Chestnut Ridge Nsg & Rehab Ctr

Based on observations, staff and resident interviews, record review, and review of the facility policies titled Handwashing/Hand Hygiene, Insulin Administration, Housekeeping-Infection Control Procedures, and Cleaning and Disinfection of Resident-Care Items and Equipment, the facility failed to follow proper infection control practices for one of four nursing units and two of two shower rooms. Specifically, top of an insulin vial not disinfected, blood pressure cuff not disinfected between residents, Housekeeping Aide pouring liquid from resident cup into mop water, and nursing staff exiting resident rooms without removing gloves and performing hand hygiene. In addition, multiple personal items in the communal shower rooms were unlabeled. The deficient practice increased the risk of cross contamination and spread of infection. Facility census was 127.Findings Include:
Review of the facility's policy titled, Handwashing/Hand Hygiene, dated 2/2020, revealed that This facility considers hand hygiene the primary means to prevent the spread of infections. Further review of item 5. Hand hygiene is the final step after removing and disposing of personal protective equipment. Item 6. The use of gloves does not replace hand washing/hand hygiene.
Review of the facility's policy titled, Insulin Administration revised September 2014, revealed under Steps in the Procedure (Insulin Infections via Syringe) step 8. Disinfect the top of the vial with an alcohol wipe.
Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment dated 1/2023 revealed that Resident-care equipment, including reusable and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. Further review of Item 4. Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturer's instructions.
Review of the facility's policy titled Housekeeping-Infection Control Procedures revised 11/2024 on page 69 documented under Infection Control Guidelines that The solution to controlling infection lies not in technology, but in human behavior. Further review revealed that The role of a housekeeping department in the infection control process is to halt the transmission of infectious organisms.
1.Observation and interview on 03/04/2026 at 10:03 AM during medication administration revealed Licensed Practical Nurse (LPN) DD drew insulin for Resident (R) (R106), Lantus (insulin glargine) 34 units subcutaneously for diabetes mellitus, and failed to clean the top of the insulin vial prior to drawing the medication. During interview, LPN DD stated she usually wipes the top of the insulin vial but did not do so on this occasion and acknowledged the infection control concern, stating that contaminants could be introduced onto the needle.
Observation and interview on 03/04/2026 at 10:36 AM, during medication administration revealed Licensed Practical Nurse (LPN) DD used the same blood pressure cuff for two residents A04-A and A04-B, who were both on Enhanced Barrier Precautions (EBP), without cleaning or disinfecting the cuff between residents. During interview, LPN DD stated she forgot to wipe down the blood pressure cuff and did not have disinfectant wipes in her medication cart. She left the area to obtain disinfectant wipes and acknowledged the concern for potential contamination and infection transmission.
Observation and interview on 03/04/2026 at 3:07 PM revealed Housekeeping Aide GG removed several dated resident cups from Room C38 and emptied the contents into the mop bucket she was using to clean resident rooms on the C-Hall. During interview, Housekeeping Aide GG indicated she spoke Creole and no English. At that time, the Director of Housekeeping was present, was informed of the observation, and spoke with Housekeeping Aide GG in English, instructing her to stop pouring used resident cups into the mop bucket.
Observation and interview on 03/04/2026 at 3:20 pm revealed Certified Nursing Assistant (CNA) II exited a resident room wearing one glove and carrying a bag of used soiled linen while walking down the hallway to dispose of the bag. During interview, CNA II stated she was not aware that gloves should not be worn in the hallway and believed it was acceptable to do so.
Observation and interview on 03/05/2026 at 10:28 AM revealed Registered Nurse (RN) JJ exited a resident room wearing one glove and walked into the hallway toward the medication cart. RN JJ removed the glove, disposed of it, and immediately opened the medication cart, removed items, and walked back toward the resident room without performing hand hygiene. During interview, RN JJ confirmed he did not perform hand hygiene after removing the glove and acknowledged walking through the hallway wearing one glove and touching items in the medication cart without performing hand hygiene.
Interview on 03/05/2026 at 11:05 AM with Director of Nursing (DON) revealed that staff should clean the top of insulin vials prior to injecting air or withdrawing medication to maintain a clean surface and prevent infection. The DON stated that gloves should not be worn in hallways after resident care, as they may carry contaminants from resident rooms, and emphasized that staff should perform hand hygiene after glove removal. Additionally, the DON stated that housekeeping staff should dispose of liquids from resident water cups, which may contain saliva, in designated areas such as the restroom, and use appropriate stations for filling mop buckets to maintain sanitation standards.
2. On 03/02/2026 at 11:48 AM, a general tour was conducted of the C Hall communal women's shower room. Observation revealed that Stall 1 contained an unlabeled bottle of shampoo/skin cleanser; in the second stall an open bottle of shampoo/skin cleaner, and a used washcloth was observed on the shower bench; on a shower room shelf there was a half-used bottle of VO5 shampoo, a reusable water bottle, resident clothing and a cell phone.
On 03/04/2026 at 12:18 PM, during a follow up tour of the woman's shower room on C Hall, observation revealed an unlabeled container of secret deodorant was open and sitting on the shelf, next to an open, unlabeled bottle of shampoo, power stick 2-in-1 shampoo and conditioner, clean towels and washcloths were sitting on a resident wheelchair with a dirty resident gown. An open bottle of shampoo was observed on the shower stretcher. A used washcloth was left hanging over the shower rail, and a used slipper sock was on the floor in front of the toilet. None of the items were labeled with resident identification.
On 03/04/2026 at 12:20 PM, during an interview with CNA QQ, she stated the aides use the residents' personal products for their bathing/showers and if the resident does not have anything they should use the multi-use bottle/product. CNA QQ stated the shower rooms are supposed to be cleaned following each use. CAN QQ confirmed the personal care products were not labeled. She stated she did not know whose belongings were in the shower room.
On 03/04/2026 at 12:30 PM, the Housekeeping Director (HKD) stated the communal showers are cleaned at 8:00 AM, 12:00 PM, and 3:00 PM. The HKD stated CNA staff are supposed to clean the showers following each resident use and make sure the towels/washcloths are removed at the completion of the task.
On 03/04/2026 at 2:48 PM, an observation tour of the men's communal shower room revealed personal items comingled. The items included a partially used bottle Thera-gel shampoo, an electric razor, Pantene shampoo and conditioner, and 2 open half used bottles of fresh scent baby lotion. Additionally, the men's shower stretcher had a greenish colored liquid pooling in the center of the foam stretcher.
On 03/04/2026 at 2:56 PM, the Regional Nurse Consultant verified the personal care items were mixed in the men's and woman's communal bathrooms and stated she would have the personal items removed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interviews, the facility failed to ensure that Minimum Data Set (MDS) assessments were accurate for two of four residents (R) (R112 and R113) reviewed for elopement risk. This deficient practice had the potential to place R112 and R113 at increased risk of not receiving care and services according to their assessed needs. Findings include:
Review of the policy titled Wandering, Unsafe Resident, dated 05/2023, documented Policy Interpretation and Implementation: 3. Monitoring and Managing Residents at Risk for Elopement and Unsafe Wandering: a. Residents shall be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care team. B. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. C. The effectiveness of interventions shall be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff.
1. Review of the electronic medical record (EMR) revealed resident R113 was admitted to the facility on [DATE] and pertinent diagnoses including but not limited to Vascular Dementia, Mild, With Mood Disturbance, Psychotic Disturbance and Mood Disturbance, And Anxiety.
Review of R113's quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 03, which indicated severe cognitive impairment. Section P: (Functional Status) coded for alarms not used.
Review of R113's care plan dated 11/20/2024, documented a problem At risk for elopement and exhibits exit-seeking behavior. I have a wander guard. Goals included but not limited to I will not successfully elope the facility and will be monitored of my whereabouts on an ongoing basis through review date. Interventions included but not limited to observe me for 'tailgating' when visitors are in the building. provide direct staff supervision for me when attending an out of facility activity. Reassess elopement risk as least quarterly. Seek a referral for a mental health evaluation from primary care physician as needed. Use audible monitoring system to alert staff of exit seeking behaviors. Use diversional activities when exit-seeking behavior is occurring (offer food, activities, one on one, company).
Review of the Physician's Orders for R113 revealed there was no evidence an order for the wander guard was written.
Review of the document titled Wander Guard List, provided by the facility revealed R113 was on the list.
Observation of R113 on 03/05/2026 at 3:00 PM revealed a wander guard bracelet applied around her ankle.
Interview on 03/05/2026 at 4:22 PM with the Director of Nursing (DON), stated that for those residents who wander, an elopement assessment is completed to see if there is a need for a wander guard. The DON further stated for those residents who wander and attempt to exit seek, they may be a good candidate for the wander guard, and the social worker is the one who would make sure the assessment is completed as well as the doctor order in place. The DON added nursing is also able to complete the assessment.
Interview on 03/05/2026 at 5:17 PM with the Administrator stated when it comes to having a doctor order for anything, the nurses should call the emergency line after hours once the Nurse Practitioners (NP) leaves the facility. Anytime they call a Medical Doctor (MD), the MD will call back in 15-20 minutes. If there is a problem staff have been instructed to let him know what is going on. There is a possibility of a negative effect on resident needs if there is no order to follow.
2. Review of the EMR revealed resident R112 was admitted to the facility on [DATE] and pertinent diagnoses included but were not limited to unspecified dementia, unspecified mood, major depressive disorder, anxiety disorder, other symptoms and signs involving appearance and behavior.
Review of R112's quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 03, which indicated severe cognitive impairment. Section P: (Functional Status) coded for alarms not used.
Review of R112 care plan dated 10/24/2025, documented a problem including wanderer and sometimes goes into other resident's rooms related to disoriented tplace. Interventions included but not limited to distracting resident from wandering, identify pattern of wandering and wander guard placement on 01/07/2026.
Review of the Physician's Orders for R112 revealed there was no evidence an order for the wander guard was written.
Review of the document titled Wander Guard List, provided by the facility revealed R112 was on the list.
Observation of R112 on 03/02/2026 at 11:15 AM, revealed a wander guard bracelet applied around her ankle.
Interview with MDS Coordinators LPN NN, and LPN OO on 03/05/2025 at 2:10 PM, confirmed that R112's quarterly MDS assessment and R113's quarterly MDS assessment were inaccurately coded in Section P. The MDS Coordinators acknowledged the coding errors and indicated that modifications would be completed to correct the assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, record review, and review of the facility's policies titled Administering Medications, Provision of Care, and Change in a Resident's Condition or Status, the facility failed to ensure that residents received care in accordance with physician orders and facility policy for five residents (R) (R47, R72, R106, R137, and R128) of 47 sampled residents. Specifically, the facility failed to: ensure a wound vac was applied and connected; ensure medications were administered by the nurse who pulled the medication; notify the physician of deviations from orders; accurately document medication administration; obtain resident weights as ordered; and provide timely pain medication. These deficient practices increased the risk of adverse clinical outcomes.
Findings Include:
Review of the facility's policy titled, Administering Medications, dated 2/2020 revealed that Medications shall be administered in a safe and timely manner, and as prescribed. Further review of item 4. The individual administering medications should check the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Item 6. The individual administering the medication should document the administration on the eMAR.
Review of the facility's policy titled, Provision of Care undated revealed that Based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the resident's choices. Further review of item 3, The standards of care shall include person-centered care, clinical care standards, safety and prevention protocols, and accurate documentation. Item 5. Qualified persons shall provide care and treatment in accordance with professional standards of practice, the resident's care plan, and the resident's choices.
Review of the facility's policy titled, Change in a Resident's Condition or Status date 05/2023 revealed that Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.). Further review of item 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a (an): f. refusal of treatment or medications.
1. Observation and interview on 3/4/2026 at 2:50 pm revealed Licensed Practical Nurse (LPN) EE handed a medicine cup containing pills to LPN FF, who was walking by in the hallway, and asked her to administer the medication to a resident in a specified room. During interview, LPN EE stated the medication in the cup was Tylenol and reported that she only hands medications to another nurse to administer in emergency situations. When asked to clarify the emergency at that time, LPN EE stated the surveyors were in the facility. Interview with LPN FF upon her return confirmed she administered the medication but did not know what medications were in the cup, as she was not the nurse who pulled the medication or verified the medication order prior to administration.
2. Review of the EMR revealed that R106 was admitted to the facility on [DATE] with pertinent diagnoses including, but not limited to, Type 2 Diabetes Mellitus (DM) with Diabetic Neuropathy, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease (COPD), and emphysema.
Review of R106 quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, indicating little to no cognitive impairment. Section GG: (Functional Status) indicated the resident required use of a wheelchair. Section N: (Medications), indicated the resident received insulin.
Review of the Physician's Orders for R106 included but was not limited to:
Order dated 09/18/2025 for Glipizide, give 1 tablet by mouth two times a day for DM
Order dated 01/07/2026 for Fluticasone-Salmeterol, 1 inhalation inhale orally two times a day for COPD
Review of the Medication Administration Record (MAR) for R106 revealed that LPN DD documented administration of Glipizide and Fluticasone at the scheduled 9:00 AM medication pass on 03/04/2026. However, these medications were not available in the facility and were not administered. Despite the medications not being available, LPN DD documented them as given on the MAR, resulting in inaccurate documentation.
Interview on 03/04/2026 at 2:11 PM with LPN DD confirmed that she had documented administering R106's Glipizide and Fluticasone when the medications were not given. She stated, I will strike them out. I just corrected it.
3. Review of the EMR revealed that R47 was admitted to the facility on [DATE], with pertinent diagnoses including, but not limited to, other intervertebral disc degeneration-lumbar region, spinal stenosis-lumbar region without neurogenic claudication, intervertebral disc disorders with radiculopathy-lumbar region, Type 2 DM with Diabetic Polyneuropathy, and pain-unspecified.
Review of R47 annual MDS assessment dated [DATE], revealed a BIMS score of 14, indicating little to no cognitive impairment. Section GG: (Functional Status), revealed that R47 required partial to moderate assistance with activities of daily living and used a walker. Section N: (Medications), indicated R47 received antidepressant, opioid, and anticonvulsant medications. Section J: (Health Conditions) reflected that R47 received pain medication, with pain present occasionally at a moderate intensity.
Review of R47 care plan, revised 01/14/2026, indicated a problem of pain management related to chronic conditions, including back pain from disc degeneration and lumbar spinal stenosis and neuropathic pain. Goals included but were not limited to reducing the impact of pain on daily life, achieving adequate pain relief or the ability to cope with partially relieved pain, and preventing adverse reactions to opioid or anticonvulsant medications. Interventions included but were not limited to administering opioid and anticonvulsant medications as ordered, monitoring and documenting side effects and reporting them to the physician, assessing pain levels and medication effectiveness, responding promptly to complaints of pain, and observing and reporting changes in functional ability, sleep patterns, or resistance to care.
Review of the Physician's Orders for R47 included but was not limited to:
Order dated 12/9/2025 for Tramadol HCL oral tablet 50 mg, give 1 tablet by mouth as needed for pain (5-10) may have between 1pm-5pm
Order dated 1/20/2026 for Tramadol HCL oral tablet 50 mg, give 1 tablet by mouth two times a day for pain
Order dated 3/3/2026 for Tramadol HCL oral tablet 50 mg, give 1 tablet by mouth as needed for pain (4-8) 1 tab prn pain between 1300-1700
Review of R47's controlled substance records and physician orders revealed that the PRN Tramadol HCL 50 mg order dated 12/09/2025 expired on 01/23/2026, leaving a six-week gap during which no refill was obtained until a new order was placed on 03/03/2026.
Observation and interview on 3/2/2026 at 2:02 pm with R47 and daughter who was on the phone at the time, revealed that R47 has been having issues with her pain medications, many times they have run out and there have been re-ordering delays. Additionally, they stopped giving her the prn pain medication even when she asks for it and does not know why.
Interview on 3/3/2026 with LPN CC revealed that R47 did not have the PRN Tramadol in the medication cart and did not know when it had run out.
4. Review of the EMR revealed that R137 was admitted to the facility on [DATE] with pertinent diagnoses including, but not limited to, unspecified severe protein-calorie malnutrition, adult failure to thrive, unspecified dementia, altered mental status-unspecified, and depression.
Review of R137 comprehensive MDS assessment dated [DATE] revealed BIMS was not completed. The Staff Assessment for Mental Status indicated short and long-term memory problems, inability to recall usual information, and severe impairment in daily decision-making, demonstrating that R137 had severe cognitive impairment. Section GG, functional status, revealed that R137 was fully dependent on staff for all activities of daily living, including eating, hygiene, dressing, and transfers. Mobility was also fully dependent, with transfers and bed mobility not attempted due to medical or safety concerns. Functional limitations were noted in both lower extremities, while upper extremities had no impairment. Section K, swallowing/nutritional status, revealed no signs of a swallowing disorder. R137 was 63 inches tall and weighed 92 pounds, requiring a mechanically altered diet (pureed or thickened foods).
Review of the Care Area Assessment (CAA) on the comprehensive MDS dated [DATE] indicated R137 was identified with cognitive loss/dementia, communication impairment, urinary incontinence/indwelling catheter, falls, nutritional status issues, dehydration/fluid maintenance needs, pressure ulcer risk, and psychotropic drug use.
Review of R137 care plan, dated 11/05/2025 indicated a problem of nutritional deficits and risk for significant weight changes related to UTI (Urinary Tract Infection), dementia, epilepsy, and adult failure to thrive. Goals included but were not limited to maintaining stable weight, preventing further malnutrition, and ensuring adequate intake and hydration. Interventions included but were not limited to monitoring and documenting weight, observing and reporting signs of malnutrition, monthly and as-needed weights, dietitian evaluation and recommendations, and promoting adequate hydration and nutrition.
Review of the Physician's Orders for R137 included but was not limited to:
Order dated 11/05/2025 for Weights: Weekly one time a day every Wed for 3 Weeks screening x3
Order dated 11/09/2025 for Weekly weights x 3 weeks every day shift every Sun for monitoring for 3 Days
Review of R137 weight monitoring revealed underweight status with a BMI of 16.5. Recorded weights were 91.6 lbs on 11/5/2025 and 93.1 lbs on 11/16/2025. Missed weights were noted on 11/9/2025, 11/12/2025, 11/19/2025, and 11/23/2025. No weights were documented between 11/16/2025 and 11/27/2025. The resident presented to the emergency department on 11/27/2025 with a weight of 76 lbs, reflecting a total weight loss of approximately 17 lbs since the last recorded weight on 11/16/2025.
Interview on 03/03/2025 at 3:36 PM with Unit Manager LPN BB revealed that weights are obtained on admission for a baseline, then on days 1, 2, and 3, followed by weekly weights for three weeks, and then monthly thereafter, usually on the first of the month. LPN BB stated that she did not notice R137 sustaining any weight loss.
Interview on 03/05/2026 at 2:26 PM with Unit Manager LPN MM revealed that she is responsible for monitoring resident weights, entering the orders, and ensuring weights are obtained monthly, typically before the 10th of the month, and recorded in her weight tracking log. She explained that during SOC (Patients at Risk) meetings, weight trends are reviewed to identify residents who may need appetite stimulants or other interventions. LPN MM confirmed that R137 did not have her weight checked for over a week, resulting in a missed weight. She noted that weights are not always obtained consistently due to staffing challenges, as only two staff members are trained to obtain weights and agency staff are unable to perform them.
Interview on 03/05/2026 at 11:05 AM with Director of Nursing (DON) revealed that staff are expected to follow physician orders and facility policies when providing care and administering medications. If medication is not available, staff should first contact the pharmacy to follow up on the refill, and if the issue is not resolved, they must notify the Unit Manager, DON, and physician for further direction. The DON emphasized that nurses must only administer medications they are familiar with and have prepared themselves; medications should not be handed off to another nurse, as improper administration could result in adverse outcomes. Regarding respiratory care, staff are expected to document the resident's preferences, perform assessments, and notify the in-house NP as needed, who then determines whether a weaning process is appropriate or if therapy should be changed to PRN, with all assessments and communications thoroughly documented. The DON also stated that weights must be obtained as ordered, particularly for new admissions, to establish baseline measurements. Accurate weights are essential for identifying changes in a resident's condition, including potential disease processes or nutritional decline. A follow-up interview at 12:32 PM, the DON further stressed that timely and accurate documentation of medication administration as they are administered is critical, as delays or inaccurate recall of medication administration can negatively impact clinical outcomes.
5. R72 was admitted to the facility on [DATE]. Diagnoses included vascular dementia, type 2 diabetes mellitus with other diabetic neurological complications and long-term use of insulin.
Record review of the physician orders for medications included Jardiance 10 mg once daily for diabetes with a start date of 08/26/2025; Metformin HCL extended release 500 mg twice daily for diabetes with a start date of 10/30/2025; Lantus Solostar 10 units inject subcutaneously at bedtime for diabetes. AccuChecks (blood sugar checks) were ordered to be checked before every meal and at bedtime, with a start date of 03/25/2025.
R72's Care plan noted Type 2 diabetes with long term use of insulin initiated 09/23/2022, and last revised on 10/05/2023.
Record review of R72's blood sugar record showed blood sugars being checked once daily at bedtime. There was no record of blood sugar checks before meals as ordered by the physician.
On 03/05/2026 at 2:21 PM, LPN MM stated R72 has a physician order to check blood sugar before meals and at bedtime. LPN MM verified blood sugars being checked once daily at bedtime. She stated she needed to clarify the order with hospice, currently it looks like they are not doing what is ordered.
On 03/05/2026 at 2:32 PM, during a joint interview the DON and Regional nurse consultant (RNC), stated if a resident had orders for accuchecks {fingerstick blood sugar} before meals and at bedtime, they should be checked according to that order.
On 03/05/2026 at 2:45 PM, The nurse practitioner (NP) stated during a telephone interview if there were active orders she would expect them to be followed, if not she would expect the nurse to notify the provider.
On 03/05/2026 at 3:40 PM, during a follow up interview the RNC stated she contacted hospice and was told the resident no longer needed before meals and at bedtime, and they would fax over an order for blood sugars to be checked at bedtime. She stated she felt the order was initially entered incorrectly in the electronic health record.
6.Resident (R) 128 was admitted to the facility on [DATE]. R128's diagnoses included Acute osteomyelitis, left ankle and foot. (infection of the bone). R128 was admitted to the facility with a wound vac medical device which used controlled suction to pull fluid and infection away from a wound to help the wound heal.
