38 AM Resident #25 was observed lying in bed with facial hair/whiskers approximately 0.25 inches to 0.5 inches in length on/under chin and neck.
During interview on 10/12/23 at 9:39 AM, Certified Nursing Assistant (CNA) #7 said residents are shaved on shower days.
During interview on 10/13/23 at 10:35 AM, The Director of Nursing (DON) said residents should be free of facial hair/ whiskers for dignity and the aides are responsible for shaving the residents.
Review of facility policy titled Shaving showed female residents often require facial shaving.
Review of Resident #42's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/14/23 showed required one person assist with personal hygiene.
The following observations were made of Resident #42:
a. On 10/09/23 at 9:14 PM, whiskers were visible on chin.
b. On 10/10/23 at 9:08 whiskers were visible on chin.
c. On 10/12/23 at 9:09 AM, chin hair/whiskers were visible.
Review of Resident #42's bath sheets showed last shower was on 10/5/23.

Based on observation, interview and record review the facility failed to ensure that nebulizer masks were stored in a manner to prevent cross contamination of 1 of 1 (Resident #21) of 3 (Resident #21, #48, and #15) sampled residents. The findings are:
Review of Resident #21's Order Summary Report showed a physician order dated 09/17/23 for a nebulizer treatment when necessary.
The following observations were on 10/09/23 :
a. Resident #21's oxygen tubing was extended out of a drawer of the bedside table. With the Resident's permission the drawer was opened, and a nebulizer mask was in the drawer.
b. Resident #21's nebulizer mask was in the drawer and had what appeared to be oil and particles of debris inside the mask.
During interview on 10/10/23 at 9:52 AM, Licensed Practical Nurse (LPN) #2 said the nebulizer mask should be cleaned and stored in a bag to prevent infection.
Review on 10/13/23 at 8:48 PM of a facility document titled cleaning the nebulizer showed after cleaning place the nebulizer in a plastic bag at the bedside.

Based on observation, record review, and interview, the facility failed to ensure the physician was notified of changes for 1 (Resident #1) and failed to ensure staff administered the correct dosage of physician ordered medication for 1(Resident #3) of 7 (#1, #2, #3, #4, #5, #6, #7) sampled residents. The findings are:
1. Resident #1 had diagnosis of Dementia, Glaucoma, and Hypertension. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/31/23 documented the resident scored 3 (0-7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS).
a. The Nurse's Note dated 06/09/23 at 1340 [1:40] documented, .Unusual Occurrence Report .Resident #2 hit Resident #1 with Resident #2's cane across Resident #1's face causing a small amount of blood to appear in Resident #1 right Nare .and causing a bruise to Resident #1's left pinky finger .Q [every] 1 hour monitoring x [times] 24 hours .
b. The Nurse's Note dated 06/12/23 (2-10) documented, .left eye appears filled with blood, resident c/o [complains of] eye pressure and pain . There was no Physician notification documented.
c. The Nurse's Note dated 06/13/23 (6-2) documented, .residents report pain and blurred vision in left eye . There was no Physician notification documented.
d. On 06/20/23 at 4:50 p.m., the Surveyor asked the Director of Nursing (DON), What was done for Resident #1's eye when she complained of pain and pressure on 06/12/23? The DON replied, Resident #1 was seen by the eye doctor on 06/13/23, the Physician had made a referral, and the family took Resident #1 to the doctor.
e. On 06/20/23 at 5:36 p.m., the Surveyor asked the Administrator, What was done for Resident #1's eye when she complained of pain and pressure on 06/12/23? The Administrator replied, The incident occurred on 06/09/23 and the family [member] took Resident #1 to the eye clinic down the road. The Surveyor asked, What are your expectations from your staff regarding following the facilities policies and procedures and the Centers for Medicare and Medicaid Services (CMS) guidelines? The Administrator replied, My expectations are for those items to be followed.
2. Resident #3 had diagnoses of End Stage Cirrhosis of the Liver and received End of Life Care. The admission MDS with an ARD of 05/23/23 revealed Resident #3 was total assist for Activities of Daily Living.
a. The Physician Order with a start date of 05/18/23 revealed an order for Hydromorphone 4mg [milligram] every 3 hours PRN [as needed].
b. The Physician Order with a start date of 05/22/23 revealed an order for Hydromorphone 4 mg 2 tabs every 1-hour PRN.
c. The Physician Order with a start date of 05/23/23 revealed an order for Hydromorphone 4 mg 2 tablets every 2 hours
d. The Medication Administration Record (MAR) revealed on May 23, 2023, Hydromorphone 4 mg 2 tablets was given at 1:15 a.m, 2 tablets at 7:30 a.m, 2 tablets at 12:00 p.m, and 2 tablets at 2:00 p.m.
e. The Narcotic Book on May 23, 2023, documented, Hydromorphone 4 mg [milligram] tablets 2 was given at 1:15 AM, 1 tab at 3:30 a.m, 2 tabs at 7:30 a.m, 2 tabs at 11:30 a.m which leaves the narcotic book at zero. At 11:50 a.m Licensed Practical Nurse (LPN) #2 entered 30 tablets under the 4 mg tablet page. At 1:50 2 tablets were given with a balance of 28 tablets.
f. The Narcotic Book on May 23, 2023 documented; Dilaudid (hydromorphone) 8 mg tablets 28 tablets signed in from Pharmacy.
g. On 06/20/23 at 10:27 a.m., a telephone interview was conducted with LPN #2. The Surveyor asked, What happened with Resident #3 and the Dilaudid order? LPN #2 replied He had a PRN [as needed] order for Dilaudid 8 mg and an order for 8 mg scheduled. No one spoke to me about this. The Surveyor replied, Did anyone have you edit the nursing notes or Narcotic Book? LPN #2 replied, I didn't know anything about this until you called. I gave the medication to Resident #3 based on signs and symptoms. Resident #3 was in pain and distress. The Surveyor asked, Did Resident #3 expire on your watch? LPN #2 replied, No.
h. On 06/20/23 at 1:48 p.m, the Surveyor asked Registered Nurse (RN) #1, What happened with Resident #3 and the Dilaudid order? RN #1 replied I got report from the nurse, and we went to count, and I found it. I realized the card didn't match the Narcotic Book. The 8 mg card was where the 4mg card was supposed to be and I reported it to the DON (Director of Nursing) and she reported it to the Administrator. When I looked at the MAR, Resident #3 had a PRN [as needed] order and a scheduled order as far as I could tell. He had a max dose he could receive in a 24-hour period. The Surveyor asked, Did anyone have you edit the Nursing Notes or Narcotic Book? RN #1 replied, No.
i. On 06/20/23 at 3:08 p.m., in an interview with LPN #1. The Surveyor asked, Tell me about Resident #3's medication Dilaudid and the Medication Error. LPN #1 replied, I was there the day they caught the error. RN #1 pulled me to the side and asked me to look at the card and count to make sure it was right. I went and got the DON, and she called the Administrator in the office and shut the door. LPN #2 is the one who quit. It looked like the wrong mg was given. The dosage on the Narcotic Book did not match the card, the card was 8mg. So, if given by the orders then she would have given 16 mg.
j. On 06/20/23 at 4:50 p.m., the Surveyor asked the DON, Were you aware of a possible medication error with Resident #3? The DON replied, Yes. The Surveyor asked, Tell me what happened. The DON replied, LPN #2 signed 8 mg tabs into the 4 mg page. LPN #2 gave 2 of the 8mg Dilaudid instead of the 2 of the 4 mg Dilaudid, Resident #2 had an order 8mg every 2 hours routine, I think, and had an order for 8 mg PRN. The nurse had got an order for the 8 mg Dilaudid, she signed the 8 mg Dilaudid on the 4 mg Dilaudid page. But gave 2-8mg tablets at 1:50 p.m and 2-4 mg tablets at 11:30 AM. The Surveyor asked, Who discovered it? The DON replied, RN #1 discovered it the next day, RN #1 came to me and told me Dilaudid was signed into the wrong page, and it had been given.
k. On 06/20/23 at 5:36 p.m., the Surveyor asked the Administrator, Tell me what happened with Resident #3's medication error with the Dilaudid? The Administrator replied, I'm aware of it, (the incident), Resident #3 received medication in the wrong order. Resident #3 had a scheduled and PRN order, and they were given simultaneously.