Clinical record review of the physician order dated 02/28/2026 included monitor wound vac dressing site every shift for intact seal, proper suction, function drainage output, and signs of infection. Ensure VAC is functioning properly and dressing remains intact. Suction set to 100mmHg. Notify provider of any abnormal findings. If vac suction is lost and cannot be patched, remove vac dressing and resume wet to dry dressing utilizing moistened gauze with quarter strength Dakin's to wound bed cover with ABD dressing, secure with tape, notify WCN. Additionally, cleanse left foot hell surgical wound bed with ns/wc {normal saline or wound cleanser] or equivalent. Apply black foam to wound. Seal and apply wound vac. Set suction to 100 mm/Hg. Change [wound vac] dressing every day shift Tuesday and Friday.
R128's care plan did not specify any focus, goal or interventions related to the wound vac device, monitoring or dressing changes.
Record review of the medication administration/treatment administration record for February and March 2026 showed two entries to monitor the wound vac. One entry specified wound suction to be set at 100mmHg. The second entry noted to monitor wound vac suction set to 125mmHg.
Record review of a nursing progress note dated 03/02/2026 at 16:47 PM, documented resident currently has wound vac in place.
On 03/02/2026 at 3:35 PM, R128 stated the wound vac was placed at the hospital and it was supposed to be on until she followed up with the podiatry surgeon. R128 stated staff took the wound vac off but she did not know why because it seemed to be working well. She stated it had not alarmed and the dressing was in place. The wound vac was observed disconnected, sitting on the bedside table.
On 30/03/2026 at 8:20 AM, The wound vac was observed still sitting on the bedside table. R128 stated wound vac taken off yesterday and the nurse said they were waiting to hear back from the podiatrist to determine if the wound vac needed to remain on.
On 03/03/2026 at 1:38 PM, during an interview R128 stated there had not been any wound care done yet today to R128's foot. The wound vac machine was observed not connected and remained on the bedside table.
03/03/2026 1:45 PM, During an interview LPN YY stated she was assigned to R128. LPN YY was not aware the wound vac was not on or connected. She verified there were no orders for the wound vac to be off or on hold. She verified there were no new dressing change orders, and stated, I don't know why it's off. I was not aware that it was off. I don't see any order for it to be off. Nurse confirmed wound vac was not on or connected to the resident.
On 03/03/2026 at 2:39 PM, during an interview, LPN AA stated he removed the wound vac on 03/02/2026 for the NP to take pictures of the wound to send to the podiatrist. The resident was discharged from the hospital following left calcaneal surgery and came to the facility with the wound vac. LPN AA stated there was no order to discontinue or hold the wound vac and that it had been disconnected for about 24 hours. LPN AA stated he was busy making rounds yesterday and did not put it back on but would put it back on today.
03/05/2026 at 2:45 PM, The nurse practitioner (NP) stated during a telephone interview if there were active orders she would expect them to be followed, if not she would expect the nurse to notify the provider

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews, and review of the policy titled, Accidents and Incidents-Investigation and Reporting, the facility failed to ensure the environment remained as free of accident hazards as possible and failed to provide adequate supervision for two residents (R) (R49 and R145) from a sample of 47 residents. The deficient practice increased the risk of avoidable accidents and injury. Findings include:
Review of the policy titled, Accidents and Incidents-Investigation and Reporting revised 02/2024 documented The facility shall provide the residents an environment free of accident hazards. Further review of section 7. Supervision item a.Adequacy of supervision is based on the individual's assessed needs and identified hazards in the resident's environment.
1. Review of the electronic medical record (EMR) revealed R145 was admitted to the facility on [DATE], with pertinent diagnoses including but not limited to Alzheimer's disease, unspecified dementia, aphasia, expressive language disorder, depression, chronic obstructive pulmonary disease (COPD), anemia, gastroesophageal reflux disease (GERD), hyperlipidemia, chronic cough, overweight, disorders of the skin and subcutaneous tissue, and a history of falling.
Review of R145's entry Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment.
Review of R145's care plan dated 02/25/2026, documented a problem of cognitive impairment related to dementia and Alzheimer's disease and a history of falling with prior fractures. Goals included but not limited to maintaining safety and preventing injury or complications through the review period. Interventions included but not limited to monitoring the resident for changes in condition, providing appropriate supervision, and implementing safety measures as indicated for the resident's condition and risk factors.
Observation on 03/02/2026 at 2:25 PM in room (A 12-B) belonging to R145 revealed a shaving razor located on the resident's windowsill. The razor was unsecured and accessible.
Observation on 03/03/2026 at 12:24 PM, revealed a shaving razor remaining on the resident's windowsill now inside a clear plastic bag.
Interview on 03/03/2026 at 5:21 PM with Licensed Practical Nurse (LPN) CC confirmed the presence of a shaving razor on the windowsill in room A 12-B and stated that it was not supposed to be in the room and should be stored in a designated area. LPN CC further stated that the razor would be removed because anyone could walk into the room, take it, and injure themselves.
Interview on 03/05/2026 at 11:05 AM with Director of Nursing (DON) revealed items such as razors should not be left in resident rooms, particularly for residents on blood thinners, as this could result in serious injury. She indicated that staff are expected to remove unsafe items if observed and notify appropriate personnel.
2. Review of the EMR for R49 revealed diagnoses including but not limited to type two diabetes mellitus, acquired absence of right leg below knee, polyneuropathy, and dysphagia.
Review of the quarterly Minimum Data Set (MDS) for R49 dated 01/06/2026 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating little to no cognitive impairment.
Review of R49's EMR revealed a physician order dated 06/13/2025 which stated Resident cannot walk or transfer with prosthetic on. Use sliding board with wheelchair to bed transfers. Do not go to the bathroom.
Review of R49 care plan dated 02/25/2026, indicated that he has an alteration in musculoskeletal status related to right BKA (below knee amputation). Interventions included but not limited to anticipating and meeting needs. Be sure call light is within reach and respond promptly to all requests for assistance.
Further review of R49's EMR revealed skin/wound note from 12/05/2025 documented WCN (wound care nurse) in to evaluate Left Upper Lateral Thigh Blister. Blister intact clear fluid sac. Area cleansed and betadine applied. No discomfort noted. Resident denies discomfort. Dry dressing applied loosely.
Review of Facility Incident Report Form from 12/08/2025 documented details of incident: A blister was observed on the resident left out thigh. Resident stated that he was carrying his coffee cup in his wheelchair between his left thigh and the arm of the wheelchair when the burn occurred.
Interview with R49 on 03/05/2026 at 11:40 AM revealed that on 12/05/2026, the resident received a cup of very hot coffee from a staff member. R49 stated that while sitting in a manual wheelchair, he needed to free his hands and placed the cup next to his left side. The resident reported that the coffee was extremely hot and had been served in a thin plastic cup that was not appropriate for holding hot liquids.
Interview with the Administrator on 03/05/2026 at 1:50 PM revealed that he reported the incident to the State Agency after it was brought to his attention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, record review, and review of the facility policy titled Oxygen Administration, the facility failed to ensure oxygen (O2) was administered according to physician's order for two of 13 residents (R) (R140 and R75) who use O2. This deficient practice had the potential to result in inappropriate respiratory treatment and adverse clinical outcomes.Findings include:Review of the facility policy titled, Oxygen Administration, undated documented Preparation: 1. Verify that there is a physician order for this procedure. Review the physician's or facility protocol for oxygen administration.1.Record review of the Electronic Medical Record (EMR) revealed R140 was admitted to the facility on [DATE] and pertinent diagnoses including but not limited to acute respiratory failure with hypoxia, sleep apnea, chronic systolic (congestive) heart failure, paroxysmal atrial fibrillation, atherosclerotic heart disease of native coronary artery without angina, presence of aortocoronary bypass graft, and anemia. Review of R140's entry MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated little to no cognitive impairment. Review of R140's care plan dated 02/26/2026, documented a problem of altered respiratory status/difficulty breathing related to underlying cardiopulmonary conditions. The goal included but was not limited to the resident remaining free from complications related to shortness of breath through the next review date. Interventions included but were not limited to observing for signs and symptoms of respiratory distress and reporting to the physician as needed (such as increased respirations, decreased pulse oximetry, tachycardia, restlessness, diaphoresis, headaches, lethargy, confusion, hemoptysis, cough, pleuritic pain, accessory muscle usage, and skin color changes); and administering oxygen as indicated in the care plan intervention, OXYGEN SETTINGS: O2 via (SPECIFY: nasal prongs/mask) @ (SPECIFY) L (SPECIFY FREQ). Review of the Physician's Orders for R140 revealed that there were no orders for oxygen prior to 03/03/2026. On 03/03/2026, an order was added for oxygen at 2 LPM (Liters Per Minute) via nasal cannula (NC) continuous.Review of R140's oxygen saturations (Sp02) indicates that over the period from 02/26/2026 to 03/04/2026 that SpO2 readings ranged from 93% to 98%. The resident's oxygen saturation revealed brief dips below 94%.Observation on 03/02/2026 at 1:35 PM revealed, R140 was wearing his oxygen via NC and the O2 concentrator was running at the setting of 2.5 LPM.Observation on 03/03/2026 at 5:08 PM revealed, R140 was wearing his oxygen via NC and the O2 concentrator was running at the setting of 2.5 LPM.Observation and interview with Licensed Practical Nurse (LPN) CC on 03/03/2026 at 5:10 PM confirmed that she was unable to locate any oxygen orders in the EMR. She stated that the resident had been admitted yesterday, 03/02/2026, and arrived from the hospital with oxygen set at 2 LPM. However, visual confirmation by LPN CC of the oxygen concentrator revealed it was set at 2.5 LPM, not 2 LPM.Interview with the Director of Nursing (DON) on 03/05/2026 at 11:05 AM, confirmed that residents receiving oxygen should have a physician order specifying the liter flow and monitoring of respirations and signs of respiratory distress. Oxygen should not be initiated without an order unless it is an emergency. Staff should complete and document a respiratory assessment and review nursing notes. Administering oxygen without an order could be unsafe, particularly for a resident with COPD, due to the risk of hyperoxygenation. The DON further stated staff should document the resident's respiratory status, notify the in-house Nurse Practitioner (NP), and obtain appropriate orders. The NP would evaluate the resident and determine whether oxygen should be initiated, continued, weaned, or changed to PRN (as needed), with all actions documented in the medical record.2. Review of the electronic medical record (EMR) revealed that R75 was admitted to the facility on [DATE], with pertinent diagnoses including, but not limited to, acute respiratory failure with hypercapnia, sleep apnea, morbid obesity, acute on chronic systolic (congestive) heart failure (CHF), cardiac arrhythmia, hypertension, and end-stage renal disease (ESRD).Review of R75's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating little to no cognitive impairment. Section GG (Functional Status) revealed that R75 required substantial to maximal assistance for activities of daily living (ADLs) and use of wheelchair. Section O: (Special Treatments) coded for the use of oxygen.Review of R75 care plan, revised 01/15/2026, indicated impaired oxygenation related to respiratory failure, sleep apnea, and congestive heart failure. Goals included but were not limited to maintaining adequate oxygenation and preventing complications related to respiratory status. Interventions included but were not limited to monitoring respirations and pulse oximetry for signs of respiratory distress, positioning with the head of the bed elevated to promote breathing, administering oxygen therapy per physician orders via nasal cannula, and notifying the physician of worsening respiratory symptoms.Review of the Physician's Orders for R75 included but was not limited to:Order dated 11/04/2024 for O2 2LPM via nasal cannula to keep SpO2 above 92%Observation and interview on 03/02/2026 at 1:03 PM with R75 revealed the resident was seated in a wheelchair wearing a nasal cannula connected to a portable oxygen tank attached to the back of the wheelchair. The oxygen flow rate was observed set at 1 liter per minute. The resident would not have been able to reach the oxygen tank to adjust the flow rate. During interview, R75 stated that she told the nurse to keep the oxygen at 1 liter and acknowledged that the physician order was for 2 liters but stated she prefers it at 1 liter.Observation and interview on 03/03/2026 at 5:04 PM with R75 and Licensed Practical Nurse (LPN) CC revealed the oxygen tank attached to the back of the resident's wheelchair was set at 1 liter per minute. LPN CC stated that the resident prefers the oxygen at 1 liter and staff maintain the oxygen at that level per the resident's request, although the physician order was for 2 liters. LPN CC stated the oxygen had been kept at 1 liter for a long time, but the order had not been changed, and she was unsure whether the prescribing physician had been notified, stating that someone may have informed the Nurse Practitioner (NP) at some

Based on observations, staff interviews, and review of facility policies titled Administering Medications, the facility failed to maintain accurate records on controlled substances for resident (R) (R43) on one of three medication carts. The deficient practice increased the risk of medication error for R43 and the potential for drug diversion. Findings include:Review of the facility's policy titled, Administering Medications, dated 2/2020 revealed that Medications shall be administered in a safe and timely manner, and as prescribed.Review of the Physicians Orders for R43 included but was not limited to:Order dated 01/27/2026 for Methadone HCl {Hydrochloride} Oral Tablet 10 MG (Methadone HCl) *Controlled Drug* Give 2 tablet by mouth every 8 hours as needed for Chronic painReview of the electronic medical record (EMR) revealed R43 received Methadone on 03/04/2026 at 10:47 AM.Observation and interview on 03/04/2026 at 3:22 PM, of the nurse's medication cart with Registered Nurse (RN) HH on C-Hall revealed the following:Controlled Substance Record Book: Multiple pages were torn, loose, and no longer secured within the binder. During inspection, these pages easily fell out, creating a risk for inaccurate or incomplete controlled substance accountability.Review of the Controlled Substance Record Book for R43's Methadone administration on 03/04/2026 revealed no documentation by the administering nurse at the time the medication was given, violating facility policy requiring timely and accurate recording of controlled substances.Interview on 03/04/2026 at 3:24 PM with RN HH revealed that she documented the administration in the Medication Administration Record (MAR) at 10:47 AM but failed to make an entry in the controlled substance log. RN HH acknowledged the importance of maintaining an accurate controlled substance count but could not clearly explain why this is critical. She also stated that missing pages were discovered in the controlled substance book. Being an agency nurse, she indicated she was unsure how to address the issue and would need to ask the supervisor.Interview on 03/05/2026 at 11:05 AM with Director of Nursing (DON) revealed that nurses are required to document administration of controlled substances immediately after giving the medication in the controlled substance log and ensure there are no missing signatures or loose pages. The DON explained that maintaining accurate documentation is necessary to ensure medication counts match and to prevent potential medication errors or delays in administration.

Based on observations, record review, staff interviews, review of the facility's policies titled Administering Medications, the facility failed to ensure accurate administration of medications for six of 25 medication opportunities observed, resulting in a medication error rate of 24% (percent.) The deficient practice increased the risk of adverse clinical outcomes. Findings Include:Review of the facility's policy titled, Administering Medications, dated 2/2020 documented that Medications shall be administered in a safe and timely manner, and as prescribed.Observation on 03/04/2026 at 9:26 AM on A-Hall with Licensed Practical Nurse (LPN) DD revealed resident (R) R106 had physician orders for Glipizide 10 mg {milligrams}, give 1 tablet by mouth twice daily for Diabetes Mellitus (DM), and Fluticasone-Salmeterol inhalation powder 500/50 mcg {micrograms}, inhale 1 puff orally twice daily for Chronic Obstructive Pulmonary Disease (COPD). These medications were not administered due to lack of availability, and the physician was not notified of the missed doses. During the same medication administration observation, LPN DD administered Isosorbide Mononitrate ER {extended release} 120 mg, ordered as 1 tablet by mouth in the morning for hypertension (HTN), incorrectly by giving one 60 mg tablet instead of two tablets to equal 120 mg. The medication card contained a written note stating Give 2 tablets to equal 120 mg. The nurse also administered Clonidine HCL {hydrochloride} 0.1 mg, ordered every 12 hours as needed for HTN if systolic blood pressure >160 or diastolic >100; however, the medication was given when the resident's blood pressure was 150/59, which was outside the ordered parameters. Additionally, the nurse administered Allopurinol incorrectly by giving three 100 mg tablets (300 mg total) when the physician's order was Allopurinol 300 mg, give 2 tablets by mouth in the morning (600 mg total) for gout flare.Observation on 03/04/2026 at 10:29 AM on A-Hall with LPN DD revealed R103 had physician orders for Pantoprazole Sodium oral tablet Delayed Release 40 mg, give 1 tablet by mouth one time a day for GERD (Gastroesophageal Reflux Disease). The medication was observed to be crushed; however, Pantoprazole is a delayed-release medication and should not be crushed.Interview on 03/04/2026 at 2:05 PM with LPN DD regarding medication administration errors revealed that she acknowledged that Pantoprazole should not have been crushed, stating she knew it was a delayed-release medication that would act faster than intended and that she would notify the physician. Regarding Clonidine, the nurse stated she usually administers it in the morning and has never noticed those parameters before. Regarding Allopurinol, the nurse stated she did not realize the dosing error and requested the Unit Manager to pull additional medication from Pyxis {med dispensing machine.}Interview on 03/05/2026 at 11:05 AM with Director of Nursing (DON) revealed that she expects to maintain medication error rates below 5 percent and emphasized that nursing staff should consistently follow proper medication administration procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to assure that two residents (R) (R34 and R90) from a sample of 47 residents, received and consumed foods in the appropriate form as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment, plan of care, in accordance with goals and preferences. The deficient practice increased the risk of adverse clinical outcomes. Findings include:Record review of the facility diet type report dated 03/05/2026, revealed R90's diet was listed as regular, mechanical soft, reduced concentrated sweets, no added salt. The report specified R34 should receive a mechanical soft, regular diet, reduced concentrator sweets, no added salt. 1.R90 was admitted [DATE]. The diagnoses included congestive heart failure, diabetes type 2, dysphagia (difficulty swallowing), and chronic kidney disease. The record also included a history of pneumonitis (aspiration). R90's diet order dated 02/13/2026, documented diet upgraded from pureed to mechanical soft texture, regular consistency.R90's care plan initiated 03/26/2025 and revised 02/26/2026, revealed R90 had a nutritional problem. and needed pureed meat/mech soft consistency for dysphagia. Speech therapy allowed some items per resident's request (see current diet order).The annual nutritional assessment dated [DATE], documented mechanical soft diet consistency/puree meat and bread; may have sandwiches and crackers as tolerated.Observation of R90's lunch meal on 03/02/2026 at 12:26 PM, revealed R90 was served pureed meat, pureed green beans, pureed mandarin oranges and pureed egg noodles. The meal tickets specified R90 could have mechanical soft sides.On 03/04/2026 at 12:38 PM, R90's lunch meal consisted of pureed roast beef, pureed squash and pineapple tidbits. The meal ticket indicated R90 was to receive pureed meat and bread, and mechanical soft sides. The meal ticket also indicated pureed meat, pureed bread, pureed squash, pureed pineapple tidbits and mashed potatoes. The Dietary Manager (DM) verified the meal served did not match the meal ticket and stated she would correct it. 2.Record review showed R34 was admitted to the facility 06/13/2023. R34's diagnoses included congestive heart failure, diabetes type 2, anemia, chronic kidney disease and dementia. R34's diet order dated 02/12/2024, specified reduced concentrated sweets, no added salt diet, mechanical soft texture, regular consistency.Record review of the annual diet assessment dated [DATE], specified reduced concentrated sweets, no added salt, mechanical soft diet. R34s care plan did not document specific dietary instructions or interventions. During lunch observation on 03/04/2026 at 12:39 PM, R34 was observed not eating. The meal consisted of shredded roast beef, with gravy, mashed potatoes, and squash. The meat was in shredded strands and contained pieces large enough that required chewing. The meat did not appear to be mechanically altered. R34 was served with pineapple chunks in place of cinnamon applesauce as was specified on the meal ticket. The meal ticket specified ground roast beef. R34 was unable to answer questions about his lunch. The dietary manager verified the meal served did not match the ticket and stated she would correct it. On 03/05/2026 at 8:46 AM, The dietary manager stated there were three staff working the tray line. There is a cook, a ticket reader and a finisher. The dietary manager stated the aid grabbed the wrong item and put it on the tray. On 03/05/2026 at 9:08 AM, the Director of Nursing (DON) stated the nursing assistants should be checking the tray slips to be sure what is placed on the tray is correct. On 03/05/2026 at 2:27 PM, during a follow up interview the DON confirmed the diet meal tickets did not match the active orders. The DON stated I see the inconsistencies and why that would be confusing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, staff and resident interviews, and a review of the facility's policy titled Personal Property, the facility failed to promote dignity by not exercising reasonable care and protection to prevent damage to the glasses for one resident (R) (R109) from a sample of 47 residents. The deficient practice had the potential to affect R109 from reaching the highest practicable level of function. Findings include:Review of the Personal Property policy dated 03/2023, documented the facility will promptly investigate any complaints of misappropriation or mistreatment of resident property.On 03/02/2026 at 10:50 AM, R109 was observed in bed wearing broken glasses. R109 showed the arm broken off one side of the glasses and demonstrated that a staff person broke the glasses when something was placed on top of them. R109 stated she informed the nurse when it happened a couple weeks ago and had not heard if they would be repaired or replaced. On 03/04/2026 at 8:55 AM, R109 was observed in bed, wearing glasses that were seated crooked on her face. R109 stated no one has given her any information about getting her glasses replaced/repaired. Record review revealed a physician order for R109 dated 07/16/2024, documented R109 could have ophthalmic (vision care) as needed.Record review of the admission Minimum Data Set (MDS) assessment dated [DATE], coded in Section B that R109 could see adequately and required corrective lenses. Section C coded that R109 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. Section I coded for diagnoses including but not limited to cerebral vascular accident (stroke), and high blood pressure.Record review of R109s care plan initiated 10/22/2024, documented deliver newspaper, or other appropriate reading material, on a regular basis for resident's reading pleasure. The care plan did not specify R109 required glasses for reading.Record review of nursing progress note for R109 dated 02/22/2026 at 6:50 PM, documented resident requested for her brother to buy her new prescription glasses as a CNA {Certified Nursing Assistant} broke them when a meal tray was placed on top of the glasses, notified desk clerk to inform social services for eyeglass replacement.Record review of a follow up social service progress note by Social Service Assistant (SSA) SSA RR dated 02/24/2026 at 1:50 PM, documented received notice resident broke her glasses. Contacted her responsible party who is requesting vision services for R109 to have a new pair of glasses made for her and provided information on [3rd party provider] completed and submitted paperwork for resident to be added to next vision clinic.On 03/04/2026 at 10:30 AM during an interview, SSA RR stated the vision provider makes quarterly visits to the facility and were last here 02/09/2026. The SSA stated if they can't come before the next visit in May, R109 will have to wait. Glasses would take a week or so later to arrive after the vision appointment. He confirmed that it may be mid-May before R109's glasses would be repaired/replaced. On 03/04/2026 at 10:50 AM, licensed practical nurse (LPN) LPN MM stated social services has a list and dates of when vision providers are coming. They are unable to schedule an appointment without an additional order from the provider. There is no order in the system currently for R109 to have a vision appointment scheduled. On 03/04/2026 at 11:29 AM, the Director of Nursing (DON) stated the facility would not delay treatment to get service and confirmed R109's glasses were broken on 02/22/2026. The DON verified the CNA put the meal tray on the glasses and broke them. The DON also confirmed the facility would absorb the cost of the glasses replacement.

Based on observations, interviews, record review, and facility policy titled Housekeeping Operations Manual, the facility failed to ensure the dining room, and 2 of 2 communal shower rooms were maintained in a safe, clean, comfortable and homelike environment. The deficient practice had the potential to affect patient comfort and safety. Findings include:Review of the undated document titled Housekeeping Operations Manual, documented The main area of concern to a housekeeping department in a healthcare facility is the transmission of bacteria.Observation of the women's communal bathroom on 03/02/2026 at 11:48 AM, 03/04/2026 at 12:18 PM and 2:48 PM, revealed on a shelf: numerous bottles of shampoo, lotion, grooming items scattered across the surface; hairbrush, scissors, wipes, lotions, and cleaning products were observed intermixed and unlabeled. There were small pieces of debris scattered across the shower room floor and appeared unclean and unsanitary with residue along the lower portion of the tile wall. Used washcloths were observed on the hand grab bar, a resident gown was draped over a wheelchair holding both clean and used linen and a dirty slipper sock was on the floor in front of the toilet. The foam pad on the shower stretcher had small openings with debris accumulation in the foam. In addition, observation of the men's communal shower revealed clutter with multiple personal items including thera-gel shampoo, a resident hat, a used electric shaver, baby lotion, open containers of wipes and briefs.Observation of the dining room on 03/03/2026 at 3:03 PM, revealed used silverware, trash and a cookie on the floor and trash on the dining area tables. The dining tables and floor were sticky and did not appear to have been recently wiped or mopped.Interview with CNA QQ on 03/04/2026 at 12:20 PM, stated the nursing assistants are supposed to clean the shower rooms after each resident use.Interview with the Housekeeping Director (HKD) on 03/04/2026 at 12:30 PM, stated the multi-use showers are cleaned at 8:00 AM, 12:00 PM, and 3:00 PM, and the CNAs are supposed to clean them following each use and make sure the towels are removed following use. Interview with the Regional Nurse Consultant n 03/04/2026 at 2:56 PM, confirmed the lack of cleanliness during a tour of the men's and women's bathrooms. Interview with CNA SS on 03/05/2026 8:25 AM, stated the shower chair and bath stretcher should be sanitized between uses, even if it's just rinsed, the water still has body fluids from the previous resident. CAN SS stated she has not been trained to sanitize the equipment, but the equipment should be sprayed off after use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the facility policy titled, Abuse Prevention Program, the facility failed to ensure safety and freedom from an act of physical abuse for one resident (R) (R84) from a sample of three residents reviewed for abuse. The deficient practice had the potential to affect the quality of life and safety for other residents. Findings include:Review of the policy titled Preventions of Resident Abuse, Neglect, Mistreatment or Misappropriation of Property, revised 7/2025, section titled Policy documented, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.Review of R84 quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R84 was admitted to the facility on [DATE] with a Brief Interview for Mental Status (BIMS) score of 04, which indicated severe cognitive impairment. Section GG: (Functional status,) revealed R1 has no impairment with upper/lower extremities benefits from the use of a wheelchair, Self-Care: range from all forms of physical assistance, and Mobility: Is independent in most areas can wheel independently in manual wheelchair.Interview with Licensed Practical Nurse (LPN) AAA on 03/05/2026 at 2:50 PM, stated on a Sunday at the end of the shift a CNA came running towards the nurses' station stating, he stabbed him, he stabbed him. The CNA stated R135 had a knife and stabbed R84. LPN AAA stated when he got down there, he saw the nurse (agency) come out of the room where the incident happened. LPN AAA stated R84 had a laceration that was bleeding, so gauze and pressure were applied to stabilize bleeding. LPN AAA stated he went into R135's room and R135 cane out of the bathroom that is shared. LPN AAA stated there was another resident who was bedbound in the room, so he made R135 sit down and relax while another staff member was calling 911 and knew law enforcement was on the way. R135 wanted to go back to the bathroom but LPN AAA stated he made sure R135 did not go to the bathroom. The police arrived and searched the room and could not find the weapon and went to the bathroom and the knife was in the toilet. Afterwards, LPN AAA called the Administrator who was already at the facility by the time he walked out of the room. R135 was arrested and R84 was sent to the hospital. LPN AAA revealed he made the necessary calls to the family of R84, does not believe R135 had a contact on the list of who to call. R135 was very independent and took care of self. LPN AAA stated he did not make calls to anyone else. He confirmed after the incident happened, the facility implemented checking residents in order to make sure the other residents were safe. He stated R135 was typically pleasant and nice and did not have any outburst that he could recall but was up and walking around. He stated R84 does have behavioral outburst.Phone interview on 03/05/2026 at 3:27 PM with the daughter of R84 revealed she was notified of the incident by a male nurse at the facility and was able to speak to the police officer. She stated the officers told her there was a resident who entered the room and cut her dad on his head and the perpetrator was removed from the facility and her dad was stable and the ambulance was at the facility to transport him to the hospital. The daughter stated she received daily updates from the Administrator when the resident returned back to the facility from the hospital and went over the plan of care and a safety plan. She stated the facility changed the entrance door code and the other resident was not allowed back into the facility. The daughter stated R84 was moved to another room and confirmed that anytime something happens with her dad the facility calls her no matter what time it happens. She does not have any issues with the treatment of the facility. Interview on 03/05/2026 at 5:17 PM with the Administrator revealed when he came into the facility, he was informed that there was a stabbing from resident to resident. The Administrator was able to speak to the police officer who let him know R135 was going to be handcuffed and taken with them to intake. The Administrator revealed he interviewed LPN AAA at that time but was unable to speak with the Agency Nurse. The Administrator stated he spoke to a CNA who no longer works in the facility and this CNA gave a statement that the bathroom door was locked and R135 was upset that he could not get in the bathroom. The Administrator stated he spoke with the Regional Nurse and told her what happened. In addition, he spoke with R84's daughter while he was on his way to the hospital via ambulance. The Administrator stated R135 was put in handcuffs and left with the police. He revealed R135 does not have family involved because he is his own responsible person. He stated R84 was referred to psych services, and he stayed in touch with R84s daughter. He confirmed abuse education was started at the time of the event.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, record reviews, and review of the facility's policy titled Transfer of Discharge Notice, the facility failed to ensure two of two sampled residents (R) (R131 and R133) were provided with a written bed hold notice or reason for transfer at the time of transfer. This failure had the potential to place the resident or resident's representative at risk of being uninformed about their rights related to hospital transfer and subsequent return to the facility.Findings include:Review of the policy, Transfer or Discharge Notice, revised [DATE], documented Our facility shall provide a resident and/or the resident's representative a notice of transfer or discharge and the reason for the move in writing (Notice Form for Transfer or Discharge). 3. The resident and or representative will be notified in writing of the following information: the reason for the transfer or discharge; the effective date; the location to which the resident is being transferred or discharged ; a statement of the residents rights to appeal . the facility bed hold policy; the name, address, and telephone number of the Office of the State Long-term Care Ombudsman . 4. A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman. 5. The reasons for the transfer or discharge will be documented in the resident medical record. 1.Review of R131's clinical record revealed an admission date of [DATE], with diagnoses including, but not limited to, malignant neoplasm of colon, unspecified, anemia, ileostomy, diverticulitis, schizoaffective disorder, bipolar type, and schizophrenia.Review of R131's entry Minimum Data Set (MDS) assessment dated [DATE] revealed, Section C: (Cognitive Patterns) Brief Interview for Mental Status (BIMS) score of 15 indicating little to no cognitive impairment. Review of R131's Clinical Census revealed R131 was transferred to the hospital from the oncologist office on [DATE], and from the facility to the hospital on [DATE]. The bed hold expired [DATE], at which time billing was stopped. R131 was readmitted to the facility on [DATE].Review of R131's clinical record revealed no evidence of a notice of bed hold or reason for transfer provided to R131 on [DATE].Review of R131's electronic medical record (EMR) revealed Licensed Practical Nurse, (LPN) LL, documented on [DATE] at 8:00 PM, During shift change patient presents to hallway at med cart that she's in severe abdominal pain that start since last night and has progressively got worse. Patient has low-grade temp 100.9, chills, abdominal pain to R quadrant, pain upon palpitation, patient reports nausea and emesis x 1 after dinner. Patient reports a history of diverticulitis and had flare up in December. Covid test negative. Also documented at 8:13 PM, by LPN LL Received an order to send R131 to the emergency department. Sent by ambulance. The transfer note revealed no documentation that the bed hold policy was provided to R131 who was her own representative.2.Review of R133's clinical record revealed an admission date of [DATE], with diagnoses including but not limited to, chronic obstructive pulmonary disease and weakness. Review of R133's Clinical Census revealed R133 was discharged on [DATE]. R133's clinical record review revealed no evidence of a bed hold or if the bed hold policy was reviewed. There was no entry MDS completed, and no care plan had been developed at the time of discharge. Review of R133's clinical record revealed no evidence of a notice of bed hold or reason for transfer provided to R133 on [DATE].An interview with the Business Office Manager (BOM) on [DATE] at 1:35 PM confirmed through chart review there was no bed hold notice located and no note of any contact with R133 to inform him of the bed hold policy. An interview with LPN MM on [DATE] at10:39 AM, stated when a resident transfers they have to go with a bed hold policy. Two copies are made, one remains at the facility, and one is sent with the resident. LPN MM stated it is explained to residents that the bed hold policy is 48 hours, and we notify the responsible party of the facility rates after the bed hold expires. The copy is sent to the business office for them to follow up. LPN MM was unable to find a copy of the bed hold agreement in the record for either R131, or R133.During a follow up telephone interview, a representative from the Office of the State Long-term Care Ombudsman office stated there was no notification of discharge or transfer for either R131, or R133.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of the facility's policy titled Resident Assessment-Coordination with PASARR (Preadmission Screening and Resident Review) Program, the facility failed to ensure one of one resident (R) (R99) reviewed with a serious mental disorder was referred for a Level II PASARR assessment on admission or within 30 days of a new diagnosis. This deficient practice had the potential to affect the appropriate level of care and services provided for R99.
Findings include:
A review of the facility's undated policy titled Resident Assessment-Coordination with PASARR Program revealed the Policy was The center coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receive care and services in the most integrated setting appropriate to their needs. The Policy explanation and Implementation section included . 8. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review.
A review of the Electronic Medical Record (EMR) revealed R99 was admitted to the facility on [DATE] with diagnoses including, but not limited to, Post Traumatic Stress Disorder (PTSD), depression, and anxiety.
A review of the admission Minimum Data Set (MDS) dated [DATE] revealed, Section A (Identification Information) documented the resident was not currently considered by the State Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section I (Active Diagnoses) documented PTSD, depression, and anxiety.
A review of the EMR revealed a PASRR Level I request dated 12/20/2022 without PTSD, depression, or anxiety marked on the form. A further review revealed no re-submission for a PASARR Level I after R34 was admitted to the facility and no PASARR Level II.
In an interview on 2/1/2025 at 11:30 am, the Social Services Director (SSD) stated when a resident was admitted to the facility, the PASRR Level I had been submitted by the referring hospital, the results went to the facility's central admissions office, and then to the facility to be scanned into the medical record. She stated she was unsure who was responsible for ensuring the diagnoses on the PASSR Level I were accurate when a resident was admitted to the facility or for re-submission for a PASRR evaluation.
In an interview on 2/1/2025 at 11:50 am, the Director of Nursing (DON) verified there was no PASSR Level II for R99. She further verified that R99's PASRR Level I, dated 12/20/2025, did not contain the resident's diagnoses of PTSD, depression, and anxiety. She stated she was unsure who was responsible for ensuring the diagnoses on the PASSR Level I were accurate upon admission to the facility. She further stated the diagnoses on the PASSR Level I submission should be accurate in order to ensure the resident's needs are met.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the resident's admission MDS assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 14, which indicated no cognitive impairment. Section GG revealed that the resident was assessed for moderate assistance for dressing and personal hygiene.
Review of the care plan for R20, dated 1/9/2025, revealed resident has self-care deficit experiencing difficulty in performing tasks of ADLs. Interventions to care include assist with dressing/undressing as needed, 1-2-person assistance with transfers and use consistent routines and allow adequate time to complete tasks.
Observation on 1/31/2025 at 9:54 am, R20 was dressed and sitting up in her bed. Her hair appeared to be oily and disheveled. She stated at this time that she had not received any type of bath since she was admitted to the facility.
Observations on 2/1/2025 at 8:47 am and 5:03 pm and 2/2/2025 at 9:20 am, R20's hair remained oily and fingernails on both hands were long with brown dirty substance underneath the nails.
4. A review of the clinical record for R90 revealed he was admitted to the facility on [DATE] with diagnoses including infection of amputated right stump, peripheral vascular disease (PVD), diabetes, HTN, dementia, anxiety, and depression.
Review of the R90's annual MDS assessment dated [DATE], revealed BIMS was coded as 13, which indicated no cognitive impairment. Section GG revealed that the resident requires maximum assistance for ADL's.
Review of the care plan for R90, dated 4/9/2024, revealed resident has ADL deficit/self-care deficit related to muscle weakness, acute illness, musculoskeletal problems, impaired cognition, and cardiovascular problem. Interventions to care include assist with dressing/undressing as needed, 1-2-person assistance with transfers.
Observation on 2/1/2025 at 9:55 am, R90 lying in bed awake. His fingernails are long and dirty. He stated at this time that he would like for someone to cut them for him.
Observation on 2/1/2025 at 4:57 pm, revealed R90 sitting in wheelchair at bedside awaiting dinner to be served. Fingernails remain dirty and long.
Observation on 2/2/2025 at 9:08 am, R90 lying in bed. Fingernails remain dirty.
Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Care Plan, Comprehensive Person Centered, the facility failed to develop and implement care plans for four of 42 (R) (R84, R50, R20, and R90) sampled residents. The deficient practices had the potential to place the residents at risk for medical complications, unmet needs, and a diminished quality of life.
Findings include:
Review of the facility policy titled Care Plan, Comprehensive Person Centered with a revision date of September 2023 revealed under Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.
1. Review of the physician orders revealed that R84 was to receive but was not limited to docusate sodium (a stool softener), and acetaminophen.
Review of the nurse's progress notes revealed that on more than one occasion between the dates of 1/18/2025 and 1/31/2025, the resident refused medications that included Colace (docusate sodium- a stool softener).
Review of the care plan revealed no mention of R84 refusing medications as a behavior on the care plan.
Interview on 2/2/2025 at 10:30 am with Licensed Practical Nurse /Unit Manager (LPN/UM) HH revealed that R84 does refuse medication. She stated that if she refused regularly, then the nurse should be documenting and then they should let the providers know. She then stated that it should then be care planned as a behavior, if it was something that continued.
Interview on 2/2/2025 at 10:40 am with Minimum Data Set (MDS) LPN JJ and MDS LPN KK, they verified that if the resident refused medications, especially if it occurred more often, then it would need to be addressed and added to the care plan as a behavior. They were to be notified if it was documented, and it would be changed during the clinical meetings. It was verified that it was not on the care plan.
Interview on 2/2/2025 at 11:18 am with the Director of Nursing (DON), she revealed that it was her expectation that if a resident refused medications, the resident representative and the medical provider would be notified of the behavior. When the medical provider was notified, they could make the decision to place the medication on hold or be discontinued. She then stated that it would need to be documented in a progress note and then care planned as a behavior. We would also need to try and find out the reason for refusing the medication.
2. Observation on 1/31/2025 at 11:02 am, R50 was observed laying in her bed. She had facial hair on the right side of her chin. The surveyor asked her if she had asked staff to help her with it, and she stated that she has, and no one would come in and help her.
On 2/1/2025 at 9:15 am, R50 was observed laying in the bed with her eyes closed. She was still noted to have facial hair on the right side of her chin.
Review of the care plan for R50 revealed that she had an ADL (activities of daily living) deficit and cognitive deficit, having trouble in performing tasks of daily living such as dressing, bathing, toileting, and bed mobility. There were no interventions added for personal hygiene.
Interview on 2/2/2025 at 10:30 am with Licensed Practical Nurse /Unit Manager HH, she stated that if a female resident had facial hair, that it needed to be taken care of. If it was refused, then it needed to be documented. If a resident refused care frequently, then it would need to be documented, responsible party notified, and care planned as a behavior.
Interview on 2/2/2025 at 11:32 am with the DON, she stated that if something needed to be added to the care plan that it should be added to the task list, so that it was a reminder for them to do it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record review, and review of the facility policy titled Activities of Daily Living (ADLs), the facility failed to ensure ADL care was provided for three of 42 sampled residents (R) (R20, R90, and R50) related to showers, nail care, and shaving of facial hair. This failure placed R20, R90, and R50 at risk for unmet needs and a diminished quality of life.
Findings include:
Review of the facility's undated policy titled Activities of Daily Living (ADLs) revealed the Policy Statement included, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The Policy Interpretation and Implementation section included . 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) . d. Dining (meals and snacks).
1. A review of the clinical record for R20 revealed that the resident was admitted to the facility on [DATE] with diagnoses including skin infection, diabetes, hypertension (HTN), hyperlipidemia, stage 4 kidney disease, coronary artery disease (CAD), and asthma.
Review of the resident's admission Minimum Data Set (MDS) assessment, dated 1/9/2025, revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 14 (indicating little to no cognitive impairment). Section GG (Functional Abilities and Goals) documented the resident required substantial/maximal assistance with shower/bath and partial/moderate assistance with personal hygiene.
Review of the undated document provided by the facility titled Shower Sheet: Shift 3:00 pm - 11:00 pm indicated that R20 was to receive showers on Monday and Thursday on the 3:00 - 11:00 pm shift.
Observation on 1/31/2025 at 9:54 am revealed R20 was dressed and sitting up in her bed. Her hair appeared to be oily and disheveled. During an interview with R20, she stated she had not received any type of bath since she was admitted to the facility.
Observation on 2/1/2025 at 8:47 am and 5:03 pm and 2/2/2025 at 9:20 am revealed that R20's hair remained oily, and her fingernails on both hands were long with a brown substance underneath the nails.
In an interview on 2/1/2025 at 8:47 am, R20 stated she hadn't had a bath in three weeks. She stated she could bathe herself if someone would set her up with a bucket of water and some soap. She stated the first shift was just too busy to give her a bath, and the second shift was unhelpful when you asked them for anything.
In an interview on 2/2/2025 at 11:12 am, Certified Nursing Assistant (CNA) AA stated that residents were bathed/showered two times per week, and nail care should be done with every bath/shower. She further stated that she asked the residents about washing their hair because some residents get their hair done at the beauty shop.
2. A review of the clinical record for R90 revealed diagnoses including infection of amputated right stump, peripheral vascular disease (PVD), diabetes, HTN, dementia, anxiety, and depression.
Review of R90's Annual MDS assessment, dated 12/12/2024, revealed section C (Cognitive Patterns) documented a BIMS of 13 (indicating little to no cognitive impairment). Section GG (Functional Abilities and Goals) documented the resident requires substantial/maximal assistance for personal hygiene.
Observation on 2/1/2025 at 9:55 am revealed R90 lying in bed. Further observation revealed his fingernails were long and dirty. In an interview, R90 stated he would like someone to cut his fingernails.
Observation on 2/1/2025 at 4:57 pm revealed R90 sitting in a wheelchair at his bedside, waiting for his dinner to be served. Observation revealed his fingernails remain dirty and long.
Observation on 2/2/2025 at 9:08 am revealed R90's fingernails remained dirty.
In an interview on 2/2/2025 at 2:00 pm, Licensed Practical Nurse (LPN) Unit Manager (UM) HH stated that nail care should be performed on the days the residents were scheduled for showers and as needed.
In an interview on 2/2/2025 at 2:26 pm, CNA CC stated that residents are not allowed to self-bath with a basin of water. She stated they either received a bed bath or shower. She stated that residents could get a bath when they requested. She stated she had not noticed R20's fingernails were long and dirty. She confirmed that R20's nails were dirty and stated she would ask the next shift to assist her with a bath.
3. Review of R50's EMR revealed diagnoses including chronic obstructive pulmonary disease (COPD), dementia, and anxiety.
Review of the Quarterly MDS, dated [DATE], revealed section C (Cognitive Patterns) documented a BIMS of 8 (indicating moderate cognitive impairment). Section GG (Functional Abilities and Goals) documented that R50 required partial/moderate assistance for personal hygiene.
Observation on 1/31/2025 at 11:02 am revealed R50 had facial hair on the right side of her chin. She stated she had asked staff to help her remove it, and no one would help her.
Observation on 2/1/2025 at 9:15 am revealed R50 with continued facial hair on the right side of her chin.
In an interview on 2/2/2025 at 10:39 am, CNA LL stated R50 had never refused to ADL care with her.
In an interview on 2/2/2025 at 11:32 am, the DON stated if facial hair was noted, the CNA should ask the resident if they wanted it removed.

Based on staff interviews, record review, and review of the facility's policy titled Competency of Nursing Staff, the facility failed to conduct annual performance reviews to ensure competency for the Certified Nursing Assistants (CNAs) employed by the facility. The census was 135.
Findings include:
Review of the undated facility's policy titled Competency of Nursing Staff revealed the Policy Statement: Licensed nurses and nursing assistants employed by the facility will participate in facility-specific, competency - based staff development and training program and demonstrate competencies and skill sets necessary to care for the needs of residents, as identified through resident assessments and described in the plan of care. Policy Interpretation and Implementation: Number 5. Facility and resident specific competency evaluations will be conducted upon hire, annually, and as deemed necessary. Number 7. Competency demonstrations will be evaluated based on staff members ability to use and integrate knowledge and skills obtained in training, which will be evaluated by staff already deemed competent in that skill or knowledge. Number 8. Inquiries concerning staff competency evaluations should be referred to the Director of Nursing Services or the Personnel Director.
Review of the facility's Staff Development Review dated 8/23/2024 completed by [name of auditor] revealed 17 Certified Nurses Aides on staff at the facility.
Review of the Certified Nursing Assistant (CNA) training hours revealed that the sampled selection of CNA's (CNA LL, CNA MM, CNA NN) met the State in-service requirements for the year. However, when asked for the yearly competency evaluations for the sampled CNA's, the facility was unable to provide the documents requested.
Review of the Job Description and Performance Evaluation provided by the facility for CNA MM, revealed she was hired on 6/15/2004 and the evaluation was dated 6/15/2005. There were no other evaluations provided for CNA MM.