Based on observation, interview, and record review, the facility failed to address 1 (Resident #2) of 7 (#1, #2, #3, #4, #5, #6, #7) sampled residents identified behaviors in a timely manner causing injury to one resident and placing other residents at risk for injury. The findings are:
1. Resident #2 had a diagnosis of Dementia with behavioral disturbance. The Quarterly Minimum Data Set (QMDS) with an Assessment Reference Date (ARD) of 03/01/23 documented resident scored 3 on the Brief Interview of Mental Status (BIMS), had verbal behavioral symptoms directed toward others .threatening others, screaming, and cussing at others; with a Mood Severity Score of 3.
2. The Physician Order with a start date of 08/25/21 documented, .speak to Resident #2 in a non-threatening tone, offer reassurance that no one is going to touch him physically .calmly redirect him away from an escalating situation .
3. The Care Plan with a review date of 03/31/23 documented, .Behavior Problem .verbally abusive, threatens others, refuses showers, clothing changes .wandering . Interventions included report to physician changes in behavioral status, investigate/monitor need for psychological/psychiatric support. Provide services if desired by the resident or family and ordered by the physician .
4. The Nurse's Note on 04/02/23 at 1600 [4:00] documented, .patient in the dining room .followed Med Tech [Technician] .yelling I'll cut your [expletive] throat. Patient highly agitated .Resident #2 exited the Dining Room and grabbed a pen off the med cart and began stabbing the air and yelling at staff, I'll kill you all. The nurse was able to get the pen and Resident #2 was re-directed to the TV [television] room. Resident #2 continued to circle the NC [nurse's circle], yelling out occasionally at staff. Residents were kept away from Resident #2. The Physician assessed Resident #2 on 04/04/23 with new orders to increase Seroquel.
5. The Nurse's Note on 04/04/23 at 1900 [7:00] documented, .X-ray Tech and this nurse attempted x-rays on Resident #2, Resident #2 started cursing and tried to hit the x-ray. MD [Medical Doctor/physician] notified.
6. The Nurse's Note on 04/06/23 at 2145 [9:45] documented, .staff attempted to help resident stand .Resident #2 tried to hit CNA [Certified Nursing Assistant], cursing at staff when assisted up .increased agitation.
7. The Nurse's Note on 04/07/23 at 0155 [1:55] documented, .staff attempting to do vitals .Resident #2 agitated with process .Resident #2 hit at CNA and accused CNA of stealing things from his room and became more threating with attempt to do neuro's [neuro-evaluation] and agitated .
8. Nurses note on 04/09/23 at 8: 25p.m, noted the resident fell, and was yelling, cursing at staff, displaying aggressive behaviors when staff attempted to assist the resident up.
9. Nurses note on 04/11/23 at 9:50 p.m., noted resident was verbally aggressive towards staff and other residents.
10. Nurses note on 04/18/23 noted the MD changed the Ativan order to 1 mg as needed at bedtime.
11. The Nurse's Note on 04/22/23 at 1559 [3:59] documented, .Resident #2 still very ugly to other residents .muttering to self and watching everyone closely .keeps going down 500 Hall and gets mad when re-directed .gave Ativan 1 mg [milligram] PRN [as needed] .
12. The Nurse's Note on 04/26/23 at 2100 [9:00] note documented, .Resident #2 walking up and down halls going into other residents' rooms .refuses to come out .cursing at staff .Resident #2 went to 400 Hall back door, started pushing on door forcefully .Resident #2 became angry and cussing at this nurse .PRN Ativan 1 mg given .Resident #2 continued to cuss at this nurse, very aggressive behavior .No documentation Physician was notified.
13. Nurses note on 04/28/23 at 12:00 p.m noted Resident #2 was in another resident's room and refused to leave. The resident attempted to hit the nurse; the staff removed all the other residents from the area. Resident refused noon medication, and continued to pace while cursing at staff, agitated.
14. Nurses note on 4/29/23 at 8:30 p.m noted the CNA came upon Resident #2 pushing and shaking another resident's wheelchair, stating what is wrong with you.
15. The Nurse's Note on 05/05/23 at 1200 [12:00] documented, .assistant brought residents tray to him in his room. Resident mumbling, CNA able to hear comments of violence .Resident #2 stated to [Assistant], I'm going to shoot you in the brain. No documentation Physician was notified.
16. The Nurse's Note on 05/14/23 at 1615 [4:15] documented .Resident #2 becoming progressively agitated, irritated with another resident for being so close to him .Resident #2 raised his voice and spoke to other resident in an aggressive tone .other resident removed from situation .Ativan 1 mg given.
17. The Nurse's Note on 05/16/23 at 1516 [3:16] documented . [named Doctor] here .no new orders .
18. The Nurse's Note on 05/17/23 at 1740 [5:40] documented, .Resident #2 at nurse's station cussing and yelling with another resident .other resident said this resident hit him on the shoulder with a cane .residents separated .24-hour behavior monitoring started .
19. The Nurse's Note on 05/27/23 at 1603 [4:03] documented, .Resident #2 sitting in circle grumbling to himself continuously about those around him and say how they were FXXXX idiots, and he should just kill them. He told a few other residents to get the hell away from him or he would hit them over the head .Ativan administered. No documentation the Physician was notified.
20. The Nurse's Note on 05/27/23 at 1757 [5:57] documented, .Resident #2 got irritated at a female resident in a wheelchair and took his cane and was trying to use it on her feet. Lortab 10/325 mg was administered.
21. The Nurse's Note on 05/31/23 at 1700 [5:00] documented, .Resident #2 up and down halls cursing talking to self, going into female rooms and in their bathrooms. When staff tries to direct to another location, he becomes aggressive, cussing at staff. Resident #2 wandered up to the front hall trying to get out of front doors, when other residents go be him, he begins cursing and trying to hit them with his cane. Staff not able to re-direct .resident refused medications .Administrator was notified .
22. The Nurse's Note on 06/01/23 at 0800 [8:00 AM] documented .MD here to speak to VA [Veteran's Administration] about options.
23. The Nurse's Note on 06/01/23 at 1100 [11:00] documented, .call placed to [family member], notified of situation .left message for VA Social Service department to call back .
24. The Nurse's Note on 06/03/23 at 1810 [6:10] documented, .Resident #2 walking by Resident #6 in a wheelchair, and he didn't like Resident #6 hollering and making noises, so reached out and pinched Resident #6 arm and told Resident #6 to shut up .then raised his cane like he was going to hit him, and CNA got in between them and was able to get resident to walk away .