There was no evidence that performance evaluations were completed since for CNA LL with hire date of 6/17/2018 and CNA NN with hire date of 6/19/2017.
Interview on 2/2/2025 at 2:19 pm, Director of Human Resources and Payroll stated that in the four years that she has been employed at the facility, there have not been any competency evaluations completed on any of the CNA's.
During Further interview, she stated that the completion of the yearly competency evaluations is the responsibility of the Director of Nursing (DON).
Interview on 2/2/2025 at 2:22 pm, with Regional Nurse Consultant (RNC) BB, stated the facility has had high turnover rates for the DON position, and stated that the other healthcare facilities in the area make it hard to keep a DON. She stated the current DON is new to the position, and the facility would work on completing competency evaluations for the nursing staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and review of the facility's policy titled Food and Nutrition Services, and review of the facility document titled [Name of supply company] TELS (The Equipment Lifecycle System) Ice Machines Preventative Maintenance, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure foods were not left open to air, label and date opened and unopened foods in addition to, serving cold fruit at 68 degrees Fahrenheit (F). Also, the facility failed to ensure that one of two ice machines was clean and sanitary as evidenced by one ice machine had discoloration on the inside middle part of the machine. This deficient practice had the potential to cause a diminished quality of life for 132 out of 135 residents receiving an oral diet.
Findings include:
Review of the facility's undated policy titled Food and Nutrition Services revealed, that foods that are left without a source of heat for hot foods or refrigeration for cold foods longer than (2) two hours will be discarded.
Review of the facility document titled [Name of supply company] TELS: Ice Machines Preventative Maintenance under the section titled Sanitize Interior revealed, 1. Sanitize interior of ice machine per manufacturer's instructions. 2. Clean out and sanitize the ice bin.
1. Observation on 1/31/2025 at 8:15 am during the initial tour of the kitchen revealed, the following:
-An open bag of breaded chicken patties in the walk-in freezer with no open date that was left open to air.
-An open box of sweet potato pie with no open or discard date and that was left open to air.
-A container of peaches in the walk-in cooler covered with saran wrap with a date of 1/30/2025.
-A metal container of cole slaw covered with saran wrap dated 1/28/2025 - 1/30/2025.
-Two bags of cheese (one Parmesan and one cheddar) were not labeled without a receive or discard date.
-Five packages of sliced cheese were not labeled without a received or discard date.
-Ground pepper, granulated onion, chicken seasoning, cinnamon, [name] seasoning salt, and Parsley flakes, were opened, and were not labeled with an open date.
Observation and interview on 1/31/2025 at 8:45am during the follow up tour of the kitchen with [NAME] II confirmed the following:
-An open bag of breaded chicken patties in the walk-in freezer with no open date that was left open to air.
-An open box of sweet potato pie with no open or discard date and that was left open to air.
Cook II stated, I didn't even know anything about that.
-A metal container of cole slaw covered with saran wrap dated 1/28/2025 - 1/30/2025.
Cook II stated, I was supposed to get rid of that yesterday, when I did the dishes, and I forgot to pull it out.
-A container of peaches in the walk-in cooler covered with saran wrap with a date of 1/30/2025. [NAME] II stated, I will take care of that.
- Two bags of cheese (one Parmesan and one cheddar) were not labeled without a receive or discard date and five packages of sliced cheese were not labeled without a received or discard date. [NAME] II, verified that they were not labeled.
-Ground pepper, granulated onion, chicken seasoning, cinnamon, [name] seasoning salt, and Parsley flakes, were opened, and were not labeled with an open date. [NAME] II stated, I just opened and used them today. I didn't have time to label them.
2. Observation on 2/1/2025 at 12:10 pm in the kitchen of the mid-day meal preparation revealed, [NAME] II was observed preparing pureed food. Before serving the meal trays, the food temperatures were collected which revealed, the apples topped with cinnamon temperature was 68 degrees F. The fruit was then pre-served in bowls, covered with saran wrap, and placed on a metal tray.
Interview on 2/1/2025 at 12:13 pm revealed, [NAME] II was asked if the fruit was to be served at that temperature. She stated, no it is not.
Interview on 2/1/2025 at 2:05 pm revealed, The Regional Dietary Manager was asked if the fruit was served at the correct temperature of 68 degrees F and he stated, probably not.
3. Observation on 1/31/2025 at 8:21 am during the initial tour of the facility's kitchen revealed, that the kitchen ice machine had discoloration on the inside middle part of the ice machine.
Observation and Interview on 1/31/2025 at 8:25 am of the ice machine with [NAME] II confirmed the inside middle part of the ice machine had discoloration. [NAME] II stated, it was the responsibility of the Maintenance department to clean it.

Based on observations, staff interviews, and review of the facility's policy titled Food-Related Garbage and Refuse Disposal, the facility failed to ensure that the area around the dumpster was free from garbage and refuse. This deficient practice had the potential to attract pest. The facility census was 135.
Findings include:
Review of the facility policy titled Food-Related Garbage and Refuse Disposal with a revision date of October 2017, revealed that garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pets. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter.
Observation on 1/31/2025 at 8:30am during the initial tour of the kitchen with [NAME] II revealed, that the area around the dumpster contained garbage and refuse on the ground.
Interview on 1/31/2025 at 8:40 am with [NAME] II revealed, that when the dumpster got too full, they must open the lid, so that they could make more room for garbage. [NAME] II revealed that when the lids were open, the wind would blow garbage out of the dumpster onto the ground behind it.
Observation on 1/31/2025 at 11:05 am revealed, staff cleaning the garbage and refuse from the area around the dumpster that contained garbage and refuse on the ground.
Observation on 1/31/2025 at 1:25 pm with the Registered Dietitian and the Regional Nurse Consultant revealed, the garbage and refuse had been picked up and the area was noted to be clean.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observations conducted on 1/31/2025 on the B Hall revealed:
At 10:37 am in room [ROOM NUMBER] the front of the PTAC was falling off and was missing paint noted behind the C-bed. There was missing paint and part of baseboard also falling off of the wall, next to the window. In the shared bathroom of 27 and 29, there was a missing ceiling tile noted, and a greyish substance on the vent cover.
At 11:24 am in room [ROOM NUMBER] both PTAC filters were covered with a grayish substance. The wall around the PTAC was white, as if it was repaired and did not match the color of the bedroom wall.
At 11:39 am in the shared bathroom for 31 and 33 there were gaps in two of the ceiling tiles and the vent cover was noted to have a greyish substance on it.
At 11:45 am in room [ROOM NUMBER] the area of the wall, that was white, appeared to have been repaired, did not match the room wall paint color
Observations conducted on 2/1/2025 on the D Hall and the kitchen revealed:
At 8:33 am in room [ROOM NUMBER] the ceiling tile was hanging down.
At 12:10 pm in the kitchen three ceiling tiles in kitchen were falling or had gaps.
Observations conducted on 2/2/2025 at 2:54 pm with the Regional Maintenance Director, Housekeeping and AIA, FF the following concerns were confirmed and verified all of the findings for B and D Halls and the Kitchen.
Based on observations, staff interviews, record review, review of the facility's policy titled Maintenance Service, and review of documents titled [Name of supply company] TELS (The Equipment Lifecycle System), the facility failed to provide a safe, clean, comfortable, homelike environment related to dirty filters in the Packaged Terminal Air Conditioner (PTAC) units, walls in disrepair and missing paint, missing chair rail, and missing/falling ceiling tiles for nine resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) on three of four halls (B,C, and D halls) and falling ceiling tiles the kitchen. The deficient practice had the potential to place the residents at risk for accidents and hazards and diminished quality of life. The facility's census was 135.
Findings include:
Review of the facility's undated policy titled Maintenance Service revealed, the Policy Statement was Maintenance service shall be provided to all areas of the building, grounds, and equipment. The section titled Policy Interpretation and Implementation revealed under number two Functions of maintenance personnel include but are not limited to:
b. Maintaining the building in good repair and free from hazards and
d. maintaining the heat/cooling system .
Review of the document titled [Name of supply company] TELS under the section titled Recommended Schedule revealed, the cleaning schedule for the PTAC filter was every three months.
Review of the TELS task titled Inspect exhaust fans for proper operation and clean if necessary revealed, that the vents are to be clean using a vacuum and air compressor, when needed to remove all dust. Staff are to ensure that air flow is sufficient to hold a piece of paper to the vent when operating.
1. Review of the maintenance Logbook Documentation revealed, that the PTAC clean air filters were marked as done on September 30, 2024, October 31, 2024, November 29, 2024, and December 26, 2024.
Observations conducted on 1/31/2025 on the C-Hall revealed:
At 8:53 am in room [ROOM NUMBER] the PTAC filters were covered in a gray fuzzy substance.
At 9:31 am in room [ROOM NUMBER] the PTAC filters were covered in a gray fuzzy substance.
At 9:50 am in room [ROOM NUMBER] the PTAC filters were covered in a gray fuzzy substance. The wallpaper behind the headboards of all three beds were peeling away from the wall, and the chair rail behind bed C was missing.
At 10:46 am in room [ROOM NUMBER] the PTAC filters were covered with a thick fuzzy.
Observations conducted on 2/2/2025 on the C-Hall revealed:
At 8:57 am in room [ROOM NUMBER] the PTAC filters were covered with a gray fuzzy substance.
At 9:04 am in room [ROOM NUMBER] the PTAC filters were covered with a gray fuzzy substance.
At 9:05 am in room [ROOM NUMBER] the wall paper behind bed A and C was peeling away from the wall, the chair rail was missing behind bed C, and PTAC filters were covered with a gray, fuzzy substance.
At 9:07 am in room [ROOM NUMBER] the PTAC filters were covered with a thick, gray, fuzzy substance.
Observations on 2/2/2025 at 9:47 am rounds made with the Corporate Maintenance Director and the Administrator in Absence (AIA), FF revealed,
room [ROOM NUMBER] - PTAC filters were covered with were covered with a thick gray substance.
room [ROOM NUMBER] - PTAC filters were covered with a fuzzy gray substance.
room [ROOM NUMBER] - PTAC filters were covered with a layer of fuzzy gray substance, the wallpaper behind bed A and C was not attached to the wall, and the chair rail was missing behind bed C.
room [ROOM NUMBER] - PTAC filters were covered with a thick gray fuzzy substance.
Interview on 2/2/2025 at 9:47 am with the Corporate Maintenance Director and AIA, FF, both confirmed and verified all observations made of rooms 40, 44, 45, and 48. The Corporate Maintenance Director revealed his expectation was that the PTAC filters would be cleaned monthly and documented on the checklist found in the TELs system and the expectation was that the building would be maintained in good repair in a timely manner, he stated wall paper should not be left peeling away from the wall and the missing chair rail should be repaired.

Based on observations, staff interviews and review of the facility's policy titled Laundry Operations Manual, the facility failed to ensure the soiled linen hampers located in the hallways of the facility, were emptied immediately when full. This failure has the potential to impact 71of 128 residents residing on the A and C Halls.
Findings include:
Review of the facility's policy titled, Laundry Operation Manual, revised in January 2022, under the section titled Sorting Soiled Linens revealed, Treat all soiled linen as if it were potentially infectious-never treat soiled linen different simply if it does not look dirty and Keep soiled linen covered at all times.
During the initial tour of the facility, it was revealed that the facility had four halls, A, B, C and D. Each hall had had two or three soiled linen hampers in the hallways.
During an observation on 10/30/2024 at 9:49 am, one soiled linen hamper on the C hall was observed to be full and overflowing as the lid to the hamper was left ajar.
During an observation on 11/5/2024 at 11:55 am, two soiled linen hampers were observed overflowing on the A hall. One of these soiled linen hampers was observed in front of a resident's room, however there was no Certified Nursing Assistant (CNA) providing patient care in that room.
During an observation on 11/5/2024 at 11:57 am, one soiled linen hamper was overflowing on the C hall.
During an observation on 11/5/2024 at 11:58 am, the Regional Nurse Consultant (RNC) alerted a facility staff to empty the overflowing cart on the A hall.
In an interview on 11/5/2024 at 12:12 pm, the Housekeeping Director revealed the soiled linen hampers were emptied by the CNAs at least every two hours. The Housekeeping Director further revealed that the hampers were moved outside during mealtimes.
Interview on 11/5/2024 at 12:25 pm, CNA UU revealed, the CNAs were responsible for emptying the soiled linen hampers when they were full and to take them outside during mealtime.
In an interview on 11/5/2024 at 12:30 pm the RNC stated the soiled linen hamper being emptied when full had been a pain point, they continued to address.
In an interview on 11/6/2024 at 9:00 am, the RNC stated they had performed an in-service regarding the soiled linen hamper on 11/5/2024 at 4:00 pm, 7:00 pm and 11:00 pm. The summary of the in-service revealed, laundry baskets need to be empty once it is full (immediately). All soiled linen needs to be disposed of in a timely manner. When hamper is full, please the take the dirty linen to the laundry room immediately.
In an Interview on 11/6/2024 at 9:46 am, the Assistant Director of Nursing and Infection Preventionist (ADON/IP) revealed that they re-educated the staff on the expectations for the soiled linen hampers being emptied on a consistent basis. The ADON/IP stated the CNAs are responsible for ensuring the soiled linen hampers were emptied when full.
In an Interview on 11/6/2024 at 2:06 pm, CNA XX revealed that everybody must be accountable for emptying the soiled linen hampers. CNA XX stated I can't be the only person dumping the cart all the time. Other people need to be held accountable for dumping the carts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of the facility's policy titled, Bladder and Bowel Evaluation, the facility failed to obtain a physician's order for a urinary catheter for one of five Residents (R) #69. The deficient practice had the potential to affect the needed care and services to meet the resident's needs.
Findings include:
Review of the facility's policy titled, Bladder and Bowel Evaluation not dated, Policy Statement revealed Based upon the resident's comprehensive assessment, all residents that are incontinent shall receive appropriate treatment and services. Under the subtitle Policy Explanation and Compliance Guidelines revealed 1. The facility shall conduct a bladder and bowel evaluation upon admission, quarterly, and with significant change in condition to determine incontinence and appropriate interventions. 4. Residents that enter the facility with an indwelling catheter, or receives one while in the facility, will be assessed for removal as soon as possible, unless the resident's clinical condition demonstrates that catheterization was necessary.
Review of the electronic medical record (EMR) revealed R#69 was admitted with diagnoses listed but not limited to sepsis due to pseudomonas, urinary tract infection (UTI), chronic congestive heart failure (CHF).
Review of R#69 Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Section-C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) of 99, which indicated R#69 had severe cognitive impairment. Section H- (Bladder and Bowel) revealed indwelling urinary catheter and frequent incontinent of bowel. Section N-(Medications) revealed antibiotics 6 days prior to assessment.
Review of R#69's care plan last revised on 7/12/2023 revealed a focus of care on indwelling urinary catheter. Goals included but not limited to remain free from catheter related trauma. Interventions included but not limited to empty catheter every shift, catheter care every shift, position catheter bag and tubing below the level of the bladder away from entrance/room door, observe/document pain/discomfort due to catheter, observe/record/report to MD for s/sx of urinary tract infection.
Review of electronic admission Nursing Evaluation dated 6/23/2023 revealed R#69 was re-admitted from hospital on 6/22/2023 at midnight and arrived via stretcher accompanied by paramedics with relevant diagnosis of septic shock and UTI. Section J-titled, GU/Bladder 1a. revealed incontinent of bladder was marked. 2a. revealed foley catheter was marked. 2d-2f revealed foley size was 16 French, with a 300 ml balloon, and urine color and consistency were clear amber colored with no sediment.
Review of the EMR revealed physician's orders for R#69 included but was not limited to urine analysis (UA) on 8/23/2023 and weekly skin assessment on day shift each Wednesday. There was no order found in the EMR for an indwelling urinary catheter.
Observation conducted on 8/22/2023 at 3:00 p.m. revealed R#69 resting quietly in bed was noted with a urinary catheter draining to bedside drainage bag inside a privacy bag attached to the bed frame and draining tea colored urine.
Observation conducted on 8/23/2023 at 9:44 a.m. revealed R#69 was noted with a urinary catheter draining to bedside drainage bag inside a privacy bag attached to the bed frame and draining pink colored urine.
Interview conducted on 8/24/2023 at 10:47 a.m. with Licensed Practical Nurse (LPN EE) confirmed and verified R#69 had a urinary catheter in place. Upon review of the EMR she confirmed and verified the MDS was coded for an indwelling urinary catheter and there was a care plan in place for the indwelling urinary catheter. She also verified and confirmed that there was no order for the indwelling urinary catheter.
Interview conducted on 8/24/2023 at 11:18 a.m. with the Director of Nursing confirmed and verified the MDS assessment documented the presence of an indwelling urinary catheter, the care plan documented had a focus of care for an indwelling urinary catheter with a goal and interventions. She confirmed and verified there was no physician order for the indwelling urinary catheter. She stated the resident most likely returned from the hospital with a catheter. Her expectation was for the nursing staff to assess the resident upon admission and assess the need for the indwelling urinary catheter and obtain a physician order for removal or if needed a diagnosis to support the need for catheter and order to leave catheter in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, review of facility documentation, and review of the facility's policy titled, Foot Care, the facility failed to identify and treat four of five wounds on the toes of the left foot for one of seven Residents (R) (R#32). The deficient practice had the potential to affect proper treatment and care to maintain mobility and good foot health.
Findings include:
Review of the facility's policy, titled Foot Care, undated revealed under the Policy Interpretation and Implementation:
1. Residents shall be provided with foot care and treatment in accordance with professional standards of practice.
Review of the clinical record for R#32 revealed he was diagnosed with, but not limited to cerebral infarction, hemiplegia and hemiparesis affecting the left non-dominant side, dementia without behavioral disturbance, and vascular dementia. In addition, he required extensive assistance for bed mobility and transfer.
Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. He required extensive assistance for bed mobility, transfer, dressing, personal hygiene, and bathing and required limited assistance for eating. The assessment revealed no unhealed pressure ulcers, venous or arterial ulcers, open lesions, burns, or skin tears.
Review of the Care Plan revealed focus topics to include self-care deficit due to hemiplegia, contractures/impaired function to the left hand/foot, risk for skin breakdown related to impaired mobility and incontinence (Date Initiated: 10/20/2022), and potential impairment to skin integrity to forehead and scalp related to him picking at his skin (Date Initiated: 11/19/2021).
Observation of R#32 on 8/22/2023 at 3:34 p.m. revealed his feet were pressed against the footboard and four of five of his toes on the left foot were bruised with scabs. He was unable or unwilling to answer whether his feet hurt or how long his toes had been bruised.
During an observation of R#32 on 8/24/2023 at 12:15 p.m. with Licensed Practical Nurse (LPN) EE revealed she was not aware of his bruised toes on the left foot. She reported she did not receive any report on it and there were no nurses' notes, progress notes or physician orders regarding the bruised toes.
Observation of R#32 on 8/24/2023 at 12:36 p.m. with the Unit Manager, LPN JJ confirmed the bruised toes and stated she was not informed of the condition. She stated she would get R#32 pulled up in the bed, contact the nurse practitioner (NP) and begin ordered treatment of the toes.

Based on observations, staff interview, review of records, and review of the facility's policy titled, Oxygen Administration, the facility failed to change disposable respiratory supplies and failed to maintain the cleanliness of respiratory supplies for eight of 22 Residents (R) (R#17, R#25, R#35, R#57, R#64, R#97, R#106, and R#108) with physician orders for continuous Oxygen (O2) and/or bilevel positive airway pressure (BiPAP) therapy. The deficient practice had the potential to affect the necessary respiratory care and services that are in accordance with professional standards of practice.
Findings include:
Review of the facility policy titled. Oxygen Administration, undated, revealed the following:
Equipment and Supplies: The following equipment and supplies will be necessary when performing this procedure.
2. Nasal cannula, nasal catheter, mask (as ordered)
3. Humidifier bottle
Steps in the Procedure:
8. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through.
1. Observation of R#64 on 8/22/2023 at 3:26 p.m. revealed she was wearing O2 via nasal cannula (NC) at two (2) liters per minute (LPM); the humidifier bottle was empty and the O2 concentrator was dusty.
Review of the Physician's Orders for R#64 revealed an order for O2 at 2 LPM via nasal canula to keep O2 saturation above 92%, dated 8/23/2023, for COPD (chronic obstructive pulmonary disease).
2. Observation of R#57 on 8/22/2023 at 3:57 p.m. revealed she was wearing O2 via NC at 1.5 LPM; humidity bottle was empty. In addition, the BiPAP mask and tubing were unbagged and laying on the nightstand.
Review of the Physician's Orders for R#57 revealed orders for but, not limited to: O2 at three (3) LPM via nasal cannula to keep SpO2 (blood O2 saturation) above 92%, dated 7/25/2023; change and date oxygen tubing and water and res [respiratory] bag every Sunday, dated 8/3/2023; and BIPAP mode: ST (settings) IPAP=12, EPAP=6, rate=12 at bedtime related to acute and chronic respiratory failure with hypoxia, dated 7/25/2023.
3. Observation of R#108 on 8/23/2023 at 9:40 a.m. revealed he was wearing O2 via NC at
2 LPM. The O2 concentrator was dusty.
Review of the Physician's Orders for R#108 revealed an order for O2 at 2 LPM via nasal cannula to keep SpO2 above 92% continuously, dated 8/2/2023.
4. Observation of R#17 on 8/23/2023 at 9:45 a.m. revealed she was alert, oriented, and pleasant. She was wearing O2 via nasal cannula (NC) at 2 liters per minute (LPM). The humidification bottle was empty and the O2 concentrator was dusty.
Review of the Physician's Orders for R#17 revealed an order for O2 with a revision date of 8/23/2023 for oxygen at 2 LPM via nasal canula to keep O2 saturation above 92%.
5. Observation of R#35 on 8/23/2023 at 9:50 a.m. revealed she was wearing O2 via NC at 2 LPM and the humidifier bottle was empty and the O2 concentrator was dusty.
Review of the Physician's Orders for R#35 revealed an order dated 7/7/2023 for O2 via NC at 2 LPM continuous for hypoxia.
6. Observation of R#97 on 8/23/2023 at 10:00 a.m., revealed she was wearing O2 via NC at 2 LPM; the humidifier bottle was empty and the O2 concentrator was dusty.
Review of the Physician's Orders for R#97 revealed orders for but not limited to: O2 at 2-4 LPM via nasal cannula to keep SpO2 above 90% continuous/PRN (as needed), dated 8/9/2023; change and date oxygen tubing and O2 water every Sunday night and PRN dated 7/25/2023.
7. Observation of R#25 on 8/23/2023 at 10:14 a.m. revealed she was alert, oriented, and pleasant. She was wearing O2 on via NC at 2 LPM with an empty humidification bottle and the O2 concentrator was dusty.