25. The Nurse's Note on 06/05/23 at (6-2) documented, .start Resident #2 on Depakote 250 mg 1 PO [by mouth] BID [2 times a day]
26. The Incident Report on 06/09/23 at 1340 [1:40] documented, .Resident #2 hit Resident #1 with cane causing injury
27. The Nurse's Note on 06/09/23 at 1405 [2:50] documented, .spoke with [family member] .in agreement to send to a mental health facility so long as Medicare pays .
28. The Nurse's Note on 06/11/23 at 1220 [12:20] documented, .a female resident approached this elder while he was eating his lunch .Resident #2 screamed at female resident, how would you like me to shove your nose into your brain, how'd ya like that. Female resident redirected to another part of the building .will continue to monitor for additional behaviors .
29. The Nurse's Note on 06/13/23 at 1355 [1:55] documented, . [named Doctor/Physician] here .no new orders .
30. On 06/20/23 at 2:53 p.m., the Surveyor asked CNA #1, What do you do if a resident is threatening staff and residents to do bodily harm? CNA #1 replied, Re-direct them and report to the nurse. The Surveyor asked, When Resident #2 threatened bodily harm to resident and staff, what was done? CNA #1 replied, Mostly re-direct, gave coffee, and moved the other residents as it was easier. The Surveyor asked, How many residents did Resident #2 have incidents with? CNA #2 replied, I heard about Resident #2 and Resident #1, there were many incidents with staff. The Surveyor asked, Why did it take from 04/02/23 till 06/15/23 to send Resident #2 to a behavioral center? CNA #1 replied, I don't know why it took so long.
31. On 06/20/23 at 3:01 p.m., the Surveyor asked CNA #2, What do you do if a resident is threatening staff and resident to do bodily harm? CNA #2 replied, If it's me, I remove myself and get help, and protect the other residents. The Surveyor asked, When Resident #2 threatened bodily harm to residents and staff, what was done? CNA #2 replied, I reported it to the nurse, I saw Resident #2 raise the cane to other residents and staff, other than Resident #1. The Surveyor asked CNA #2, Why did it take from 04/02/23 till 06/15/23 to send Resident #2 to a Behavioral Center? CNA #2 replied, I have no idea.
32. On 06/20/23 at 3:08 p.m., the Surveyor asked Licensed Practical Nurse (LPN) #1, What do you do if a resident is threatening staff and residents to do bodily harm? LPN #1 replied, separate and diffuse the situation, if they are cognitive, I call the DON (Director of Nursing) and the MD, if they are demented, I re-direct them. The Surveyor asked LPN #1, when Resident #2 threatened bodily harm to residents and staff, what was done? LPN #1 replied, reported to the DON and physician, they tried different medications and Resident #2 got worse, we watched Resident #2. I begged for the locked down unit and to send Resident #2 to Geri [Geriatric] Psych [Psychiatric Unit]. The Surveyor asked, How many residents has Resident #2 caused injury to? LPN #1 replied, 1. The Surveyor asked, How many residents did Resident #2 have incidents with? LPN #1 replied, Too many to count. The Surveyor asked, Why did it take from 04/02/23 till 06/15/23 to send Resident #2 to a behavioral center? LPN #1 replied, I would love to know that answer.
33. On 06/20/23 at 4:50 p.m., the Surveyor asked, What do you do if a resident is threatening staff and resident to do bodily harm? The DON replied, Monitor the resident. The Surveyor asked, When Resident #2 threatened bodily harm to residents and staff, what was done? The DON replied, We didn't always put Resident #2 on 24-hour monitoring, we sent a referral to the behavioral unit on 06/09/23, but they denied. The Surveyor asked, How many residents has Resident #2 caused injury to? The DON replied, I'm not sure. The Surveyor asked, How many residents did Resident #2 have incidents with? The DON replied, I'm not sure. The Surveyor asked, Why did it take from 04/02/23 till 06/15/23 to send Resident #2 to a behavioral center? The DON replied, I think we kept trying other options with medications and increasing Resident #2 medications, we sent the referral on 06/09/23 and didn't hear back till the next week and they denied Resident #2.
34. On 06/20/23 at 5:36 p.m., the Surveyor asked the Administrator, What do you do if a resident is threatening staff and resident to do bodily harm? The Administrator replied, Monitor them for 24 hours. The Surveyor asked, When Resident #2 threatened bodily harm to residents and staff, what was done? The Administrator replied, Monitoring and re-direction. The Surveyor asked, How many residents did Resident #2 cause injury to? The Administrator replied, I don't know. The Surveyor asked, How many residents did Resident #2 have incidents with? The Administrator replied, I don't know. The Surveyor asked, Why did it take from 04/02/23 till 06/15/23 to send Resident #2 to a behavioral center? The Administrator replied, We reached out to the VA they said Resident #2 wouldn't qualify, we waited for the Physician to direct us. The Surveyor asked, What are your expectations from your staff regarding following the facilities policies and procedures and the Centers for Medicare and Medicaid Services (CMS) guidelines? The Administrator replied, My expectations are for items to be followed.

Based on observation, interview, and record review, the facility failed to ensure physician ordered oxygen flow rate was consistently maintained for 1 (Resident #30) of 8 (#2, #13, #20, #27, #30, #36, #41 and #44) final sample residents who used oxygen. The findings are:
Resident #30 had diagnosis of Congestive Heart Failure and Shortness of Breath. A Quarterly Minimum Data Set with an Assessment Reference Date of 5/16/2022 documented the resident scored 2 (0-7 indicates severely impaired in cognitive skills) per a Brief Interview for Mental Status.
a. A physician order dated 11/27/2021 documented, .Oxygen (O2) 5 LPM [liters per minute]/NC [nasal cannula] QS [every shift] .
b. A Care Plan with a problem date: 02/21/2022 . documented . O2 [oxygen]5 L [liters]/Min via NC PRN [as needed] .
c. On 07/05/22 at 11:10 AM, was in resting in bed and receiving O2 set at 3L/M via cannula.
d. 07/06/22 10:46 AM, the resident was resting in bed and receiving oxygen. The oxygen concentrator set at 2 1/2 l/m via nasal cannula
e. On 7/7/2022 at 7:34 AM, Licensed Practical Nurse (LPN) #3 was asked to identify the reading on resident ' s Oxygen concentrator. She squatted down to eye level and stated it was set at 2 1/2 liters. She was asked, Is that the setting that is ordered? She stated, Yes. She was asked, Does the resident adjust her own concentrator? She stated, No, I don't think so. The resident was resting in bed with oxygen via nasal cannula
f. A Policy received 7/6/2022 at 12:24 PM from the DON documented .Oxygen will be administered by Licensed personnel only when ordered by the physician. The physician should specify number of liter, method of administration, and length of time to be administered ., Set flow rate to prescribed liter/minutes .

Based on observation, interview and record review the facility failed to ensure physician ordered as needed antianxiety medication was re-evaluated by the physician every 14 days for 1 (Resident # 2) of 9 (Resident#2, #5, #18, #20, #23, #30, #37, #38 and #44) final sample residents who had as needed antianxiety medication physician's orders. The findings are:
Resident #2 had a diagnosis of Generalized Anxiety Disorder. A Quarterly Minimum Data Set with an Assessment Reference Date of 3/29/2022 documented the resident scored 15 [13-15 cognitively intact on a Brief Interview for Mental Status.
a. A Physician Orders dated, .9/23/2021 . Xanax 1 mg [milligrams] oral tablet 1 tab PO [by mouth] PRN [as needed] Q [every] 6 hours prn anxiety .
b. A Resident Plan of Care .problem date .10/08/2021 . documented .Alteration of mood state sad, apathetic, anxious appearance .
c. On 7/6/2022 at 4:33 PM, the Director of Nursing (DON) was asked if as needed antianxiety medication should be ordered for more than 14 days without a physician review for continuation of the medication? She stated, Yes, I know the antianxiety meds should only be for 14 days and then reviewed. She was asked, Why was the medication continued past the 14 day allowed period? She shrugged and stated, I have to talk to Doc and see what I can do .
d. On 7/08/2022 at 9:05 AM, the medication administration records documented Xanax 1 mg 1 tab po prn Q 6 hours was administered as follow
July 2022 9 times
June 2022 19 times
May 2022 20 times
April 2022 9 times
March 2022 3 times
February 2022 13 times
January 11 times
December 2021 6 times
November 2021 7 times
October 2021 6 times
September 2021 3 times

Based on observation, record review, and interview, the facility failed to ensure medications were labeled and stored accordance with state law and accepted principles of pharmacy laws and regulations. This failed practice had the potential to affect 46 residents according to the Resident Census and Conditions of Residents dated 7/5/2022. The findings are:
1. On 7/8/22 at 8:31 AM, there was a half full 10 ounce bottle of Magnesium Citrate in the side door of the nourishment refrigerator located in the medication storage room. There was no name on the bottle of whom the medication belonged to. The DON said, That shouldn't be in here.
2. On 7/8/22 at 11:07 AM, the DON provided a policy titled, Medication and treatment supply storage that documented, . Medications will be stored in med cart or med room. Med cart will be locked when unattended or not in locked med room .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: [NAME], [NAME]
Based on observation, record review and interview, the facility failed to ensure foods stored in the kitchen freezer, refrigerators, and dry storage area were labeled and dated when received and/or opened and expired food items were promptly discarded on or before expiration date to prevent growth of bacteria and the dishes were properly sanitized by immersion in either hot water (at least 171 F) for 30 seconds; or a chemical sanitizing solution (chlorine: 50-100 ppm minimum 10 seconds contact time) for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 46 residents who received meals from the kitchen (total census: 46), as documented by a diet order report provided by the Certified CDM) on 7/8/22. The findings are:
1. On 07/05/22, during initial tour of kitchen with Certified Dietary Manager (CDM) the following observations were made:
a. At 10:45 AM, the CDM was asked if dish washer was low or high temp. CDM stated, Low temp. The CDM was asked to test the amount of chlorine. The test strip registered about 30 ppm (parts per million), just barely darker than 25 ppm color on bottle. The CDM stated, just above 25. The CDM was asked what the bottle stated and the CDM stated, The label on the test bottle states it should be 100 ppm. The CMD was asked, What do you do when the chlorine is not up to proper ppm? CDM stated, We tell [Maintenance] and then he calls [sanitizer company] to come adjust it. The CDM was asked, Do you do anything to ensure dishes are clean and sanitized when this happens? CDM stated, We use the 3-compartment sink until it is fixed.
b. At 10:49 AM the CDM was asked to check ppm of sanitizer in compartment of 3 compartment sink. The CDM stated, It registered at 700.
c. At 10:51 AM, the snack rack on the bottom shelf standing against the wall near 3 compartment sink contained 13 rice krispy treats that did not have a received date.
d. At 10:52 AM, the ledge on the half wall between prep tables, in the middle of the kitchen, contained:
1) One bottle of chocolate syrup with no date.
2) A plastic spice containers of garlic salt, onion powder and black pepper with no dates and the flip tops open with buildup of spice on the flip top
e. At 10:54 AM, in the walk-in freezer contained:
1) Three ground beef 80/20 rolls that were not dated
2) Four ground beef 75/25 rolls that were that not dated
3) An open box of cut breakfast potatoes, 3 bags in a box, 1 opened with no open date
4) An open box of Veggie blend in plastic bag tied but no open date
5) One v-shaped bag of whipped cream topping that was not dated
f. At 11:10 AM, in the walk-in refrigerator there was an open box of sausage patties not sealed or covered and no open date.
g. At 11:22 AM, in the standing refrigerator near the dry storage room there was a flat of apple Danish with no date sitting on top of a full sealed box. In the second standing refrigerator from dry storage room there was a Ziploc bag with orange colored cheese slices with no open date.
h. At 11:28 AM, in the dry storage room the following observations were made:
1) Two bags of multicolored tortilla chips (1 open with black binder clip, 1 sealed unused) stamped expired date 4/8/22, written date received 5/11/22. The CDM stated, I will be contacting our distributor. It looks like we just got those in May [2022].
2) A bag ¼ full of banana pudding powder was not closed or sealed and had no open date.
3) A bag ½ full of vanilla pudding, received 6/22 (no day), was closed with black binder clip and had no open date.
4) A bag of Ziti pasta held closed with a black binder clip had no open date.
3. On 07/07/22 at 09:32 AM, the following observations were made:
a. The Dietary Manager (DM) was using Quaternary ammonium compound test strip to check the parts per million (PPM) of the sanitizer dispensing in the low temperature dish machine. The wash temperature was 120 and the rinse was 128. The dietary manager placed the strip in the water at the end of the rinse cycle. The test strip color indicated the parts per million of sanitizer was below 50. The DM was asked what type of sanitizing chemical was used for the machine and the DM said, I couldn't get what I we usually use so we got this and showed the surveyor a container of Multi-Use Chlorine Sanitizer. The DMS was asked, What test strips were compatible with the chlorine sanitizer? The DM stated, The other ones [Chlorine test strips] weren't working so I went and got these [Quaternary ammonium compound test strips] out of my office. The Dietary Manager called the chemical representative and verified that Chlorine test strips were required to test sanitizing level. The Dietary Manager tested with a chlorine test strip laying on a rack near the dish machine which indicated the sanitizer level was below 50 PPM. The Dietary Manager said, I think I have some new strips in my office. Upon testing again, the PPM of the dish machine water was 50 PPM.
4. On 7/8/22 at 8:31 AM, the following observations were made in the nourishment refrigerator located in the med room near the nurses' station:
a. Two six-ounce bottles of applesauce one with a use by date of 7/5/22 and another with a use by date of 7/7/22 were stored on the top shelf of the refrigerator.
b. A square clear container of beans with no date was stored on the third shelf.
5. A food storage policy received from the Dietary Manager on 7/7/22 at 10:56 AM documented, . Seamless container with tight-fitting lids, clearly labeled, shall be provided for bulk storage of dry foods . Leftover foods shall be labeled and dated with the date of preparation. Foods stored in freezers shall be wrapped in air-tight package, labeled, and dated .
6. A policy for sanitation of dishes provided by the Dietary Manager on 7/8/22 at 8:40 AM documented, . Low Temperature Dishwasher . Sanitation 50 PPM Hypochlorite .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the QAA committee put forth Good Faith attempts to correct and reassess its own quality deficiencies for medication storage and respiratory care for 12 residents who were on oxygen therapy according to the oxygen list provided 07/08/22 08:24 AM by the Director of Nursing (DON). The facility had deficiencies for these two areas in the past three recertification surveys. The findings are:
1. On 07/05/22 and 07/06/22 Surveyors noted the following oxygen issues:
a. R30 oxygen level was set at 3L/M via nasal cannula and 2nd observation set at 2 1/2 l/m via nasal cannula with 5L/M per June physicians orders.