Review of the Physician's Orders for R#25 revealed an order for O2 revised on 3/13/2023 for O2 at 2 LPM via nasal cannula continuously. An additional order to change and date oxygen tubing and O2 water every Sunday night, dated 2/24/2023.
8. Observation of R#106 on 8/23/2023 at 10:25 a.m. revealed he was wearing O2 via NC at 3 LPM and the humidifier bottle was empty and the O2 concentrator was dusty.
Review of the Physician's Orders for R#106 revealed orders for but not limited to: O2 at 3 LPM continuously via NC for COPD, dated 3/13/2023; change and date oxygen tubing and O2 water every Sunday night, dated 2/26/2023.
Observation conducted on 8/24/2023 beginning at 4:15 p.m., of residents receiving oxygen with the Director of Nursing (DON) confirmed the O2 humidifier bottles were empty and O2 concentrators were dusty for R#64, R#17, R#35, R#97, R#25, R#108, and R#106. DON confirmed R#57 was wearing O2 via NC at 3 LPM as ordered and the humidifier bottle was changed and dated for 8/24/2023, but the O2 concentrator remained dusty. In addition, the BiPAP tubing and mask remained unbagged. During an interview at this time with the DON, she stated the night shift nurses were responsible for changing O2 supplies such as nasal cannulas and humidifier bottles which should be changed weekly or when the water level of the humidifier bottle reaches the refill line on the bottle. In addition, she stated O2, and other respiratory supplies should be bagged/labeled when not in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of the facility's document titled, Internal Agreement Request Prep Form; Nursing Home Dialysis Transfer Agreement, the facility failed to secure a contract with the dialysis center. The facilities census was 133.
Findings include:
Review of the Internal Agreement Request Prep Form, Nursing Home Dialysis Transfer Agreement dated 2/6/2020 under the Agreement Description revealed the agreement type was for nursing home residents who are transferred from a nursing home to a chronic dialysis facility for treatment. The standard process up to 10 business days. 5. Once approved, agreement sent for signatures, you will receive a copy once all parties sign. Date Prep Form Submitted was 2/6/2020 with Date Agreement Needed by on 2/10/2020.
Review of the electronic medical record (EMR) revealed R #66 with diagnoses listed but not limited to end stage renal disease (ESRD) and diabetes mellitus.
Review of R#66 admission Minimum Data Set (MDS) assessment dated [DATE] revealed for Section C (Cognitive Patterns)- Brief Interview for Mental Status (BIMS) of 15, which indicates R#66 was cognitively intact. Section O - (Special treatments, procedures, and programs) revealed he was receiving dialysis.
Review of R#66's care plan dated 8/8/2023 indicated a focus of care on diagnosis of anemia related to ESRD and hemodialysis. Goals included but not limited to remain free of signs/symptoms or complications related to anemia or dialysis. Interventions included but not limited to monitor/bleeding,/report as needed signs/symptoms of anemia, obtain and monitor lab/diagnostic work as ordered and report results to physician; dialysis on Monday, Wednesday, and Friday chair time 10:30 a.m., check dialysis shunts for thrill/bruit every shift, encourage resident to go to scheduled dialysis appointments, monitor vital signs, signs/symptoms of infection at access site, renal insufficiency, bleeding or hemorrhage, and remove dressing to left upper arm 5-6 hours after return from dialysis.
Interview conducted on 8/24/2023 at 3:43 p.m. with the Administrator revealed the document titled Internal Agreement Request Prep Form, Nursing Home Dialysis Transfer Agreement was the only documentation he could find related to an agreement with the dialysis center. He also stated the dialysis center reported to him that this is the only form they have related to an agreement as well. He stated they have asked him to initiate the renewal of the agreement between the facility and the dialysis center.

Based on observations, staff interviews, and review of the Contracted Dietary Company's policies titled, General HACCP Guidelines, Uniform Policy and Personal Hygiene Policy, the facility failed to allow dishes to air dry prior to use, ensure kitchen staff perform hand hygiene and wear gloves when preparing food for residents, to ensure staff entering the kitchen wear hair net and perform hand hygiene upon entering the kitchen. This deficient practice had the potential to affect 128 of 133 residents receiving an oral diet.
Review of policy titled General HACCP Guidelines dated January 2022, under subtitle, Policy revealed, Staff must be educated and supervised on all HACCP information and procedures. A good training program and the proper systems and tools will help to assure a successful HACCP /Food Safety program. Under the subtitle, Procedure revealed, Educate and monitor staff on the following: Hand washing -Train staff to wash hands prior to working with food, after using restroom, or soiling hands. 10. Dishwashing -Air Dry: use drying racks if needed; do not stack dishes immediately before or after washing.
Review of policy titled Uniform Policy revised date 5/25/2023 under subtitle, Procedure revealed: Hair nets must be worn by anyone entering the department and must completely cover all hair from front to back. No bonnets or durag. Head wraps are approved. Disposable gloves are single use and must be changed between tasks.
Review of policy titled Personal Hygiene Policy undated, under subtitle, Procedure revealed Cover all hair and facial hair with restraint (hairnet, cap, or hat).
Findings include:
Observation on 8/24/2023 at 12:10 p.m. of the Dietary Manager (DM) preparing lunch plates on the tray line revealed she removed a plate from a stack of plates and dried the plate with a towel before scooping food onto the plate. DM traded places with [NAME] BB, removed her gloves and began adding pre-packaged foods to the tray after [NAME] BB scooped food onto plates for each tray.
Observation on 8/24/2023 at 12:30 p.m. of dietary staff preparing lunch plates on the tray line revealed every plate used was removed from a stack of plates and all plates were wet. [NAME] BB used a dry towel to dry the dishes as he plated the food for each resident. During this time, the DM was observed answering the door multiple times throughout preparation of trays for a resident, provided requests from several staff members and from residents. On each of these occurrences she did not perform hand hygiene or re-glove her hands prior to rejoining the tray line. Continued observation revealed a nurse entered the kitchen and began walking toward the tray line, the DM stopped the nurse and instructed her to not enter the kitchen without a hairnet, before returning to the doorway to request a sandwich.
Observation on 8/24/2023 at 12:50 p.m. revealed the DM scooped food onto a resident plate without performing hand hygiene or wearing gloves prior to scooping food onto plate.
Observation on 8/24/2023 at 1:05 p.m. revealed the DM scooped food onto a resident's plate without performing hand hygiene or wearing gloves prior to scooping the food onto the plate.
Observation on 8/24/2023 at 1:10 p.m. revealed the Administrator entered the kitchen through the back entrance and did not stop to put on a hairnet or wash hands. He entered the dry storage room and after a few minutes (three-five minutes), he returned from the dry storage room and exited the kitchen through the back entrance.
Interview on 8/24/2023 at 2:30 p.m. with the Dietary manager confirmed the dishes and trays were wet during serving line preparation of trays for resident's lunch. She confirmed that she and [NAME] BB were both using dish towels to dry dishes as they served the food on to the plate and placed plates onto trays. She stated the dishes should be allowed to air dry prior to using. She stated she should have utilized disposable trays for lunch since the dishes were not dry. She confirmed and verified she removed her gloves when she changed places in the tray line with [NAME] BB. DM confirmed and verified she left the tray line to assist staff and residents at the kitchen door during tray line. She confirmed and verified she scooped food onto a resident plate on two occasions during the tray line without wearing gloves or performing hand hygiene prior to scooping the food onto a plate. DM confirmed and verified that the Administrator entered the kitchen through the back entrance without putting on a hair net or performing hand hygiene and going into the dry storage room before exiting the kitchen through the rear entrance of the kitchen.
Interview on 8/24/2023 at 2:45 p.m. with the Administrator revealed the dietary staff were contracted staff and the kitchen is run by a contracted company. He confirmed and verified that he entered the kitchen without wearing a hairnet. He stated he did not think he needed to wear a hair net if he did not go near the food prep area. He revealed his expectations were for staff to follow proper sanitation guidelines. He expected the leadership to set an example for staff of following proper sanitation guidelines. He stated that plates must air dry prior to use, so he expected that the dietary staff do not use a towel to dry dishes and to allow them to air dry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain personal use equipment in a sanitary manner for two of six shared bathrooms on the B Hall. Specifically, unlabeled/unbagged wash basins were observed in the bathrooms serving rooms [ROOM NUMBERS].
Findings include:
Observations on 8/22/2023 at 3:35 p.m. and 8/23/2023 at 12:40 p.m. of the shared bathroom for room [ROOM NUMBER] revealed two unlabeled/unbagged wash basins.
Observations on 8/22/2023 at 3:47 p.m. and 8/23/2023 at 12:45 p.m., of the shared bathroom for room [ROOM NUMBER] revealed four unlabeled/unbagged wash basins and one urinal.
Observations on 8/24/2023 beginning at 3:30 p.m. of rooms [ROOM NUMBERS] with the Unit Manager confirmed the unbagged/unlabeled wash basins. Interview during this time with the Unit Manager, stated staff should be labeling and bagging wash basins, urinals, graduates, and toiletries for multiple residents sharing a bathroom.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of facility documentation, the facility failed to maintain a functional and sanitary environment in two of 20 sampled resident rooms on the A Hall. Specifically, the facility failed to maintain its packaged terminal air conditioners (PTAC) in a sanitary condition in rooms [ROOM NUMBERS]. In addition, the facility failed to maintain one of 35 resident wardrobes on the B Hall, room [ROOM NUMBER], in a functional condition.
Findings include:
Observation of room [ROOM NUMBER] on 8/22/2023 at 12:09 p.m. revealed a drawer missing from wardrobe #1 behind the door of the room.
Observation of room [ROOM NUMBER] on 8/22/2023 at 2:40 p.m. revealed the PTAC (heating and air unit) had a large amount of a black substance on the grill.
Observation of room [ROOM NUMBER] on 8/22/2023 at 3:24 p.m., revealed a large amount of a black substance on the grill of the PTAC.
Observation of rooms [ROOM NUMBER] on 8/23/2023 beginning at 12:40 p.m. revealed black substance remained on the PTAC in rooms [ROOM NUMBERS]; and the drawer was still missing from wardrobe #1 in room [ROOM NUMBER].
During the observation of rooms [ROOM NUMBER] with the Maintenance Assistant on 8/24/2023 beginning at 2:00 p.m., he confirmed the PTAC had black substance on the grills in rooms [ROOM NUMBERS]. He stated the maintenance team makes monthly rounds to inspect and clean the PTAC. He stated, when it's damp outside or raining, the PTAC are more prone to collecting the black substance. In addition, he confirmed the drawer had been missing from the wardrobe in room [ROOM NUMBER], but he repaired it earlier today. He stated staff use the TELS Task Manager to schedule routine tasks and fulfill maintenance requests. He stated staff use the TELS system to report maintenance concerns or they speak to him directly. He stated monthly tasks included removing the PTAC cover to clean the grill and cleaning the air filters. He stated the PTAC had been cleaned routinely, but he would clean these two again.
The Maintenance Assistant stated there was no facility policy related to these concerns. Review of Work Order #16232 dated 8/24/2023 documented the repaired wardrobe drawer. Review of the monthly tasks from the TELS system revealed PTAC cleaning was listed. Review of the Monthly PTAC Cleaning log revealed the PTAC in rooms [ROOM NUMBERS] had not been cleaned in July 2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews. and the facility failed to provide dental services for one of one sampled resident (R) (R#15) reviewed for dental services.
Findings include:
Review of clinical record revealed R#15 was admitted to the facility on [DATE] with a primary diagnosis of peripheral autonomic neuropathy and was discharged from the facility on 12/2/2022.
The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Section G revealed resident required extensive assistance of one person for personal hygiene, required a mechanically altered diet, and had mouth or facial pain and discomfort or difficulty with chewing.
Review of the Clinical Physician Orders, indicated dental care as needed.
Review of the Nutritional Evaluation, dated 7/10/2022, indicated resident required a mechanical soft diet, had partial dentures, had chewing impairments affecting nutrition, and had a prior hospitalization with a diagnosis of failure to thrive. It was documented R#15 received a mechanically soft diet due to chewing issues, was to receive new dentures, and wanted to remain on a mechanically soft diet.
Review of the Progress Notes, dated 10/4/2022, revealed resident complained of his bottom chipped tooth hurting. Additionally, on 10/4/2022, it was documented, . Resident called [family member] and got no answer and then dialed 911. Officers in the building to follow up. Resident telling them his tooth hurts, and no one is doing anything. This writer medicated him with Tylenol times two and reported to SW (Social Worker).
Review of the Progress Notes, dated 10/6/2022, revealed resident had complained of tooth pain and required oral pain medication.
Review of the Progress Notes, dated 10/7/2022, revealed resident had complained of tooth pain and required oral pain medication.
Review of the Clinical Physician Orders, dated 10/7/2022, indicated resident was to receive amoxicillin (an antibiotic) for 10 days related to tooth pain.
Review of the Progress Notes, 10/14/2022, revealed resident had complained of tooth pain and required oral pain medication.
Interview on 4/27/2023 at 4:00 p.m. Licensed Practical Nurse (LPN) JJ confirmed that R#15 had complained of tooth pain and that she notified the physician and received orders for antibiotics.
Interview on 4/27/2023 at 4:15 p.m., LPN KK stated she did not recall any information regarding R#15, but stated when residents report dental or oral pain, the nurse should enter a progress note and list the information on the 24-hour report log so that when the physicians did their rounds, they could see the resident.
Interview on 4/28/2023 at 5:51 p.m. the Social Services Assistant (SSA) stated the facility policy regarding dental referrals included staff bringing the concern to their attention, the Social Services office then making a referral, and coordination would also be made with the business office for billing/insurance purposes. The SSA stated the dentist came to the facility quarterly, and all new admissions or newly identified needs would be seen by the dentist at that time. The SSA reviewed the list of residents who had dental referrals and R#15 was not on the list. The SSA reviewed the EMR progress notes and plan of care and was unable to locate any information regarding a dental referral but confirmed there should have been one submitted. The SSA reviewed residents quarterly care conference note, dated10/25/2022, and confirmed the need for a dental referral was not discussed. The SSA stated it was unknown if the resident attended the conference or not.
Interview on 4/28/2023 at 5:51 p.m., visiting Administrator (VA) EE confirmed a dental referral should have been completed for R#15 but was not done.

Based on record review, interviews, and review of the policy titled Abuse Neglect and Exploitation, the facility failed to ensure administration provided oversight and monitoring related to the prevention, reporting and investigation of abuse. Four of 31 sampled residents (R) (R#11, R#12, R#18, and R#28) reported allegations of abuse and these allegations were not reported and/or investigated per facility policy. In addition, the Administration failed to ensure residents were appropriately protected from further potential abuse after the allegations. The facility's systemic failure to ensure the prevention of abuse created the potential for residents to be or to continue to be abused/neglected/exploited which can lead to serious physical and/or psychological harm for all 126 residents residing in the facility.
On 4/28/2023 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents.
The facility's Administrator and Clinical Nurse Consultant was informed of the Immediate Jeopardy (IJ) on 4/28/2023 at 3:50 p.m. The noncompliance related to the IJ was identified to have existed on 12/21/2022.
An Acceptable Removal Plan was received on 5/2/2023. The removal plan included in-service training for staff on Abuse prevention, Reporting Abuse allegations, and Investigating allegations of abuse, and in-service training for administration staff on reporting and investigating alleged violations. Through observations, record review, and interviews the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on 5/1/2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures regarding Abuse prevention, Reporting, and Investigating allegations of Abuse.
Findings include:
Review of the policy titled Abuse Neglect and Exploitation dated December 2017 indicated each resident has the right to be free from verbal, sexual, physical, and mental abuse; corporal punishment; involuntary seclusion; mistreatment of any kind. Residents will not be subjected to abuse by anyone, including but not limited to, center staff, other residents, consultants, volunteer staff, family members, friends or others. Bullet III. Prevention of Abuse, Neglect and Exploitation: Provide education on what constitutes abuse, neglect, and misappropriation of property. Take appropriate action to allegations or questions of abuse by residents, family members, employees, or visitors. Supervise staff to identify inappropriate behaviors, such as using derogatory language, rough handling or ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in their beds. Bullet IV. Identification of Abuse, Neglect and Exploitation. The facility will consider factors indicating possible abuse, neglect and/or exploitation of residents including, but not limited to, the following possible indicators: Resident, staff, or family report of abuse. Verbal abuse of a resident overheard. Physical abuse of a resident observed. Reporting/Documentation Requirements: When abuse, neglect or exploitation is suspected: Immediately report all alleged violations to the Administrator/Designee, state agency, adult protective services, and all other required agencies (e.g., law enforcement when applicable) within specified time frames. Investigation of abuse, neglect, and exploitation: When suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Components of an investigation may include, identifying staff responsible for the investigation; exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence; ensure resident safety is not jeopardized. Physically assess resident; investigating different types of alleged violations; Identifying an interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, ensure confidentiality; focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and providing complete and thorough documentation of the investigation; continue investigation to determine if other residents may be at risk for similar occurrences. If similar residents are at risk, appropriate measures/changes will be implemented.
Review of the Administrator Job Description indicated the Basic Function: Responsible for directing the overall operation of the facility's activities in accordance with current applicable federal, state, and local standards, guidelines and regulations as directed by corporate office and for ensuring that the highest degree of quality patient/resident care is maintained at all times. Number 6. Ensure that patient/resident rights to fair and equitable treatment, self-determination, individuality, privacy, property, and civil rights, including the right to wage complaints are well established and maintained at all times.
The Role of the Abuse Coordinator within the facility's undated Abuse Investigation and Reporting Policies, revealed the role of the Abuse Coordinator: 1. The facility administrator may take the role of the Abuse Coordinator in the facility. 2. If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown origin is reported, the Administrator/Abuse Coordinator will assign the investigation to an appropriate individual. 3. The Abuse Coordinator shall provide any supporting documents relative to the alleged incident to the person in charge of the investigation. 4. The Abuse Coordinator or designated staff shall keep the resident and his/her representative (sponsor) informed of the progress of the investigation. 5. The Administrator/Abuse Coordinator or designated staff (i.e., DON (Director of Nursing), Department Manager) shall suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. 6. The Administrator/Abuse Coordinator shall ensure that any further potential abuse, neglect, exploitation, or mistreatment is prevented. 7. The Administrator or designated staff shall inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident.
Review of the Incident Follow-Up Investigation Report revealed on 1/9/2023, an allegation of physical and verbal abuse was reported for R#11 to the Social Worker (SW). The allegation was not reported to the Administration until 1/17/2023, by R#11's Responsible Party. After the allegation of physical abuse was reported to administration on 1/17/2023, the facility failed to ensure resident safety by suspending the potential perpetrator, failed to assess the resident for potential injury, and failed to thoroughly investigate the allegation of abuse (staff and resident interviews were not completed to attempt to identify whether abuse was occurring in the facility). Due to the staff member not reporting the abuse allegations timely, Certified Nursing Assistant (CNA) BB and CNA CC continued to work with residents.
Review of the Incident Follow-up Investigation Report revealed on 4/9/2023, an allegation of sexual abuse was reported for R#12. The facility failed to ensure resident safety by suspending the potential perpetrators and failed to thoroughly investigate the allegation of abuse (staff and resident interviews were not completed to attempt to identify whether or not abuse was occurring in the facility). The facility failed to attempt to identify the staff member who perpetrated the abuse, hence allowing multiple potential perpetrators (male staff members) to continue to work with residents during the investigation.
Review of the Facility Reported Incident revealed on 4/12/2023, an allegation of multiple injuries of unknown origin/physical abuse was reported for R#18. Facility staff failed to timely report the injuries to administration, the facility failed to thoroughly investigate the injuries of unknown origin (staff and resident interviews were not completed to attempt to identify whether abuse was occurring in the facility), and the facility did not perform a follow-up investigation (5-day) until 4/28/2023.
Review of the Incident Follow-Up Investigation Report revealed on 12/21/2022, an allegation of physical and verbal abuse by CNA DD was made for R#28. The facility did not ensure resident safety by suspending the alleged perpetrator during the investigation (the alleged perpetrator remained at work for the remainder of her shift while working in direct contact with residents), R#28's allegation of abuse was not reported to facility Administration until the next morning (12/22/2022), an investigation into the allegation of physical/verbal abuse was not thorough (it failed to include interviews of staff and residents to determine whether the abuse occurred), and the resident was not physically assessed related to the allegation of physical/verbal abuse. In addition, the alleged abuse allegation was not substantiated despite reports from two staff members that the alleged perpetrator of the abuse loudly made the statement ''You should have offered him some food and watched how fast he got up'' in front of the resident before knocking the residents' cups off his overbed table and storming out of the room.
Interview 4/27/2023 at 10:25 a.m., the Director of Nursing (DON) and the Administrator confirmed the Administrator acted as the facility's Abuse Coordinator. The Administrator confirmed the above staff members were not placed on suspension per policy, assessments were not completed of the residents per policy, and the investigations into the allegations of abuse were not thorough.
Interview on 4/27/2023 at 1:05 p.m., the Administrator stated in response to the survey team's questions, you were right. I thought I was thorough but that is not what it is. [After talking with the surveyors] I realize staff should be suspended and were not suspended.
Interview on 4/29/2023 at 12:30 p.m., the DON stated she was aware the abuse investigations were not thorough. She stated the Administrator was the facility's abuse coordinator and his involvement with abuse investigations was not what it should be.
Cross-reference F600, F609, and F610.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to ensure a clean, safe, and sanitary environment for residents, staff, and visitors related to foul odors on two of four hallways (B and D). Residents during the Resident Council meeting complained specifically about foul odors from R#28. The census was 126.
Findings include:
Review of the clinical record revealed R#28 was admitted to the facility on [DATE] with diagnoses including morbid obesity, unspecified psychosis (out of touch with reality), and Wernicke's Encephalopathy.
The resident's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of eight, indicating severe cognitive impairment. Section G revealed the resident required extensive assistance from staff to conduct his Activities of Daily Living (ADLs) including grooming, toileting, and bathing. Section H indicated resident was incontinent of bowel and bladder.
Review of the care plan dated 4/25/2023 indicated resident had a self-care deficit related to his morbid obesity. Interventions to care included assist with toileting, requires use of briefs and pads, and is totally dependent on two staff for toilet use, and praise all efforts at self-care. Resident is incontinent of bowel and bladder related to his immobility. Interventions to care included checking on resident during rounds, assisting with toileting as needed, provide loose fitting, easy to remove clothing, and provide peri care after each incontinent episode. The resident had a care plan for resistive to care, specifically, refused to change his clothes, and tended to refuse incontinence care and bathing. Interventions to care include allow resident to make decisions about treatment regimen, provide sense of control, encourage as much participation/interaction as possible during care, if resident resists ADL care, reassure him and leave and return 5 - 10 minutes later and try again, and offer resident 2 - 3 alternatives for activity that ultimately leads to the desired task completion.