2. On 7/8/22 8:31 AM, the Surveyor observed a 10 ounce bottle which was half full of Magnesium Citrate in the side door of the nourishment refrigerator located in the med storage room. There was no name on the bottle of whom the medication belonged to. The DON said, That shouldn't be in here.
a. On 07/08/22 02:18 PM the Surveyor ask the DON, you have had deficiencies on med storage ad labeling before. What did you do about it and she stated, We completed in-services and check frequently. The DON was asked, Did your plan work? She said, Evidently not.
3. On 07/07/22 at 09:02 AM, the Administrator was asked, How do you address if you get positive outcomes from your plan of correction? Administrator stated, Well, by monitoring. We had a deficiency for NOMNCs last year and we put a new policy in place. I think that was the only issue. Surveyor stated, The facility has had 3 repeat deficiencies with respiratory care and the survey team is finding the same deficiencies now. Do you have quality implementations in place? If so, I need to see the documentation for when, what, and the reassessments or monitoring. Administrator stated, I just got here last year. I will have to check on those for you.
4. On 07/07/22 at 12:57 PM, the Surveyor stated, Checking to see if you have all of the QA and QAPI documentation I requested? Administrator stated, I am still trying to get all of it together for you. The Administrator was asked, Do you have your updated QAPI Plan? The one Surveyors were given is dated 2016. The Administrator stated, We have not changed it since then. I have not had time to change the date and initial signing off on it.
5. On 07/07/22 at 01:35 PM, the Surveyor received the following documents:
a. Statement signed by Administrator, Respiratory equipment is being checked every two weeks by QA/IP nurse but hasn't been documented.
b. Oxygen in-service signed by 5 staff dated 4/23/21
c. Chart with F695 Respiratory/Tracheostomy Care & Suctioning with observations from 4/26/21 to 5/21/21
6. On 07/06/22 at 09:50 AM, the Facility assessment dated [DATE] received from Administrator stated, .5-10 range of residents .oxygen therapy . and .common diagnoses .Chronic Obstructive Pulmonary Disease (COPD), Pneumonia, Asthma, Chronic Lung Disease, Respiratory Failure .

Based on observations, interview, and record review, the facility failed to ensure implementation of proper infection prevention and control practices to prevent the development and transmission of COVID-19 and other communicable diseases and infections by wearing a face mask, wearing a face mask to cover the nose and mouth. These failed practices had the potential to affect the 46 residents who resided in the facility according to the Resident Matrix 7/5/22 provided by the Director of Nursing. The findings are:
1. On 07/05/22 at 10:02 AM, upon entrance, the Administrator stated facility was in a COVID 19 outbreak and had 2 positive COVID residents. Surveyor asked for any additional PPE or precautions and Administrator stated, a mask needs to be worn.
2. On 07/05/22 at 10:30 AM, a male visitor was allowed in facility by the Assistant Administrator/Business Office Manager (Asst Admin/BOM). The visitor walked down the hall without a mask over nose.
3. On 07/05/22 at 11:22 AM, 3 family members were visiting R#44. R44 and her 3 sons were visiting in her room and were not wearing a mask. Family Member #1 had his mask around his ears but pulled down under his chin. Family Member #2 when asked about his mask, pulled it from his pants pocket and put it on. Family Member #3 was holding his mask in his hand, and when his Family Member #2 was asked about his mask, Family Member #3 put on his mask. A staff was walking past the room and into the room prior to this Surveyor entering the resident's room.
4. On 07/05/22 at 11:42 AM, Resident # 19 was visiting with his brother, who was sitting in resident's room without his mask on. Resident's brother was holding it in his hand.
5. On 07/05/22 at 11:42 AM, the Surveyor entered laundry room dirty side. The door between the clean and dirty sides was held open with hook and eye latch lock. Laundry Worker #3 and Laundry Worker #4 were both on the dirty side and Laundry Worker #3 had a mask on under their nose.
6. On 07/05/22 at 12:01 PM, the Administrator was in the office with the Asst Admin/BOM. The Administrator did not have a mask on. The Administrator put on a mask when the Surveyor entered the office.
7. On 07/06/22 at 10:15 AM, Laundry Worked #1 answered door to dirty side with no mask on.
a. The door between dirty and clean held open with hook & eye latch lock.
b. Laundry Worker #2 and Laundry Worker#3 were standing and/or sitting on the clean side, within 6ft of each other. Laundry Worker #2 did not have a mask on, and Laundry Worker #3 wore his mask under his nose.
c. Laundry Worker #3 was asked, Should your mask be over both your nose and mouth? Laundry Worker #3 stated, No, only when I am on the halls and around the residents.
8. On 07/06/22 at 02:40PM Surveyor went to laundry area and asked Maintenance supervisor, who was sitting at desk with 4 bottles of beverages in front of him, and asked, Do you have a measuring tape we could use? Maintenance responded, Yes. Surveyor asked, Is this door left locked open all the time? Maintenance stated, They only attach it open at 1:30pm when they are done for the day. Surveyor asked, Did you notice it was open when you arrived for the tour with me earlier? Maintenance stated, No, I did not. Surveyor stated, It was open when I started to come in yesterday, open this morning when I came in for my tour, and again just now. Maintenance stated, It is open now because they attach it when they are done at the end of the day. It should be closed.
The Surveyor asked Maintenance to measure between the folding table and the dryer. Distance measured 5 ft. The Surveyor asked Maintenance to measure between the folding table and the plastic chair. Distance measured 47 inches. The Surveyor asked Maintenance to measure from Microwave/Refrigerator to plastic chair. Distance measured 7 1/2 ft. Maintenance asked the reason for the measurements. The Maintenance Supervisor was asked, Should laundry staff be wearing their masks while in here together? Maintenance stated, Yes, unless they are alone or on opposite sides. The Maintenance Supervisor was asked, Are you meaning clean and dirty sides? Maintenance stated, Yes. Surveyor stated, The measurements are due to staff not having masks on appropriately yesterday or today when I came in. The Maintenance Supervisor was asked, Do laundry staff receive any additional in-services than what the rest of staff receive? Maintenance stated, Not generally. Only when we have any additional equipment or questions about things like dry times.
9. On 07/06/22 at 10:35 AM, the Administrator was asked:
a. Does the facility have any other Infection control policies or guidelines other than the 3 given to surveyors? Administrator stated, We also follow the CDC [Centers for Disease Control] guidelines. I can print out the ones we follow for you.
b. Should staff have their mask over their nose and mouth? Administrator stated, Yes.
c. Should 3 staff who are within 6ft of each other have their masks on appropriately? Administrator stated, Yes.
d. Do laundry staff have to wear masks even when not around residents? Administrator stated, Yes.
e. Should staff be informing visitors that their masks need to be over their nose and mouth? Administrator stated, Yes, well we might not say it specifically, but yes it should be over their nose and mouth. When they check in, we do make sure they have their mask on properly.
f. Is everyone trained to do the screening at the front door? Administrator stated, No, only certain staff. I can get you a list.
10. On 07/06/22 at 10:51 AM, the list of staff allowed to screen visitors at the entrance received from Administrator. List included Administrative staff and stated .After hours and on weekends, the nurses on duty are allowed to screen visitors.
11. On 07/06/22 at 04:04 PM, the Infection Control Preventionist was asked:
a. Does the facility have any other Infection control policies or guidelines other than the 3 given to surveyors and the CDC guidelines? ICP stated, No, well also the Antibiotic Stewardship I also gave.
b. Does the facility have a contingency plan for unvaccinated staff? ICP stated, Unvaccinated staff are tested 1 time a week.
c. Should staff have their mask over their nose and mouth? ICP stated, Yes.
d. Should 3 staff within 6ft of each other have their masks on appropriately? ICP stated, Yes.
e. Do laundry staff have to wear masks even when not around residents? ICP stated, Yes, unless they are 6ft apart.
f. Should staff be informing visitors that their masks need to be over their nose and mouth? ICP stated, Yes, we all should be.
g. Is everyone trained to do the screening at the front door? ICP stated, No, only us up here in front and a few nurses on the other shifts.
12. The Infection Control policy titled Novel Coronavirus Prevention and Response received on 7/5/22 and CDC Interim Infection Prevention and Control Recommendations received 7/6/22 do not mention how to properly wear a mask or ensuring clean and dirty sides of laundry are separated.
13. On 07/07/22 at 09:02 AM, the unvaccinated staff contingency plan was requested from Administrator.
On 07/07/22 at 09:38 AM. the Administrator came to Surveyor in conference room and provided a document of contingency plan signed by unvaccinated staff stated, Employee to wear N95 or equivalent face mask and Employee will be tested at least weekly. Administrator stated, Our lawyer said instead of adding contingency plan to policy it was alright to have non-vaccinated staff sign this [pointing to form].
14. On 07/07/22 at 09:49 AM, the Administrator met with surveyor in front lobby and stated, We have this [pointing to in-service] that reads .3. Wear .masks as needed to protect your mouth and nose .] but no specific training or in-service on how to appropriately wear masks.
On 07/07/22 at 09:52 AM, the Administrator brought the surveyor a copy of a mask wearing poster and stated, This was hanging in the break room and was included in that in-service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: [NAME], [NAME] L
Based on interview and record review, facility failed to inform residents and representatives/families by 5 p.m. the next calendar day following the occurrence of a confirmed infection of COVID-19 for 45 residents per notify report received from Administrator 7/6/22. Findings are:
1. On 07/06/22 at 09:50 AM, the Administrator was asked for notification of families of positive COVID to go with the list of positive COVID residents and staff for the last 4 weeks.
2. On 07/06/22 at 02:06 PM, the Administrator was asked to help Surveyor match up positive COVID tests with the notification reports.
a. Positive staff 6/25/22 - notify report 6/27/22. The Administrator was asked about the notification on 6/27/22. Administrator stated CDM (Certified Dietary Manager) did not notify them until the next day after the results came back.
b. On 07/06/22 at 02:08 PM, the Administrator provided documentation from the hospital for CDM who tested positive on 6/25/22 and stated, I think the results did not come back until the next day, so we were not informed until the 26th.
The COVID 19 test was an RT-PCR (reverse transcription polymerase chain reaction test) which provides results in 15 minutes.
3. On 07/07/22 at 07:43 AM CDM was interviewed regarding recent positive COVID 6/25/22 and what facility's process was. Surveyor stated, The facility has record that you tested positive for COVID in May 2022. Was that from a test performed here? CDM stated, I guess I was positive. No, I was scheduled for a procedure and tested positive and immediately called the ADON. They called after a few days to check on me and had the hospital records sent. I stayed home for 7 days and then got tested and came back day 8. Surveyor asked, So you got the results right away the same day and called the facility? CDM stated, Yes.

Based on record review and interviews, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected medication use based upon pharmaceutical category for 1 (Resident #27) of 2 (Resident #37 and R#27) sampled residents who had a physician order for Plavix an anti-platelet. The findings are:
Resident (R) #27 had diagnoses of Coronary Artery Disease (CAD), Angina, and a history of a CVA (Cerebral Vascular Accident). The Comprehensive MDS with an Assessment Reference Date of 5/3/22 documented the resident scored 12 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status and received an anticoagulant 7 of 7 days.
a. On 07/06/22 at 2:54 PM, the R#27's a physician order documented, Plavix 75mg [milligrams] oral tablet 1 Tab po [by mouth] QD [every day] . for diagnosis of CAD .start date 12/17/2021 .
b. The May 2022 Medication Administration Record (MAR) dated documented R #27 received Plavix, an antiplatelet, every day of the month of May.
c. On 7/7/22 at 1:14 PM, the MDS Coordinator was asked, Is [R #27] receiving an anticoagulant? She stated, Yes, Plavix She was asked, When was her last MDS completed? She stated, 5/3/22. She was asked, Does her MDS document that she was receiving the anticoagulant? She stated, Yes, N0410 has she received five doses. The MDS Coordinator looked at the residents May and June 2022 Medication Administration Record and stated, She got it on May 26th, 29th, 30th 31st and June 1st . She was asked, What is the classification of Plavix? She looked at her cell phone and stated, Antiplatelet. She was asked, Should it have been documented that she was receiving an anticoagulant? She stated, No .

Based on interview and record review, the facility failed to ensure care plans were updated/revised to include the most current treatments and medications to meet the resident ' s medical and nursing needs for 1 (Resident #38) of 4 (Residents #17, #27, #38 and #40) on the final sample who received anticoagulant therapy, for 1 (Resident #27) of 8 (Residents #2, #13, #20, #27, #30, #36, #41 and #44) on the final sample who received oxygen therapy, and 1 (Resident #40) of 3 (Resident #5, 18, and 40) final sample residents who had physician's orders for Insulin therapy. The findings are:
1. Resident #38 had diagnosis of Embolism and Deep vein Thrombus. An Annual MDS with an ARD of 6/1/2022 documented the resident scored 4 (00-07 indicated severely impaired) in the BIMS.
a. The July 2022 Physician Orders documented, .Eliquis . 5mg [milligram] 1 tab PO [by mouth] BID [twice a day] Monitor and document if any signs of bleeding .
b. As of 7/7/2022, the plan of care did not document the use of an anticoagulant.
c. On 7/7/2022 at 1:30 PM, the MDS/CPC (Care Plan Coordinator) was asked, Who is responsible for ensuring the accuracy and individualization of the care plan? The MDS/CPC stated, I am responsible for the care plans. She was asked, What type of medications are included in the care plan? The MDS/CPC stated, Americare adds certain medications to the care plan. She was asked, Should an anticoagulant be added to the residents plan of care? She stated, Yes, it should be. She was asked, What is an important intervention related to anticoagulant therapy? She stated, Being careful with immunizations, injections, bleeding precautions, using a soft toothbrush, safety razors. She was asked, Should anticoagulants be addressed on the care plan? She stated, They should be, yes. She was asked, How do staff know where to look for an intervention related to bleeding? She stated, They would not know unless they were educated by the nurse. She was asked, If an Anticoagulant was not on the care plan, how would staff know what to look for while providing care? She stated, They could look at the care plan if it was on it, but wouldn't know unless they were educated by the nurse. She was asked, Are care planned interventions implemented for Anti-Coagulants in this resident record? She stated, No
2. Resident( R) #27 had diagnoses of Coronary Artery Disease (CAD), Angina, Anxiety Disorder, and a history of a CVA (Cerebral Vascular Accident). The Comprehensive MDS with an Assessment Reference Date of 5/3/22 documented the resident scored 12 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status; required extensive assistance of one person for bed mobility, dressing, toileting; one person assist with bathing; had functional limitation in range of motion of the left upper and lower extremities; and was occasionally incontinent of bowel and bladder.
a. A physician's order documented, .Oxygen [O2] 2LPM [liters per minute] start date 1/26/2022 .
b. The Plan of Care with a review date of 5/3/22 did not document the use of Oxygen.
c. On 07/05/22 at 10:50 AM, R#27 was asked, Do you use your oxygen? She stated, I use my oxygen at night. There was an oxygen concentrator at the bedside.
d. On 7/7/22 at 10:48 AM, the Director of Nursing (DON) was asked, Who is responsible for creating and updating the resident's care plan interventions? The DON stated, The MDS Coordinator.
e. On 7/8/22 at 10:56 AM, the DON was asked, Is [R27] receiving oxygen? She stated, Yes. She was asked, Is there interventions on her Care Plan for Oxygen? She looked at the current Care Plan and stated, No. She was asked, Should there have been Oxygen interventions been Care Planned? She stated, Yes.