During the initial tour of the facility on 4/24/2023 between 10:10 a.m. - 10:25 a.m. revealed foul odor of bowel movement (BM) on all four hallways. The odors were strongest near the nurses' station and on the B and D hallways of the facility.
Observations of the facility on all four hallways were made on 4/24/2023 at 11:30 a.m. and 1:05 p.m., on 4/25/2023 at 9:15 a.m., 10:25 a.m., and 1:35 p.m., on 4/26/2023 at 10:15 a.m. and 3:05 p.m., on 4/28/2023 at 10:15 a.m., and on 4/29/2023 at 1:00 p.m. There was consistently a strong BM odor on two of the four hallways (Hallway B and Hallway D) as well as around the nurse's station in the middle of the hallways during each of these observations.
Observation on 4/27/2023 at 5:45 p.m. and 4/28/2023 at 11:30 a.m. and 2:15 p.m., R#28 was seated outside of his room in his wheelchair with a large basin and absorbent pads under his wheelchair. The resident's appearance was disheveled.
Observation on 4/29/2023 at 1:00 p.m., R#28 was observed seated outside of his room in his wheelchair with the basin and pads on the floor under his wheelchair. Resident smelled of urine and BM and the pads on the floor under the wheelchair appeared to be wet.
Interview 4/24/2023 at 10:50 a.m., the Ombudsman stated she was frequently in the building and had most recently visited the facility the prior week. She stated there was frequently a foul odor on certain hallways and thought the odor could be attributed to soiled linens, and to R#28. She stated R#28 was typically seated in his wheelchair in the hallway and stated from what she understood the resident often refused care, resulting in his briefs becoming saturated with urine and BM with human waste running onto the floor underneath him.
Interview on 4/28/2023 at 9:55 a.m., during a Resident Council meeting, residents voiced the smell was horrible down the hallway and the aides would try to spray stuff in the air, but it was just as bad as the odors. R#28's roommate revealed R#28 was being complained about how R#28 smells and how he piss [sic] and shits in the hallway; and how roommate cannot get in or out of his room.
Interview on 4/28/2023 at 5:45 p.m., Certified Nursing Assistant (CNA) CC indicated she worked in the facility frequently and stated, Certain halls have odors, like the back of D and the B Hall. They smell like BM and urine. B [smells bad] because there is a patient who sits in the hall and defecates on himself.
Interview on 4/29/2023 at 9:45 a.m., Licensed Practical Nurse/Unit Manager (LPN/UM) SS and UM TT, both stated odors in the facility were consistently a problem, and were particularly bad on the B Hallway near where R#28 generally sat outside of his room during the day. UM SS stated, The end of B Hall around R#28 gets really bad and other residents and staff do complain.
Interview on 4/29/23 at 10:10 a.m., CNA UU stated she worked in the facility frequently. She stated, R#28 will sit in his BM and urine all day and the smell is bad. It is odorous. Oh, yes! She indicated R#28's roommate complained about the bad odor often. She stated, And staff complain, too.
Interview on 4/29/2023 at 10:23 a.m., CNA DD stated, I know where R#28's area is, and there are odors. He does not want us to help him clean himself. The odors are like if you sit in pee and poo and do not allow people to take care of you and of course (those odors) will be strong. She stated R#28's roommate frequently complained to staff about the odors.
Interview on 4/28/2023 at 2:30 p.m., Director of Nursing (DON) and the Administrator, revealed the hygiene issues with R#28 had been a problem for a long time. Staff attempted to contact the resident's family member to address the issue and had attempted to get the resident to move to another area during the day, but this had not prevented the odor problem. The DON stated the disposable pads and basin were put under R#28's wheelchair to prevent waste from pooling on the floor and causing an accident hazard.
Interview 4/29/2023 at 11:45 a.m., Housekeeping Director stated odors had been a problem on the B hallway and throughout the facility. He stated part of the problem was nursing staff tended to leave dirty briefs in the trash bins in resident rooms and the shower rooms and the waste was not removed often enough. He also stated part of the problem was the odor related to R#28. During further interview, he stated R#28 sits in his chair in the hallway and defecates and urinates on himself and in his chair and on the floor. He stated nursing would call housekeeping staff to clean up after an incident with R#28, but stated housekeeping staff was not able to remove biohazardous waste like feces and urine. He stated the waste often had to sit on the floor until nursing staff could get around to cleaning it up. He stated, It's an issue. The odors related to this have been a problem and still are currently.
Interview on 4/29/2023 at 2:20 p.m., Clinical Nurse Consultant (CNC)/ Interim Director of Nursing stated his expectation was there would be transient odors which was normal, but overall, the facility should be odor free.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, family and staff interviews, and review of the policy titled Abuse Neglect and Exploitation policy and Accidents and Supervision, Investigation, and Reporting, the facility failed to ensure the immediate reporting of verbal, sexual, and/or physical abuse for three of 31 sampled residents (R) (R#11, R#18, and R#28). Specifically, the facility failed to ensure allegations of physical and verbal abuse for R#11 and R#28 were reported to the Abuse Coordinator, and an allegation of physical abuse was reported timely to the State Survey Agency (SSA) for R#18. The facility's systemic failure to ensure the reporting of abuse created the potential for residents to be or to continue to be abused/neglected/exploited which can lead to serious physical and/or psychological harm for all 126 residents residing in the facility.
On 4/28/2023 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents.
The facility's Administrator and Clinical Nurse Consultant was informed of the Immediate Jeopardy (IJ) on 4/28/2023 at 3:50 p.m. The noncompliance related to the IJ was identified to have existed on 12/21/2022.
An Acceptable Removal Plan was received on 5/2/2023. The removal plan included in-service training for staff on Abuse prevention, Reporting Abuse allegations, and Investigating allegations of abuse, and in-service training for administration staff on reporting and investigating alleged violations. Through observations, record review, and interviews the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on 5/1/2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures regarding Abuse prevention, Reporting, and Investigating allegations of Abuse.
Findings include:
Review of the policy titled Abuse Neglect and Exploitation policy, dated 12/2017 indicated that each resident has the right to be free from verbal, sexual, physical and mental abuse; corporal punishment; involuntary seclusion; mistreatment of any kind. Reporting/Documentation Requirements: When abuse, neglect or exploitation is suspected: immediately report all alleged violations to the Administrator/Designee, state agency, adult protective services and all other required agencies (e.g., law enforcement when applicable) within specified timeframes.
1. Review of the clinical record revealed R#11 was admitted to the facility on [DATE] with diagnoses including fracture of upper and lower end of right fibula and fracture of right tibia.
Resident #11 is a new admission and entry tracking Minimum Data Set (MDS) dated [DATE] is only MDS available, therefore, no data available at this time.
R#11's Brief Interview for Mental Status (BIMS) score, dated 1/6/2023 and found in the electronic medical record (EMR) under the MDS tab, was 14, indicating the resident was cognitively intact.
Review of document titled Grievance Log dated 9/1/2022 through 4/26/2023 revealed a grievance entered on behalf of R#11 on 1/9/2023, by the resident's family member and the nature of the grievance indicated care. The log entry indicated the outcome was Reportable and the resolution date of the grievance indicated 1/17/2023, eight days after the grievance was initially reported.
Review of the Incident Report Form, dated 1/17/2023, indicated the above allegation was entered into the facility's incident tracking system on that date (eight days after the initial report).
Review of the Incident Follow-Up Investigation Report related to the resident's report of care concerns dated 1/17/2023 indicated, Initial Report: Abuse. The report indicated on 1/9/2023, R#11 alleged to the Social Worker (SW) that Certified Nursing Assistant (CNA) BB (agency) was rough and verbally abusive during activities of daily living (ADL) care. She alleged CNA BB and CNA CC left her lying in her own feces. According to the investigation report, the SW never reported the allegation of abuse to the Administration. Administration was not made aware of these allegations of abuse until reported by the resident's Representative (RP) to the Director of Nursing (DON) on 1/17/2023 (eight days later). Because the allegation of abuse was not timely reported to the Administration, CNA BB and CNA CC were not put on administrative leave and continued to work in the facility with R#11 and other residents for eight days after the initial allegation of abuse.
Review of the Nursing Schedules, dated 1/9/2023 through 1/17/2023 revealed CNA BB and CNA CC remained at work in direct contact with residents, including R#11.
Interview on 4/24/2023 at 12:30 p.m., responsible party (RP) for R#11, confirmed report of an allegation of physical abuse/rough treatment by two CNAs was made to the facility SW on 1/9/2023 and then again to the DON on 1/17/2023.
Interview on 4/28/2023 at 5:45 p.m., CNA CC, she verified she was still working consistently in the facility as a CNA and indicated she did not recall R#11. CNA CC stated she did not remember ever being put on administrative leave related to any allegation of abuse.
Interview on 4/27/2023 at 2:15 p.m., the Social Services Director (SSD) confirmed the Grievance related to R#11's allegation of physical and verbal abuse had not been reported to the facility's Administration as it should have. She stated the grievance should have been immediately referred to the Abuse Coordinator/Administrator on 1/9/2023 when the allegation was initially reported.
2. Review of the clinical record revealed R#28 was admitted to the facility on [DATE] with diagnoses including morbid obesity, unspecified psychosis, and Wernicke's Encephalopathy.
The resident's MDS dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as eight, which indicated moderate cognitive impairment.
Review of the Incident Report Form, dated 12/21/2022, indicated an allegation of physical abuse was entered into the facility's incident tracking system on that date for the resident. The details indicated, Resident had a fall and states CNA pushed me. The form indicated the alleged perpetrator of the abuse to be CNA DD.
Review of the Incident Follow-Up Investigation Report dated 12/21/2022 related to the resident's allegation of physical abuse was reviewed and indicated Initial Report: Staff to Resident Abuse. The report indicated R#28 alleged physical abuse by a staff member on 12/21/2022. The resident stated CNA DD pushed him down and he cried for help, and no one would help him. The report indicated R#28 was found on the floor by another CNA crying and lying face down next to his bed. The report indicated interviews were obtained from three staff members who were working with the alleged perpetrator on the night of the alleged abuse. Two of the three staff members interviewed indicated they were present in the resident's room while he was alleging, he had been abused by CNA DD. Both staff members indicated the resident was found face down on the floor and was crying. Two staff members revealed R#28 was further abused (verbally) by CNA DD when she returned to the resident's room and loudly yelled, ''You should have offered him [R#28] some food and watched how fast he got up'' before knocking the resident's cups off his bedside table, and then storming out of the room. According to the investigation report, the allegation of potential abuse was not reported to the facility's Abuse Coordinator until the following morning. Because the alleged abuse was not timely reported to the Administrator/Abuse Coordinator until the morning of 12/22/22, CNA DD was not put on administrative leave after the allegation of abuse, and instead remained in the facility for the remaining seven hours of her shift while working in direct contact with residents.
Review of the Nursing Schedules, dated 12/21/2022 revealed CNA DD remained in the facility for the remainder of her shift on 12/21/2022, in direct contact with residents, including R#28.
Interview on 4/29/2023 at 10:23 a.m. with CNA DD, confirmed she was not put on administrative leave on the night of the alleged abuse. She stated she remained in the facility working with residents until the end of her shift the next morning. She stated she was put on administrative leave the next day after the Administrator arrived at work.
Interview on 4/27/2023 at 10:25 a.m., the DON and the Administrator confirmed the Administrator was acting as the facility's Abuse Coordinator. The Administrator stated abuse was to be reported to himself immediately after an allegation and stated any facility staff member could report abuse. He stated after abuse allegations had been reported to him, it was his responsibility to investigate the allegation.
Interview on 4/29/2023 at 2:20 p.m. the Clinical Nurse Consultant (CNC), serving as Interim Director of Nursing (DON), stated his expectation was any allegation of abuse was to be reported to a supervisor immediately and the supervisor was to then immediately call the Abuse Coordinator.
3. Review of the policy titled Accidents and Supervision, Investigation, and Reporting, revised September 2022, revealed all accidents or incidents must be reported and recorded.
Review of the clinical record revealed R#18 was admitted to the facility on [DATE] with diagnoses including osteoarthritis and dementia.
The resident's annual MDS dated [DATE], revealed a BIMS score of five, indicating the resident had severe cognitive impairment. Additionally, it was indicated R#18 had no falls since admission, required extensive assistance of one person with bed mobility, dressing, transfers, required two-person assistance with toileting, extensive assistance of one person with personal hygiene, and had impairments to the lower extremities bilaterally.
Review of the care plan revised 2/27/2023 indicated R#18 required assistance with bathing, bed mobility including turning and repositioning, dressing, undressing, transfers, and incontinence care.
Review of the Incident Note dated 4/12/2023 at 1:30 p.m. revealed Administrator was present onsite and aware of incident at the time of the concern. The DON, ADON (Assistant Director of Nursing), and Administrator responded to bedside to address family and resident concern. When DON asked the resident what caused her bruises, the resident stated, I don't know. DON asked resident directly, Did anyone hurt you intentionally? Resident responded, No. DON requested wound care nurse to complete a head-to-toe skin assessment. DON offered to call MD (Medical Doctor) for radiology of left foot and ankle and resident's two daughters refused, stating to call 911 and have her transported to a hospital. DON called 911 for transport and the resident was transferred to non-emergent transport.
Review of Weekly Skin Observation dated 4/12/2023 at 1:39 p.m., indicated the resident had purple/blue discolorations to the left dorsal great toe and left dorsal proximal foot, purple/blue discolorations to the right upper arm and left upper arm, purple/blue discolorations with petechiae (pinpoint, round spots that appear on the skin as a result of bleeding) to the right lower extremity, a small open area to left labia, and yellow discolorations to left temple.
Review of a document titled Risk Management indicated R#18 was noted to have an injury of unknown cause on 4/12/2023 at 3:00 p.m. The document recorded family members at bedside and requested an immediate call to 911 for EMS (Emergency Medical Services) to remove the resident from facility due to their concerns of care. Resident states that her left great toe and foot has pain and there is a small bruise on top of left great toe, and small bruise to left ankle, and a yellow discoloration to left temple. Scattered petechiae to right shin. Head to [sic] assessment from wound care nurse completed. 911 called to transport the patient to acute hospital per family request. Administrator aware and submitting reportable and called Ombudsman. The DON notified MD and RP and sister at bedside.
Review of the Facility Incident Report Form, dated 4/12/2023, indicated R#18 had a dark bruise on left foot reported by resident's family member and informed the Administrator/Abuse Coordinator of the bruise. The report recorded the concern was an injury of unknown origin and the alleged perpetrator was unknown. The incident report's conclusion portion indicated the investigation is inconclusive. During the interview with DON and others, the resident stated that she wasn't experiencing ankle pain. Secondly the resident takes both Anticoagulant and Anastrozole medications, and lastly the Responsible Party informed the Administrator that her friend advised her how to get the [R#18] closer to home. Corrective action is Administration will continue employee's education on residents' assessments and reporting injuries. This is a late reportable and will be QAPI (Quality Assurance and Performance Improvement) in facility up-coming QAPI.
Interview on 4/27/2023 at 7:00 p.m., the CNC stated R#18's injuries noted on 4/12/2023 were not reported because nothing happened.
Interview on 4/28/2023 at 10:37 a.m., the WCN confirmed that she performed a full body skin assessment on R#18 after the family had reported bruising to her left upper foot. The WCN reported the skin assessment revealed yellow discoloration to the temple, purple/blue discoloration to bilateral upper extremities, petechiae to left lower extremity, and a small ulcer opening to the labia.
Interview on 4/28/2023 at 10:58 a.m., the DON confirmed that on 4/12/2023, R#18's family reported she had bruising of which she was unaware. The DON stated she was aware of R#18's complaints of foot pain. The DON stated the WCN performed a full body skin assessment and that is when she became aware of the bruising on R18's body. which revealed discoloration to her foot, possible injury to the foot, and pain reported in one of her feet.
Interview on 4/28/2023 at 2:55 p.m., the Administrator/Abuse Coordinator stated that he reported the injury on 4/12/2023 but confirmed he did not submit a five-day follow-up. The Administrator did not provide a reason the five-day follow-up report was not submitted.
Interview on 4/28/2023 at 4:24 p.m., the Infection Preventionist (IP) confirmed that staff working with R#18 did not report the bruising immediately as they should have reported. The IP confirmed it was the family member who brought the bruising to the attention of the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, family and staff interviews, and review of policy titled ''Abuse Neglect and Exploitation policy'', the facility failed to maintain an environment free from verbal, sexual, and/or physical abuse for four residents (R) R#11, R#12, R#18, and R#28) of 31 sampled residents. The facility failed to ensure the residents were protected after allegations of abuse by suspending alleged perpetrators of abuse during each investigation of alleged abuse and failed to thoroughly investigate and report potential allegations of abuse. The facility's systemic failure to ensure the prevention of abuse created the potential for residents to be or to continue to be abused/neglected/exploited which can lead to serious physical and/or psychological harm for all 126 residents residing in the facility.
On 4/28/2023 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents.
The facility's Administrator and Clinical Nurse Consultant was informed of the Immediate Jeopardy (IJ) on 4/28/2023 at 3:50 p.m. The noncompliance related to the IJ was identified to have existed on 12/21/2022.
An Acceptable Removal Plan was received on 5/2/2023. The removal plan included in-service training for staff on Abuse prevention, Reporting Abuse allegations, and Investigating allegations of abuse, and in-service training for administration staff on reporting and investigating alleged violations. Through observations, record review, and interviews the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on 5/1/2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures regarding Abuse prevention, Reporting, and Investigating allegations of Abuse.
Findings include:
Review of the facility's ''Abuse Neglect and Exploitation policy'' dated 12/2017 indicated each resident has the right to be free from verbal, sexual, physical and mental abuse; corporal punishment; involuntary seclusion; mistreatment of any kind . Resident will not be subjected to abuse by anyone, including but not limited to, Center staff, other residents, consultants, volunteer staff, family members, friends or others. Bullet III. Prevention of Abuse, Neglect and Exploitation: Provide education on what constitutes abuse, neglect, and misappropriation of property. Take appropriate action to allegations or questions of abuse by residents, family members, employees, or visitors . Supervise staff to identify inappropriate behaviors, such as using derogatory language, rough handling or ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in their beds. Bullet IV. Identification of Abuse, Neglect and Exploitation: The facility will consider factors indicating possible abuse, neglect and/or exploitation of residents including, but not limited to, the following possible indicators: Resident, staff or family report of abuse. Verbal abuse of a resident overheard. Physical abuse of a resident observed.
1. Review of the clinical record revealed R#11 was admitted to the facility on [DATE] with diagnoses including fracture of upper and lower end of right fibula and fracture of right tibia. The resident was discharged from the facility on 3/11/2023.
The resident's admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 14, which indicated no cognitive impairment.
Review of document titled Grievance Log dated 9/1/2022 through 4/26/2023 revealed a grievance entered on behalf of R#11 on 1/9/2023, by the resident's family member and the nature of the grievance indicated care. The log entry indicated the outcome was Reportable and the resolution date of the grievance indicated 1/17/2023 (more than a week after the grievance was initially reported).
Review of the Incident Report Form, dated 1/17/2023, indicated the above allegation was entered into the facility's incident tracking system on that date (eight days after the initial report).
Review of the ''Incident Follow-Up Investigation Report'' dated 1/17/2023 related to R#11's report of care concerns was reviewed and indicated Initial Report: Abuse. The report indicated on 1/9/2023, R#11 alleged to the Social Worker (SW) that Certified Nursing Assistant (CNA) BB (agency) was rough and verbally abusive during activities of daily living (ADL) care. R#11 also alleged CNA BB and CNA CC left her lying in her own feces. According to the investigation report, the SW never reported the allegation of abuse to the Administration. Administration was not made aware of R#11's allegations of abuse until reported by the resident's Representative (RP) to the Director of Nursing (DON) on 1/17/2023 (eight days later) during a Circle of Care/Care Coordination Meeting. The investigation did not include interviews with residents related to potential verbal abuse and rough care by staff members, rather six residents were interviewed by the SW regarding the amount of time it took for staff to answer call lights. The investigation also did not include interviews with any other staff members other than the two CNAs about whom the allegations were made. CNA BB and CNA CC were not put on administrative leave after the first allegation of abuse on 1/9/2023 or during the investigation after a second report of abuse on 1/17/2023. Both CNAs continued to work in the facility with R#11 and other residents after the initial allegation of abuse. A physical assessment of the resident was not completed of R#11 after the allegation of abuse to ensure no injuries were obtained. The investigation conclusion revealed Abuse not verified. Both staff members were still working regularly at the facility in direct contact with residents through the survey exit date of 5/3/2023.
Interview on 4/24/2023 at 12:30 p.m., R#11's RP confirmed report of an allegation of physical abuse/rough treatment by two CNAs was made to the facility social worker on 1/9/2023 and then again to the DON on 1/17/2023.
Interview on 4/28/2023 at 5:45 p.m. with CNA CC, verified she was still working consistently in the facility as a CNA and indicated she did not recall R#11. She stated she did not remember ever being put on administrative leave related to any allegation of abuse.
CNA BB was unavailable for interview during the survey.
Interview on 4/27/2023 at 2:15 p.m., the Social Services Director (SSD) confirmed the Grievance related to R#11's allegation of physical and verbal abuse had not been reported to the facility's Administration as it should have. She stated the grievance should have been immediately referred to the Abuse Coordinator/Administrator on 1/9/2023 when the allegation was initially reported.
2. Review of the clinical record revealed R#12 was admitted to the facility on [DATE] with diagnoses including gastrointestinal hemorrhage and anemia.
The resident's MDS dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 13, which indicated no cognitive impairment.
Review of a ''Progress Notes,'' dated 4/9/2023 at 7:31 p.m. revealed the CNA reported to the writer that resident reported to her someone had come to her room and took his penis and rubbed it against her vagina. The writer accompanied by the fllor [sic] nurse went to the resident's room. Resident A/O [alert and oriented] x 2 narrated +- what the CNA had reported to the writer. With the help of the floor nurse the resident's generterial [sic] area was assessed. Noted was redness to inner thighs. Resident was also able to show where the rubbig [sic] was by touching the top of her vagina. The note indicated the facility's Abuse Coordinator'' (Administrator), the police, and the resident's family had been notified of the allegation.
Review of the Incident Report Form, dated 4/9/2023, indicated an allegation of sexual abuse was entered into the facility's incident tracking system on that date for the resident. The details indicated, ''Resident informed staff that a man sexually abuse [sic] her, however she could not recall the date and time of the incident.''
Review of the Incident Follow-Up Investigation Report dated 4/9/2023 related to the resident's allegation of sexual abuse was reviewed and indicated Initial Report: Staff to Resident Sexual Abuse. The report indicated R#12 alleged sexual abuse by a staff member to an unidentified CNA on 4/9/2023 at approximately 7:30 p.m. The CNA immediately reported the allegation to the charge nurse. The resident reported that a male tech came into her room, took his penis, and rubbed it against her vagina. The investigation report indicated the resident was noted to have redness to her inner thighs and was able to point out the area that was being rubbed by pointing to the top of her vagina. The report indicated the resident was sent to the hospital after the report of sexual abuse on the evening of 4/9/2023 and sexual abuse could not be determined by the staff at the Emergency Department. Review of the investigation report revealed the facility did not attempt to identify the potential perpetrator of the abuse or conduct interviews with staff and residents to attempt to determine if the abuse had occurred. The investigation conclusion indicated unsubstantiated.
Review of the Nursing Schedules, dated 4/7/2023 through 4/9/2023 revealed four male staff members had been working in direct contact with residents, including R#12 during the allegation timeframe. None of the four staff members were put on administrative leave during the investigation to ensure the residents' protection. All four of the identified staff members were still working consistently in the facility and in direct contact with residents as of the survey exit date of 5/3/2023.
R#12 was unavailable for interview due to the resident being hospitalized for part of the survey timeframe and was too ill to interview/asleep during the remaining timeframe.
Interview on 4/27/2023 at 10:25 a.m., the Administrator confirmed there were multiple male staff members who worked during the time frame of R#12's allegation.
3. Review of the clinical record revealed R#28 was admitted to the facility on [DATE] with diagnoses including morbid obesity, unspecified psychosis, and Wernicke's Encephalopathy.
The resident's MDS dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 8, which indicated moderate cognitive impairment.
Review of the Incident Report Form, dated 12/21/2022, indicated an allegation of physical abuse was entered into the facility's incident tracking system on that date for the resident. The details indicated, Resident had a fall and states CNA pushed me. The form indicated the alleged perpetrator of the abuse to be CNA DD.
Review of the Incident Follow-Up Investigation Report dated 12/21/2022 related to the resident's allegation of physical abuse was reviewed and indicated Initial Report: Staff to Resident Abuse. The report indicated R#28 alleged physical abuse by a staff member on 12/21/2022. The resident stated CNA DD pushed him down and he cried for help and no one would help him. The report indicated R#28 was found on the floor by another CNA crying and lying face down next to his bed. The report indicated interviews were obtained from three staff members who were working with the alleged perpetrator on the night of the alleged abuse. Two of the three staff members interviewed indicated they were present in the resident's room while he was alleging he had been abused by CNA DD. Both staff members indicated the resident was found face down on the floor and was crying. Both staff members confirmed the allegation of abuse by CNA DD. Both staff members revealed R#28 was further abused (verbally) by CNA DD when she returned to the resident's room and loudly yelled, ''You should have offered him [R#28] some food and watched how fast he got up'' before knocking the resident's cups off his bedside table, and then storming out of the room. According to the investigation report, the allegation of potential abuse was not reported to the facility's Abuse Coordinator until the following morning. CNA DD was not put on administrative leave after the allegation of abuse, and instead remained in the facility for the remaining seven hours of her shift while working in direct contact with residents. According to the report, no additional staff interviews were conducted, and no resident interviews were conducted related to the allegation to determine if the abuse occurred. According to the records, R#28 was not physically assessed to determine if he had been injured during the incident. The investigation conclusion indicated: Unverified, even though reports of verbal abuse by CNA DD to R#28 were verified per interview with staff members present during the incident.
Review of the Nursing Schedule for 12/21/2022 revealed CNA DD remained in the facility for the remainder of her shift on 12/21/2022. In addition, the schedule verified CNA DD was still working consistently in the facility as of the survey exit date of 5/3/2023.
R#28 was unable to be interviewed related to the allegation due to his poor cognition.
Interview on 4/29/2023 at 10:23 a.m. with CNA DD, indicated she was familiar with R#28 and stated she remembered the incident from 12/21/2022. She stated, All I know is I cleaned him [R#28] up and he didn't want to get clean. I cleaned him up and when I finished, I put the bed to the lowest [position] and he pushed himself to the ground. CNA DD confirmed she was not put on administrative leave on the night of the alleged abuse. She stated she remained in the facility working with residents until the end of her shift the next morning. CNA DD stated she was placed on administrative leave the next day after the Administrator arrived at work. She stated after the investigation was done, she was asked to return to work.
Interview on 4/2720/23 at 10:25 a.m., the DON and the Administrator confirmed the Administrator was acting as the facility's Abuse Coordinator. The Administrator stated abuse was to be reported to himself immediately after an allegation and stated any facility staff member could report abuse. He stated after abuse allegations had been reported to him, it was his responsibility to investigate the allegation. The Administrator confirmed his expectation was witness statements would be obtained and the police, the family, the physician, and the local Ombudsman be called. He stated the alleged perpetrator should be suspended pending the outcome of the investigation. The DON confirmed the allegation of potential abuse was not reported timely for R#11 and stated she did not believe any of the above investigations were thorough. The Administrator stated, We should have interviewed residents about staff treatment and other staff as well (related to the above allegations of potential abuse).
Interview on 4/29/2023 at 2:20 p.m. the Clinical Nurse Consultant (CNC) stated his expectation was any allegation of abuse was to be reported to a supervisor immediately and the supervisor was to then immediately call the Abuse Coordinator. He stated allegations of abuse were expected to be thoroughly investigated and residents were to be protected while the investigation was conducted.
4. Review of the policy titled Accidents and Supervision, Investigation, and Reporting, revised 9/2022, indicated the facility shall provide the residents an environment free of accident hazards and each resident receives adequate supervision and assistive devices to prevent accidents. All accidents or incidents must be reported and recorded.
Review of the clinical record revealed R#18 was admitted to the facility on [DATE] with diagnoses including osteoarthritis and dementia.
The resident's MDS dated [DATE], revealed a BIMS score of five, indicating the resident had severe cognitive impairment. Additionally, it was indicated R#18 had no falls since admission, required extensive assistance of one person with bed mobility, dressing, transfers, required two-person assistance with toileting, extensive assistance of one person with personal hygiene, and had impairments to the lower extremities bilaterally.
Review of the care plan revised 2/27/2023 indicated R#18 required assistance with bathing, bed mobility including turning and repositioning, dressing, undressing, transfers, and incontinence care. The care plan indicated R18 had a diagnosis of atrial fibrillation and required the administration of blood thinners.
Review of the Incident Note dated 4/12/2023 at 1:30 p.m. revealed Administrator was present onsite and aware of incident at the time of the concern. DON, ADON (Assistant Director of Nursing), and Administrator responded to bedside to address family and resident concern. When DON asked the resident what caused her bruises, the resident stated, I don't know. DON asked resident directly, Did anyone hurt you intentionally? Resident responded, No. DON requested wound care nurse to complete a head-to-toe skin assessment. DON offered to call MD (Medical Doctor) for radiology of left foot and ankle and resident's RP refused stating to call 911 and have her transported to a hospital. DON called 911 for transport and the resident was transferred to non-emergent transport.
Review of Weekly Skin Observation dated 4/12/2023 at 1:39 p.m., indicated the resident had purple/blue discolorations to the left dorsal great toe and left dorsal proximal foot, purple/blue discolorations to the right upper arm and left upper arm, purple/blue discolorations with petechiae to the right lower extremity, a small open area to left labia, and yellow discolorations to left temple.
Review of a document titled Risk Management indicated R#18 had an injury of unknown cause on 4/12/2023 at 3:00 p.m. The document recorded family members at bedside and requested an immediate call to 911 for EMS (Emergency Medical Services) to remove the resident from facility due to their concerns of care. Resident states that her left great toe and foot has pain and there is a small bruise on top of left great toe, and small bruise to left ankle, and a yellow discoloration to left temple. Scattered petechiae [pinpoint, round spots that appear on the skin as a result of bleeding] to right shin. Head to [sic] assessment from wound care nurse completed. 911 called to transport patient to acute hospital per family request. Administrator aware and submitting reportable and called Ombudsman. The DON notified MD and RP and [family member] at bedside onsite at facility and packed up her belongings. DON answered all question for family.
Review of the Facility Incident Report Form, dated 4/12/2023, indicated R#18 had a dark bruise on left foot reported by resident's family member and informed the Administrator/Abuse Coordinator of the bruise. The report recorded the facility offered to obtain an x-ray, but the family declined. The report recorded the concern was an injury of unknown origin and the alleged perpetrator was unknown. There was no documentation of steps taken by the facility to prevent further incidents.
The conclusion of the investigation on 4/12/2023 recorded, . The conclusion of this investigation is inconclusive. During the interview with DON and others, the resident stated that she wasn't experiencing ankle pain. Secondly the resident takes both Anticoagulant and Anastrozole medications, and lastly the Responsible Party informed the Administrator that her friend advised her how to get the [R#18] closer to home. Corrective action . Administration will continue employee's education on residents' assessments and reporting injuries. This is a late reportable and will be QAPI (Quality Assurance and Performance Improvement) in facility up-coming QAPI.
Interview on 4/26/2023 at 4:29 p.m., the Wound Care Nurse (WCN) stated R#18 was not able to turn and reposition herself, had limited range of motion to her upper extremities, and required full assistance with bilateral lower extremity movement.
Interview on 4/27/2023 at 7:00 p.m., the CNC stated R#18's injuries noted on 4/12/2023 were not reported because nothing happened.
Interview on 4/28/2023 at 9:40 a.m., the Visiting Administrator (VA) EE confirmed the facility did not do an investigation on 4/12/2023 related to R#18's injuries and no witness statements or investigation documentation were available.
Interview on 4/28/2023 at 10:37 a.m., the WCN confirmed that she performed a full body skin assessment on R#18 with the family at the bedside. WCN stated R#18's family member reported bruising to left upper foot and further skin assessment revealed yellow discoloration to the temple, purple/blue discoloration to bilateral upper extremities, and petechiae to left lower extremity, and a small ulcer opening to the labia.
Interview on 4/28/2023 at 10:58 a.m., the DON confirmed that on 4/12/2023, R#18's family was visiting in the resident's room and was upset, stating they wanted her moved out of the facility. The DON she was not aware of any bruising to R#18's body but was aware that the resident was complaining of foot pain. The DON stated the WCN performed a full body skin assessment which revealed discoloration to her foot, possible injury to the foot, and pain reported in one of her feet.
Interview on 4/28/2023 at 2:55 p.m., the Administrator/Abuse Coordinator stated that he reported the injury on 4/12/2023 but did not submit a five-day follow-up. The Administrator did not provide a reason the five-day follow-up report was not submitted.
Interview on 4/28/2023 at 4:24 p.m., the Infection Preventionist (IP) confirmed that on 4/12/2023 she was employed as the ADON and was asked to speak with R#18's family at the bedside. The IP stated she was made aware of a dark purple discoloration to R#18's left great toe, along with purple discoloration to the left ankle, and yellow discoloration to the left temple/forehead area. The ADON confirmed that staff working with R#18 should have reported any bruising immediately but did not. The IP confirmed it was the family member who brought the bruising to the attention of the facility.
Interviews with 11 staff members throughout the facility on 4/27/2023 between 12:00 p.m. and 12:30 p.m. indicated nine of 11 staff members were agency staff working in the facility and three of 11 reported they had not received abuse training from the facility. One agency CNA staff member indicated she had not received abuse training from either her agency or the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, family and staff interviews, and review of the policy titled Abuse Neglect and Exploitation policy, the facility failed to ensure allegations of verbal, sexual, and/or physical abuse were thoroughly investigated for four of 31 sampled residents (R) (R#11, R#12, R#18, and R#28). Specifically, resident and staff interviews were not conducted during investigations into the allegations to determine if abuse occurred, and the facility failed to identify potential perpetrators of abuse. The facility's systemic failure to ensure the thorough investigation of abuse allegations created the potential for residents to be or to continue to be abused/neglected/exploited which can lead to serious physical and/or psychological harm for all 126 residents residing in the facility.
On 4/28/2023 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents.
The facility's Administrator and Clinical Nurse Consultant was informed of the Immediate Jeopardy (IJ) on 4/28/2023 at 3:50 p.m. The noncompliance related to the IJ was identified to have existed on 12/21/2022.
An Acceptable Removal Plan was received on 5/2/2023. The removal plan included in-service training for staff on Abuse prevention, Reporting Abuse allegations, and Investigating allegations of abuse, and in-service training for administration staff on reporting and investigating alleged violations. Through observations, record review, and interviews the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on 5/1/2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures regarding Abuse prevention, Reporting, and Investigating allegations of Abuse.
Findings include:
Review of the policy titled Abuse Neglect and Exploitation policy dated 12/2017 indicated each resident has the right to be free from verbal, sexual, physical, and mental abuse; corporal punishment; involuntary seclusion; mistreatment of any kind. Residents will not be subjected to abuse by anyone, including but not limited to, center staff, other residents, consultants, volunteer staff, family members, friends, or others. Investigation of abuse, neglect, and exploitation: When suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Components of an investigation may include: Identifying staff responsible for the investigation; Exercising caution in handling evidence that could be used in a criminal investigation (e.g. not tampering or destroying evidence); Ensure resident safety is not jeopardized. Physically assess resident; Investigating different types of alleged violations; Identifying an interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, ensure confidentiality; Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and Providing complete and thorough documentation of the investigation; Continue investigation to determine if other residents may be at risk for similar occurrences. If similar residents are at risk, appropriate measures/changes will be implemented.
1. Review of the clinical record revealed R#11 was admitted to the facility on [DATE] with diagnoses including fracture of upper and lower end of right fibula and fracture of right tibia. The resident was discharged from the facility on 1/11/2023.
Resident #11 is a new admission and entry tracking Minimum Data Set (MDS) dated [DATE] is only MDS available, therefore, no data available at this time.
R#11's Brief Interview for Mental Status (BIMS) score, dated 1/6/2023 and found in the electronic medical record (EMR) under the MDS tab, was 14, indicating the resident was cognitively intact.
Review of the Incident Report Form, dated 1/17/2023, indicated the above allegation was entered into the facility's incident tracking system on that date.
Review of the Incident Follow-Up Investigation Report related to the resident's report of care concerns dated 1/17/2023 indicated, Initial Report: Abuse. The report indicated on 1/9/2023, R#11 alleged to the Social Worker (SW) that Certified Nursing Assistant (CNA) BB (agency) was rough and verbally abusive during activities of daily living (ADL) care. She alleged CNA BB and CNA CC left her lying in her own feces. Administration was not made aware of these allegations of abuse until reported by the resident's Representative (RP) to the Director of Nursing (DON) on 1/17/2023 (eight days later). The investigation did not include interviews with residents related to potential verbal abuse and rough care by staff members, rather six residents were interviewed by the SW regarding the amount of time it took for staff to answer call lights. The investigation did not include interviews with other staff members, other than the two CNAs about whom the allegations were made. In addition, a physical assessment was not completed of R#11 after the allegation of potential abuse to ensure no injuries were obtained.
2. Review of the clinical record revealed R#12 was admitted to the facility on [DATE] with diagnoses including gastrointestinal hemorrhage and anemia.
R#12's BIMS score, dated 3/27/2023, and found in the EMR under the MDS tab, was 13, indicating the resident was cognitively intact.
Review of a ''Progress Notes,'' dated 4/9/2023 at 7:31 p.m. revealed CNA reported to the writer that resident reported to her someone had come to her room and took his penis and rubbed it against her vagina.
Review of the Incident Report Form, dated 4/9/2023, indicated an allegation of sexual abuse was entered into the facility's incident tracking system on that date for R#12. The details indicated, ''Resident informed staff that a man sexually abuse [sic] her, however she could not recall the date and time of the incident.''
Review of the Incident Follow-Up Investigation Report dated 4/9/2023 related to the resident's allegation of sexual abuse was reviewed and indicated Initial Report: Staff to Resident Sexual Abuse. The report indicated R#12 alleged sexual abuse by a staff member to an unidentified CNA on 4/9/2023 at approximately 7:30 p.m. Review of the investigation report revealed the facility did not attempt to identify the potential perpetrator of the abuse or conduct interviews with staff and residents to attempt to determine if the abuse had occurred. The investigation conclusion indicated unsubstantiated.
Review of the Nursing Schedules, dated 4/7/2023 through 4/9/2023 revealed four male staff members had been working in direct contact with residents, including R#12 during the allegation timeframe. There was no investigation to specifically rule in or out if any of the four male staff members who were identified as working in direct contact with residents during the time frame of the allegation of sexual abuse.
3. Review of the clinical record revealed R#28 was admitted to the facility on [DATE] with diagnoses including morbid obesity, unspecified psychosis, and Wernicke's Encephalopathy.
R#28's BIMS score, dated 2/2/2023, and found in the EMR under the MDS tab, was eight, indicating the resident was moderately cognitively impaired.
Review of the Incident Report Form, dated 12/21/2022, indicated an allegation of physical abuse was entered into the facility's incident tracking system on that date for the resident. The details indicated, Resident had a fall and states CNA pushed me. The form indicated the alleged perpetrator of the abuse to be CNA DD.
Review of the Incident Follow-Up Investigation Report dated 12/21/2022 related to the resident's allegation of physical abuse was reviewed and indicated Initial Report: Staff to Resident Abuse. The report indicated R#28 alleged physical abuse by a staff member on 12/21/2022. The resident stated CNA DD pushed him down and he cried for help, and no one would help him. The report indicated R#28 was found on the floor by another CNA crying and lying face down next to his bed. The report indicated interviews were obtained from three staff members who were working with the alleged perpetrator on the night of the alleged abuse. Two of the three staff members interviewed indicated they were present in the resident's room while he was alleging, he had been abused by CNA DD. Both staff members indicated the resident was found face down on the floor and was crying. Two staff members revealed R#28 was further abused (verbally) by CNA DD when she returned to the resident's room and loudly yelled, ''You should have offered him [R#28] some food and watched how fast he got up'' before knocking the resident's cups off his bedside table, and then storming out of the room. According to the report, no additional staff interviews were conducted, and no resident interviews were conducted related to the allegation to determine if the abuse occurred. According to the records, R#28 was not physically assessed to determine if he had been injured during the incident. The investigation conclusion indicated: Unverified, even though reports of verbal abuse by CNA DD to R#28 were verified per interview with staff members present during the incident.
Interview on 4/2720/23 at 10:25 a.m., the DON and the Administrator confirmed the Administrator was acting as the facility's Abuse Coordinator. The Administrator stated after an abuse allegation had been reported to him, it was his responsibility to investigate the allegation. The Administrator confirmed his expectation was witness statements would be obtained, including additional residents and staff who might know of the potential abuse. The DON stated she did not believe any of the above investigations were thorough. The Administrator stated, We should have interviewed residents about staff treatment and other staff as well (related to the above allegations of potential abuse).
Interview on 4/29/2023 at 2:20 p.m. the Clinical Nurse Consultant (CNC) stated his expectation was any allegation of abuse was expected to be thoroughly investigated and residents were to be protected while the investigation was conducted.
4. Review of the clinical record revealed R#18 was admitted to the facility on [DATE] with diagnoses including osteoarthritis and dementia.
The resident's MDS dated [DATE], revealed a BIMS score of five, indicating the resident had severe cognitive impairment. Additionally, it was indicated R#18 had no falls since admission, required extensive assistance of one person with bed mobility, dressing, transfers, required two-person assistance with toileting, extensive assistance of one person with personal hygiene, and had impairments to the lower extremities bilaterally.
Review of the care plan revised 2/27/2023 indicated R#18 required assistance with bathing, bed mobility including turning and repositioning, dressing, undressing, transfers, and incontinence care.
Review of the Incident Note dated 4/12/2023 at 1:30 p.m. revealed Administrator was present onsite and aware of incident at the time of the concern. The DON, ADON (Assistant Director of Nursing), and Administrator responded to bedside to address family and resident concern. When DON asked the resident what caused her bruises, the resident stated, I don't know. DON asked resident directly, Did anyone hurt you intentionally? Resident responded, No. DON requested wound care nurse to complete a head-to-toe skin assessment. DON offered to call MD (Medical Doctor) for radiology of left foot and ankle and resident's two daughters refused, stating to call 911 and have her transported to a hospital. DON called 911 for transport and the resident was transferred to non-emergent transport.
Review of Weekly Skin Observation dated 4/12/2023 at 1:39 p.m., indicated the resident had purple/blue discolorations to the left dorsal great toe and left dorsal proximal foot, purple/blue discolorations to the right upper arm and left upper arm, purple/blue discolorations with petechiae (pinpoint, round spots that appear on the skin as a result of bleeding) to the right lower extremity, a small open area to left labia, and yellow discolorations to left temple.
Review of the Facility Incident Report Form, dated 4/12/2023, indicated R#18 had a dark bruise on left foot reported by resident's family member and informed the Administrator/Abuse Coordinator of the bruise. The report recorded the concern was an injury of unknown origin and the alleged perpetrator was unknown. There was no documentation of steps taken by the facility to prevent further incidents.
Review of the Incident Follow-Up Investigation Report dated 4/28/2023 at 11:00 p.m. and signed by the Administrator indicated summary of interview(s) with other residents: at approximately 3:10 p.m., resident 30-A was asked if she had observed anyone mistreat [R#18] and responded no. At 3:15 p.m., resident 30-B was asked if they had observed anyone mistreating [R#18] and responded no. At 3:18 p.m., resident 31-A was asked if she had observed anyone mistreating [R#18] and responded that she was not aware. The Report recorded the direct-care staff assigned to R#18 on 4/12/2023 was asked if she had observed a bruise on R#18's left foot, and she stated she saw a little purple bruise on the foot but did not report it. The Report recorded the charge nurse assigned to R#18 on that day denied knowledge of R#18 being in pain. The conclusion section of the report indicated, . The conclusion of this investigation is inconclusive. During the interview with DON and others, the resident stated that she was not experiencing ankle pain. Secondly the resident takes both Anticoagulant and Anastrozole medications, and lastly the Responsible Party informed the Administrator that her friend advised her how to get the [R#18] closer to home. Corrective action . Administration will continue employee's education on residents' assessments and reporting injuries. This is a late reportable and will be QAPI [Quality Assurance and Performance Improvement] in facility up-coming QAPI.
There was no documentation of the residents' interviews or whether the residents were asked any other questions related to abuse and neglect. There were no interviews with staff members or potential witnesses, other than the two assigned to the resident. The report was not completed until 04/28/23, after the surveyors had brought the incident to the attention of the Administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews, and review of the policy titled Bath, Shower/Tub, the facility failed to ensure that activities of daily living (ADL) was provided for two residents (R) (R#17 and R#19) related to showers and facial grooming/ assistance with toileting. The sample size was 31.