3. Resident #40 had diagnoses of Insulin Dependent Type 2 Diabetes, Coronary Artery Disease (CAD), Angina, Anxiety Disorder, and a history of a Myocardial Infarction, and Atherosclerotic Heart Disease of Native Coronary. The Significant Change MDS with an Assessment Reference Date of 6/1/22 documented the resident scored 8 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status and required assistance of one person for ADL (Activities of Daily Living).
a. A physician order documented, Lantus 100 units/ml [milliliter] subcutaneous (SQ) solution 20 units SQ .Diagnosis Type 2 Diabetes Mellitus .with a start date of 8/24/2021.
b. On 7/7/22 at 11:07 AM a review of R#40 's current Care Plan did not have interventions for Insulin.
c. On 07/06/22 at 1:14 PM, the MDS Coordinator was asked, Does [R#40] have Insulin interventions on his Care Plan? She looked at his Care Plan and stated, Looks like I am missing that. I will do a whole section on hypoglycemia. She was asked, What is a potential complication for Insulin interventions not being on the Care Plan? She stated, They could possibly not know how to alter his Blood Sugars.

Based on interview and record review, facility failed to ensure the development of a discharge summary which included a recapitulation of the resident's stay and a final summary of the resident's status for 1 of 1 (Resident #46) sampled selected closed records who discharged to the community. The findings are:
Resident 46 had a diagnosis of Dementia, Encephalopathy, Hyperlipidemia, & COPD. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 2/7/22 documented the resident scored 6 (0-7 indicates severely impaired) on a brief interview for mental status (BIMS).
a. On 07/07/22 at 12:40 PM, the Discharge summary and Discharge Home Information stated, .Summary of course of treatment while in nursing facility . home for care . and was signed by the physician 5/24/22. It did not contain a recapitulation of R46 ' s stay.
b. On 07/07/22 at 12:47 PM, the Director of Nursing (DON) was asked for a discharge summary for Resident #46. Discharge Summary document was shown to the DON and she was asked if the nursing staff completed a discharge summary and she stated, No, this is all we have. The DON was asked, Was there a recapitulation of the stay on this document? She stated, No, that's filled out by the doctor, that's all he does. The DON was asked, Was there a summary of this admission completed within 24 hours of resident ' s discharge that documented his needs, medications and services provided during his stay and services he would have required upon discharge? DON stated, No, there isn't one. We don't do that for any discharges.
c. On 07/08/22 at 10:16 AM, the Discharge policy was requested from DON.
d. On 07/08/22 at 10:53 AM, the DON provided a signed statement that the facility does not .have a discharge policy in place .

Based on observation and interview, the facility failed to ensure 2 of 4 clothes dryers remained free of lint build-up to decrease the potential for fire and loss of laundry services for 1 of 1 laundry room. This failed practice had the potential to affect all 46 residents due to the potential for the interruption of laundry services due to the proximity of the laundry room, according to the Resident Matrix received 7/5/22 from Director of Nursing (DON). The findings are:
1. 07/06/22 10:15 AM, there were 4 gas dryers in the clean area of the laundry room. Maintenance Supervisor (MS) was asked, When are dryer vents/lint traps emptied? MS stated, They are cleaned at end of each day. The Surveyor opened 2 lint traps; one contained a single 2 inch thick round of lint build up on floor of trap and 1/2 inch thick lint hanging from vent; second contained two 1-2 inch thick rounds of lint build up on the floor of the trap and 1/2 inch thick lint hanging from vent filter. Maintenance stated, Can you believe all that is only from 5-6 loads? Surveyor asked, They are only cleaned at the end of the day? Laundry #2 stated, There is only one shift. MS stated, Yes, usually. There is only one laundry shift.
2. On 07/06/22 at 04:50 PM, the Administrator was asked, How often should lint traps be changed? The Administrator stated, It depends on how much laundry they do. Surveyor stated, I was informed that the lint traps were emptied at the end of each day and when I went in there the lint traps had 1-2 inches of lint on the filter and the bottom of the pan. Administrator stated, Oh, they know better than that. That could cause a fire.
3. On 07/07/22 at 10:36 AM , the manufacturer ' s manual for the dryers received from Administrator documented. a.Warning: For your safety the information in this manual must be followed to minimize the risk of fire or explosion or to prevent property damage, personal injury or loss of life . b. A program and/or schedule should be established for periodic inspection, cleaning, and removal of lint from various areas of the dryer . c. Warning: Lint from most fabrics is highly combustible. The accumulation of lint can create a potential fire hazard .

Based on observation, record review and interview that facility failed to document weekly pressure ulcer wound assessments that included wound measurements, and changes in the wound characteristics in order to monitor the impact of the interventions and manage the stage III pressure ulcer according to professional standards of practice for 1 of 1 (R#27) of sampled selection of resident who had a pressure ulcer. The findings are:
Resident(R) #27 had diagnoses of Stage III Pressure Ulcer, Coronary Artery disease (CAD), Angina, Anxiety Disorder, and a history of a CVA (Cerebral Vascular Accident). The Comprehensive Minimum Data Set with an Assessment Reference Date of 5/3/22 documented the resident scored 12 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status; required extensive assistance of one person for bed mobility, dressing and toileting; one person assist with bathing; had functional limitation in Range of Motion of the left upper and lower extremities; was occasionally incontinent of bowel and bladder; and had an unhealed pressure ulcer.
a. The Braden Scale dated 4/21/22 documented a score of 15 A total score of 12 or less represents HIGH RISK.
b. A Care Plan with the revision date of 6/1/22 documented, 5/3/22 Resident is at risk for developing a pressure ulcer Resident has pressure ulcer(s) Location: Left heel; Stage: unstageable .Report changes in skin status .to physician .
c. A physician order dated 6/14/22 documented, Clean L[left] heel [with] wc [wound cleaner], pat dry, apply Betadine, cover [with] foam adhesive [and] [change] Q [every] 7 days or prn [as needed] if soiled or dislodged .
d. On 7/6/22 at 1:46 PM, a wound measurement report for the left heel dated 6/9/2022 documented 2 X 1.8 cm (centimeters) Unstageable. The DON was asked, Do you have any other wound measurements? The DON stated, No.
e. On 7/6/22 at 1:56 PM, the DON was asked, Who is responsible for measuring the pressure ulcers and how often should they be measured. The DON stated that the wound should be measured weekly, and that the Infection Control and Prevention Nurse was responsible for measuring the pressure ulcer.
f. On 7/6/22 at 2:13 PM, the Infection Control and Prevention Nurse/Quality Assurance Nurse was asked, Are you responsible for measuring [R#27] pressure wounds? She stated, I am. She was asked, Where is your wound measurements documented? She stated, That's a good a question. I can't find them anywhere this is on me. The last time I saw it was approximately two weeks ago when [Licensed Practical Nurse (LPN) #1] was changing her dressing. We had switched from Betadine to the foam dressing, and it was looking better. She was asked, What measures do you have in place to prevent her pressure ulcer from worsening? She stated, Heel floats or pillow.
g. On 7/6/22 at 2:16 PM, the Surveyor and Infection Control and Prevention Nurse/Quality Assurance Nurse went to the R#27's room. The resident ' s feet were elevated on the base of the recliner with her heels resting on the recliner. The nurse stated, She must have pushed her pillow off. There was a neck pillow lying beside her foot. The nurse placed the heel up on the pillow floating her heel.
h. On 7/6/22 at 2:21 PM, LPN #1 was asked, Are you the one providing wound care to [R #27]? She stated, Yes, I do it on Tuesdays. She was asked where she documents her wound care, she confirmed that she documents it on the TAR. She stated that she does not do the wound measurements that Infection Control and Prevention Nurse/Quality Assurance is responsible for them. LPN #1 stated that the wound has gone from A quarter size to a dime size now since we started using the sponge every 7 days. There is still some odor though. She was asked, Is [R#27] being seen by a wound clinic? She stated, No.
i. On 7/6/22 at 4:02 PM, LPN#1 removed the 2x2 foam dressing from R#27's left heel. There was a 1 cm light brown drainage on the 2x2. The RN was asked, Does it have an odor? She stated, Yes, it has a slight odor. The wound had a thin black layer of eschar over the top on it and slightly attached at the far end of the wound by whitish tissue. The RN measured the wound, 1cm X 1.5 cm x 0.4 depth. RN#1 cleaned the wound, applied Betadine, and covered the wound with a 2x2 foam dressing.
j. On 7/6/2 at 4:47 PM RN#1 provided a document titled Weekly Pressure Injury Record that documented, [R#27] Date 7/6/22 .Date of onset 1/5/22 .site location left heel .necrotic center attached loosely to slough fibrous tissue .
k. On 7/ 6/22 a review of the physician's progress notes copied from R#27's dated 1/11/22 through 5/3/22 did not address the pressure ulcer to the left heel.
l. On 7/7/22 at 3:47 PM The DON was asked, Who is responsible for ensuring the Pressure ulcers are being assessed, documented and monitored? She stated, Me. I am going to be watching that more closely.
m. On 7/8/22 at 2:16 PM received a TAR (Treatment Administration Report) dated 1/5/22 documented, .Apply Betadine to L [left heel] .
n. A policy titled Treatment provided by the DON documented, .3. All residents with a pressure ulcer will have at least weekly assessment .The Quality Assurance Nurse will audit the total number of pressure ulcers in the facility each month to analyze quality improvement .A weekly pressure ulcer report will be given to Director of Nurses, MDS coordinator Administrator and Dietary Manager . A weekly progress report will also be given to resident's attending physician description, size, and progress.Family will be notified each week on the progress or decline of the pressure ulcer .

2. Resident #44 had diagnosis of Urinary Retention. An admission Minimum Data Set with an Assessment Reference Date of 6/06/2022 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status.
a. A physician order dated 5/31/22 documented, Foley Catheter 16 FR [French] 5 cc [cubic centimeter] bulb. Change Monthly and PRN[ as needed] if occluded or dislodged.
b. The Resident Plan of Care with a .problem date: 6/6/2022 . documented .Elder requires assistance with toileting . Residents Foley Catheter was not addressed in the plan of care.
c. On 07/05/22 at 11:17 AM, the resident ' s Foley Catheter tubing was sitting on the floor on the window side of the chair.
d. On 07/06/22 at 10:43 AM, the Foley Catheter bag/tubing was hanging on the side of the trash can, with the bottom part of the catheter and tubing sitting on the floor.
e. On 7/8/2022 at 1:35 PM, the Director of Nursing (DON) was asked, Should the catheter bag be sitting on the floor and hanging on the trash can? She stated, No.
f. A Foley Catheter Care . policy was received from the DON on 7/6/2022 at 12:24 p.m. and documented, .The catheter and drainage bag should be kept as a closed system with the drainage bag kept at a level lower than the bladder to allow drainage by gravity . Catheter and tubing should be arranged so it doesn't kink or hang in a dependent loop .
Based on observation, record review and interview, the facility failed to ensure all fecal matter was cleaned during incontinent care and a back to front motion was not used during incontinent care to prevent the potential for urinary tract infections for 1 of 1 (Resident #27) sampled resident who was incontinent of bowel and dependent on staff for peri care. The facility failed to ensure a urinary catheter bag and tubing were not lying on the floor to prevent potential contamination for 1 (Resident #4) of 2 (Residents #23 and #44) final sample residents who had a urinary catheter. The findings are:
1. Resident (R) #27 had diagnoses of Coronary Artery Disease (CAD), Angina, Anxiety Disorder, and a history of a CVA (Cerebral Vascular Accident). The Comprehensive MDS with an Assessment Reference Date of 5/3/22 documented the resident scored 12 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status; required extensive assistance of one person for bed mobility, dressing, toileting; one person assist with bathing; and had functional limitation in range of motion of the left upper and lower extremities; and was occasionally incontinent of bowel and bladder.
a. A care plan with the revision date of 5/3/22 documented, . Resident has ADL [Activities of Daily Living] Self-Care Deficit As Evidenced by : Needs assistance with Toilet use: Ext [Extensive] x [times] 1 .Resident at risk of experiencing incontinent episodes of Bowel and/ or Bladder .Resident is at risk for Pressure Ulcer .
b. On 7/6/22 at 3:50 PM, Certified Nursing Assistant (CNA #1) removed the resident ' s soiled brief that had a moderate amount of loose Bowel Movement (BM) from R#27's buttocks. She then cleaned the resident's buttocks from back to front. After she finished wiping the resident with the wet washcloths and placed them in the plastic bag. CNA #1 picked up the clean brief and began to place it under the resident's buttocks. CNA #1 was asked, Are you finished cleaning her? CNA #1 stated Yes. CNA #1 was asked to wipe between the resident's vaginal area. CNA#1 wiped the area with clean white cloth from front to back. CNA#1 was asked to show this surveyor the cloth. It had a quarter size of smeared BM on it. CNA#1 got another cloth and wiped residents peri area and buttocks until the cloth came back clean. She then placed the clean brief under R#27.
c. On 7/6/22 at 4:02 PM , Registered Nurse (RN)#1 was asked, When should the CNA know when the Resident is clean when providing peri care after a BM? She stated, When her washcloth comes back clean. The RN was asked, What was on the washcloth after the CNA was asked to wipe the peri area, after she stated she was finished? The RN stated, I think they had to clean her a little bit more. RN#1 was asked, What is a potential complication of the CNA leaving BM on the Resident's peri area? She stated, UTI [urinary tract infection]
d. On 7/6/22 at 4:22 PM, CNA#1 was asked, What should the washcloth look like when you finished cleaning the bowel movement from [R#27]? She stated, There should have been nothing on it. She was asked, What was on the washcloth when I asked you to wipe her? She stated, Poop. She was asked, What is a potential complication of leaving poop on a resident? She stated, Infection.
e. On 7/6/22 at 4:26 PM, the Director of Nursing (DON) was asked, When a CNA is cleaning BM from a resident, when do they know they are finished? She stated, They are clean. The DON was asked, What is a potential complication of a resident being left with poop in their peri area? She stated, They could get an infection, UTI.
f. A policy provided by the DON titled, Peri-Care DID NOT address wiping peri area until cloth comes back clean.