Findings include:
Review of the policy titled Bath, Shower/Tub, revised February 2018, provided directions for bathing/showering residents, and instructions for documentation and reporting. Documentation 1. The date and time the shower/tub bath was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/tub bath. 3. All assessment data (e.g., any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath. 4. How the resident tolerated the shower/tub bath. 5. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. 6. The signature and title of the person recording the data. Reporting 1. Notify the supervisor if the resident refuses the shower/tub bath. 2. Notify the physician of any skin areas that may need to be treated. 3. Report other information in accordance with facility policy and professional standards of practice.
1. Review of the clinical record revealed R#19 was admitted to the facility on [DATE] with diagnoses including history of stroke and contractures of her right hand and bilateral lower extremities.
The resident's annual MDS dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating no cognitive impairment. Section G revealed resident required extensive assistance of one staff member for grooming and bathing/showering.
Review of the care plan dated 1/27/2023 revealed resident has difficulty performing tasks of daily living such as bathing and dressing. Interventions to care included the resident's preference was for a bed bath, required total assistance with bathing and personal hygiene. The care plan did not indicate the number of times per week or time of day the resident preferred to bathe.
Review of electronic medical record (EMR) and paper record lacked evidence an assessment had been completed to determine the number of times per week or the time-of-day R#19 preferred to be bathed.
Review of the facility's shower schedule located in a binder at the nurses' station indicated R#19 was to be showered twice per week on Wednesday and Saturday evenings.
Review of shower records for R#19, dated 4/1/2023 through 4/27/2023, indicated the resident received bed baths on 4/3/2023, 4/8/2023, and 4/23/2023 with assistance from staff. The resident's grooming records of the same date range indicated the resident received grooming services at least once daily with the exception of 4/15/2023, 4/19/2023, 4/20/2023, and 4/22/2023. No refusal of bathing or grooming was documented on the record.
A request for Shower Sheets for 4/1/2023 through 4/27/2023 for R#19 was requested. Only one shower sheet dated 4/26/2023 was provided for the R#19. The shower sheet indicated R#19 refused a shower on that date.
Observation on 4/24/2023 at 11:45 a.m. and 1:15 p.m., resident was seated in a geri-chair in the hallway outside of her room with a full facial beard of abundant approximately half-inch long chin hair. She looked unkempt, as though she had not been recently bathed. Her hair appeared oily.
Observation on 4/25/2023 at 10:25 a.m. and 1:35 p.m., resident's facial hair had been shaved but the resident remained unkempt and continued to appear unbathed.
Observation on 4/26/2023 at 8:50 a.m., resident continued to appear unbathed.
Interview on 4/25/2023 at 1:35 p.m., R#19 stated she wanted her facial hair to removed routinely but when she asked staff to assist her with this, she was usually told, It's not my job. During further interview, she stated staff shaved her facial hair the day before, but it had been a long time prior to that since she had been assisted with facial grooming. She stated she was aware her facial hair was very long, and she did not want it that way. She stated, I want it removed. Shaved, not plucked.
Interview on 4/27/2023 at 12:20 p.m. Certified Nursing Assistant (CNA) FF, indicated she was an agency employee but was familiar with the facility. She stated residents sometimes missed showers because staff were busy and stated facial hair was to be shaved on shower days.
Interview on 4/29/2023 at 1:00 p.m. CNA GG, indicated she worked at the facility three days per week and stated showers were given twice weekly based on resident's room numbers. She stated facial grooming was supposed to be done on shower days. During further interview, she stated if a resident refused a bath the nurse was to be told and staff was supposed to document the refusal in the resident's record.
Interview 4/28/2023 at 12:07 p.m., CNA HH stated he worked frequently in the facility and was familiar with the residents. He stated showers were given based on room number. He stated if a shower was refused, it was to be documented in the resident's record. CNA HH stated he was familiar with R#19 and, though he had not recently given her a bath, he did not know her to refuse her bathing.
Interview on 4/29/2023 at 2:20 p.m., Clinical Nurse Consultant (CNC) Interim Director of Nursing (DON)) stated that baths/showers were scheduled twice weekly based on resident room number. He stated residents had the right to refuse bathing, but if a resident refused a bath or shower that was to be documented in the resident's electronic record and/or on the resident's shower sheet.
2. Review of the clinical record revealed R#17 was admitted to the facility on [DATE] with diagnoses including bladder cancer, respiratory failure, protein-calorie malnutrition, weakness, and osteoarthritis.
The resident's MDS dated [DATE] revealed a BIMS score that was unable to be completed due to impaired cognition. The assessment indicated the resident required one person assistance with bed mobility, dressing, toileting, personal hygiene, and that bathing was not provided to the resident during the lookback period. The assessment recorded resident was always incontinent of bowel and bladder.
Review of the care plan dated 3/16/2023 documented staff was to keep resident skin clean and dry.
Review of the Progress Notes, dated 3/14/2023 through 3/17/2023 revealed no documentation resident had refused any baths or hygiene care.
Review of the facility's shower schedule indicated R#17 was to receive a shower/bath on Tuesdays and Fridays during the 3:00 p.m. - 11:00 p.m. shift.
Review of the Documentation Survey Report v2, indicated the resident was not monitored for bladder continence/incontinence, bowel continence/incontinence, personal hygiene, toilet use, or bowel movements during one or more shifts from 3/14/2023 through 3/17/2023 or bathed from 3/14/2023 - 3/17/2023.
Interview on 4/25/2023 at 5:34 p.m., Hospital Registered Nurse (HRN) II stated R#17 came to the hospital on 3/17/2023 complaining of pain to the lower abdomen/bladder area. HRN II stated upon assessment, during urinary catheterization, it was noted that residents' labia, buttocks, and inner thighs were raw and excoriated. HRN II stated R#17 was alert and oriented to person, place, time, and situation and reported the staff at the facility did not change her very often. HRN II stated R#17's family was at the bedside and stated they did not want her to return to the facility due to lack of incontinent and hygiene care.
Interview on 4/28/2023 at 10:58 a.m., Director of Nursing (DON) stated the Unit Managers (UM) were responsible for checking CNAs documentation before they left their shift for the day. The DON stated the CNAs knew they were supposed to document all hygiene care, bathing, and showering provided to every resident before leaving for the day. The DON stated, If it wasn't documented, it wasn't done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of the clinical record revealed R#19 was admitted to the facility on [DATE] with diagnoses including history of stroke.
The resident's annual MDS dated [DATE] indicated the resident was at risk for pressure ulcers but did not have any pressure ulcers at the time of the assessment.
Review of the care plan dated 1/27/2023 indicated the resident was at risk for developing pressure sores due to her medical fragility. Interventions to care included follow facility procedures for the prevention of skin breakdown.
Review of the Weekly Skin Observation Report, dated 2/27/2023 through 4/27/2023 revealed there were weekly skin assessments present 8/20/2022 and then not again until 2/27/2023. In addition, there were two Weekly Wound Reports dated 3/6/2023 and 3/13/2023. The 3/13/2023 Weekly Wound Report indicated the resident's skin was clear. After 3/13/2023 there were no additional weekly skin assessments in the resident's record.
Interview on 4/26/2023 at 4:29 p.m., the Wound Care Nurse (WCN) stated the floor nurses were responsible for performing weekly skin assessments.
Interview on 4/28/2023 at 10:37 a.m. the WCN confirmed that residents were not receiving weekly skin assessments due to having agency staff nurses.
Interview on 4/28/2023 at 10:58 a.m., the Director of Nurses (DON) stated that in February or March of 2023, the facility realized residents were not receiving their weekly skin assessments. The DON stated since that time, she had been trying to get a team together to ensure compliance, and the WCN had an assignment sheet that was provided to the floor nurses for weekly skin assessments. The DON stated that she felt the weekly skin assessments were not being done due to inconsistent Unit Managers and staffing turnover with agency staff.
Interview on 4/28/2023 at 4:24 p.m., the Infection Preventionist (IP) stated that weekly skin assessments were not being done on a consistent basis due to agency nurses' turnover which made it hard to keep skin assessments ongoing.
Interview on 4/29/2023 at 2:20 p.m. the Interim Director of Nursing (DON), stated his expectation was weekly skin assessments were to be done by licensed nursing staff weekly. He stated his expectation was that any nurse working in the facility, whether a facility employee or from an agency, should know to conduct the skin assessments each week.
6. Review of the policy titled Transportation Policy, dated 7/19/2021, revealed the facility will provide assistance in arranging transportation for residents.
Review of the clinical record revealed R#20 was admitted to the facility on [DATE] with a primary diagnosis of peripheral vascular disease.
The residents quarterly MDS dated [DATE] revealed a BIMS score of 14, indicating the resident was cognitively intact.
Review of the Progress Note, dated 12/5/2022 at 7:10 p.m. revealed resident returned from appointment. Resident able to voice needs and concerns. The resident only voices concern of having to wait so long for transportation back to facility.
Interview on 4/24/2023 at 2:45 p.m., the Manager of Hospital Care Coordinator stated that R#20 had a doctor's appointment on 12/5/2022 and staff at the clinic noticed him sitting alone after his appointment. She stated she called the facility multiple times, and no one ever returned her call. The Manager stated she also called the Clinical Liaison (Licensed Practical Nurse (LPN) LL) who told her she would call for transport, but no one ever came for R#20.
Interview on 4/25/2023 at 2:35 p.m., the DON stated that on 12/5/2022, R#20 was transported to a doctor's appointment, and the transport company was supposed to pick him up after the visit was completed and bring him back to the facility. The DON stated the transport company did not pick him up, so staff at the clinic called an Uber for him. The DON reported the transport company told the DON and the Administrator during a meeting after the incident that they were expecting the resident to call for a pickup. The DON confirmed that LPN MM documented that R#20 returned to the facility at 7:10 p.m. on 12/5/2022.
Interview on 4/25/2023 at 2:44 p.m., the Administrator stated that at 5:00 p.m. on 12/5/2022, staff were looking for R#20 and one of the nurse managers called the clinic to see if R#20 was still there and was told they did not have a patient by that name. The Administrator stated later that day, he found out that someone from the hospital had sent R#20 back to the facility via Uber. The Administrator stated the facility protocol for medical appointments was for the driver to provide the resident with a paper listing instruction for the provider to call when the resident's appointment was completed.
Interview on 4/25/2023 at 3:32 p.m., LPN MM stated she was on duty on 12/5/2022 and overheard staff saying they were looking for R#20, and then shortly after that, R#20 showed up at the facility. LPN MM stated that R#20 was upset he had to wait so long to get back to the facility.
Interview on 4/26/2023 at 10:27 a.m., LPN LL stated she was aware R#20 had to wait for transportation for an extended period after his appointment on 12/5/2022. She stated a case manager from the hospital clinic notified her at approximately 5:00 p.m. on that day reporting they noticed R#20 unattended in the lobby and they were concerned because he had been waiting there for so long after his appointment. She stated she called the facility and was told that transport had been notified the resident needed transportation back from his appointment. During further interview, she stated she made two or three calls to the facility and to the transportation company, and no one had picked R#20 up. LPN MM stated that she was not aware until the following day that the clinic had made Uber arrangements for R#20 to get back to the facility.
Interview on 4/26/2023 at 11:09 a.m., the Social Services Director (SSD) stated on 12/5/2022 she received a phone call at approximately 5:00 p.m. from the transport company stating R#20 had already been picked up from the medical clinic. The SSD stated she informed them that R#20 had not been picked up because the resident was on the phone with a nurse from the clinic. The SSD stated the facility policy was for the Unit Clerk to make transportation arrangements and that she did not have any responsibilities related to arranging transportation for residents and their medical appointments.
Interview on 4/26/2023 at 11:21 a.m., R#20 stated that after he finished his visit with the physician on 12/5/2022, he called the transport company several times and no one ever showed up. R#20 reported a lady from the hospital eventually called for an Uber to come pick him up from the clinic and bring him back to the facility. During further interview, he stated his appointment was around 2:00 p.m. that day and he was finished around 4:00 p.m. R#20 reported he did not return to the facility until 7:00 p.m. that evening.
Based on record review, interviews, and policy review, the facility failed to ensure weekly skin assessments were performed for five residents (R) (R#14, R#15, R#16, R#18, and R#19) reviewed for skin assessments; and failed to ensure R#20 was provided return transportation from a medical appointment in a timely manner. The sample size was 31.
Findings include:
Review of the document titled, Job Description and Performance Evaluation - Social Worker, dated 5/2017, revealed to assist in arranging transportation to other facilities when necessary.
Review of the policy titled Pressure Injury Prevention and Management, dated 5/2018, revealed Licensed nurses will conduct a skin assessment on all residents upon admission/re-admission, weekly, and as needed. Findings will be documented in the medical record. The Nurse Manager, or designee, will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance and document a summary of findings in the medical record.
1. Review of the clinical record revealed R#14 was admitted to the facility on [DATE] with a primary diagnosis of nontraumatic intracranial hemorrhage and discharged from the facility on 8/17/2022.
The resident's admission Minimum Data Set (MDS) dated [DATE], revealed resident was at risk for pressure ulcers but did not have any pressure ulcers at the time of the assessment.
Review of Weekly Skin Assessments for R#14 revealed no documentation of weekly skin assessments from 7/30/2022 through 8/17/2023.
2. Review of clinical record revealed R#15 was admitted to the facility on [DATE] with a primary diagnosis of peripheral autonomic neuropathy and was discharged from the facility on 12/2/2022.
The resident's quarterly MDS dated [DATE], revealed the resident was at risk for pressure ulcers but did not have any pressure ulcers at the time of the assessment.
Review of Weekly Skin Assessments, for R#15 revealed no documentation of weekly skin assessments from 7/9/2022 through 9/17/2022 or from 9/17/2022 until R#15 was discharged on 12/2/2022.
3. Review of the clinical record revealed R#16 was admitted to the facility on [DATE] with a primary diagnosis of respiratory failure and was discharged from the facility on 3/28/2023.
The resident's annual MDS dated [DATE], revealed R#16 was at risk for pressure ulcers and had one stage IV pressure ulcer.
Review of the Weekly Skin Assessments, for R#16 revealed a skin assessment was completed on 1/6/2023 but no additional skin assessments were completed before she was discharged on 3/28/2023.
4. Review of clinical record revealed R#18 was admitted to the facility on [DATE] with a primary diagnosis of osteoarthritis and was discharged from the facility on 4/12/2023.
The residents annual MDS dated [DATE], revealed R#18 was at risk for pressure ulcers but did not have any pressure ulcers at the time of the assessment.
Review of the Weekly Skin Assessments, for R#18 revealed weekly skin assessments were done on 2/10/2022, 3/24/2022, 7/4/2022, 7/28/2022, and 4/12/2023. No other skin assessments were documented between these dates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and review of the policy titled Food and Nutrition Services and Activities of Daily Living, the facility failed to assess and monitor the nutritional status of one resident (R) (R#14) of five sampled residents reviewed for nutritional status.
Findings include:
Review of the policy titled Food and Nutrition Services, revised October 2017, revealed the multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs. Nurse aides and feeding assistants will provide support to enhance the resident experience. Nursing personnel, with the assistance of the food and nutrition services staff, will evaluate (and document as indicated) food and fluid intake of residents with, or at risk for, significant nutritional problems. Variations from usual eating or intake patterns will be recorded in the resident's medical record and brought to the attention of the nurse. A nurse will evaluate the significance of such information and report it, as indicated, to the attending physician and dietitian.
Review of the undated policy titled, Activities of Daily Living (ADLs), Supporting, indicated residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with dining (meals and snacks).
Review of the clinical record revealed R#14 was admitted to the facility on [DATE] with a primary diagnosis of nontraumatic intracranial hemorrhage and discharged from the facility on 8/17/2022.
The resident's admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview due to cognitive impairment.
Review of Orders, revealed no physician orders for weight monitoring or dietary supplements.
Review of the care plan dated 7/21/2022, revealed the resident was at risk for altered nutrition and weight loss related to a diagnosis of cerebral vascular accident (stroke) with left-sided deficits, left thalamic hemorrhage, chronic kidney disease stage V, and weight loss on admission. The goal was listed as the resident would have no unaddressed significant weight changes of 5% in one month or 10% in six months. Interventions to care included therapeutic/mechanically altered diet, monitor, record, and report signs and symptoms of malnutrition to the physician; monitor and record intake at every meal; weigh monthly and as ordered; and to encourage resident to feed herself as much as possible.
Review of the Documentation Survey Report v2, dated July 2022 - August 2022, revealed:
1. No documentation staff provided feeding assistance on 7/21/2022, 7/22/2022, 7/31/2022, 8/3/2022, 8/7/2022, or 8/15/2022.
2. No documentation of the amount of food consumed at any meal on 7/21/2022 or at the morning and noon meals on 7/22/2022 and 7/23/2022.
3. No documentation of fluids offered in addition to meals or bedtime snacks on the evening shift on 8/3/2022, 8/6/2022, and 8/7/2022.
4. No documentation of the amount of food consumed on one or more meals on 8/3/2022, 8/7/2022, and 8/15/2022.
5. Documentation resident refused one or more meals on 8/9/2022, 8/11/2022, 8/13/2022, 8/14/2022, 8/15/2022, 8/16/2022, and 8/17/2022; and
6. Documentation resident was sent to the emergency room on 8/17/2022 due to a change in status related to no oral intake.
Review of the Progress Notes, from 7/25/2022 through 8/17/2022 indicated nursing staff was not made aware of resident refusing food/fluids on 8/13/2022 through 8/17/2022.
Review of the recorded weights revealed resident weighed 137 pounds on 7/29/2022 and 130.6 pounds on 8/11/2022. This represented a 4.67% (6.4 pounds) weight loss in 13 days.
Interview on 4/29/2023 at 11:08 a.m., the Registered Dietitian (RD) stated the facility policy for weight and nutrition monitoring was to obtain a baseline weight upon admission, daily weights for three days, then weekly weights, and then once monthly weights. The RD stated that she was made aware of any residents with weight loss by doing a weekly review of a Weight Exception Report located in the electronic medical record (EMR). The RD stated she was not aware of R#14's weight loss.
Interview on 4/29/2023 at 12:53 p.m., Director of Rehabilitation stated that on 7/22/2022 nursing staff were made aware that R#14 required maximum queuing to close her lips around the spoon during meal and had fatigued labial movements.
Interview on 4/29/2023 at 1:30 p.m., the Unit Manager (UM) TT confirmed that all residents should be weighed upon admission, then for three days, then weekly for four weeks, and then monthly. UM TT reviewed a paper weight monitoring log located at the nurses' station and confirmed that R#14 was not weighed until 7/29/2022, which was one week after she was admitted . She stated staff documented resident had refused multiple meals from 8/13/2022 through 8/17/2022, but nursing staff had not been made aware of the refusals. During further interview, UM TT stated when weights were recorded in the EMR, the system would trigger to notify the nurse of weight loss; however, due to staff not weighing the resident, the nurses were not alerted of the weight loss. UM TT confirmed that R#14 was not being offered any meal supplements and had no orders for supplements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of policies titled Medication Orders and Receipt Record and Administering Medications, the facility failed to ensure medication was consistently available for four out of 31 sampled residents (R) (R#8, R#26, R#28, and R#31). Specifically, medications were not administered to the residents due to lack of availability of the medications in the facility.
Findings include:
Review of the policy titled Medication Orders and Receipt Record revised 4/2007 indicated the facility shall document all medications that it orders and receives. Number 4. Medications should be ordered in advance, based on the dispensing pharmacy's required lead time.
Review of the undated policy titled Administering Medications revealed medications shall be administered in a safe and timely manner, and as prescribed. Number 3. Medications must be administered in accordance with the orders, including the required time frame.
1. Review of the clinical record revealed R#8 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD). The resident was discharged from the facility on 6/26/2022.
A Minimum Data Set (MDS) assessment was not available for R#8 due to her short duration of stay in the facility.
Review of June 2022 Order Summary Report dated 6/21/2022 through 6/26/2022 indicated orders for the resident to receive Fluticasone (a nasal steroid medication) 50 micrograms (mcg) one squirt in each nostril twice daily.
Review of June 2022 Medication Administration Record (MAR) dated 6/21/2022 through 6/26/2022 the code 9 under the Fluticasone administration for 6/22/2022 at 8:00 p.m. and 6/23/2022 at 9:00 a.m. indicated to review Administration Progress Notes for additional information.
Review of the Administration Progress Note, dated 6/23/2022 at 4:40 a.m. and 6/23/2022 at 6:50 p.m. indicated the resident's Fluticasone was not administered on the above referenced dates due to being unavailable in the facility.
2. Review of the clinical record revealed R#26 was admitted to the facility on [DATE] with diagnoses including recent left femur fracture requiring rehabilitation services.
Review of the ''Order Summary Report,'' dated 3/1/2023 through 4/27/2023 indicated orders for the resident to receive: Amiodarone (a heart medication used to regular heart rhythm) 200 Milligrams (mg) once daily, Lexapro (an antidepressant medication) 20 mg twice daily, Atorvastatin (a medication used to lower cholesterol levels) 20 mg once daily at bedtime, and Lidocaine Patch (a pain-relieving topical patch) 4% applied to right shoulder once daily.
Review of the MAR dated 3/1/2023 through 4/27/2023 indicated the code ''9'' under: Amiodarone administration for 3/7/2023 and 3/23/2023; Atorvastatin administration for 03/13/23; Lexapro administration for 3/10/2023; and Lidocaine patch for 4/5/2023, 4/6/2023, 4/7/2023, 4/17/2023, 4/18/2023, 4/19/2023, 4/21/2023, 4/24/2023, and 4/26/2023. The code indicated to review Administration Progress Notes for additional information.
Review of the Administration Progress Notes, dated 3/1/2023 through 4/27/2023 indicated the resident's above referenced medications were not given on the noted dates due to being unavailable in the facility.
3. Review of the clinical record revealed R#28 was admitted to the facility on [DATE] with diagnoses including morbid obesity, unspecified psychosis, and Wernicke's Encephalopathy.
Review of the Order Summary Report, dated 3/1/2023 through 4/27/2023 indicated orders for the resident to receive Xifaxan (a medication used to treat encephalopathy (a brain condition that causes swelling in the brain)) 550 mg twice daily.
Review of the MAR dated 3/1/2023 through 4/27/2023 indicated the code ''9'' under the Xifaxan administration 3/1/2023 through 3/4/2023, at least once daily 3/6/2023 through 3/13/2023, 3/16/2023, 3/17/2023, 3/23/2023, 3/24/2023, 3/26/2023, at least once daily 3/28/2023 through 4/1/2023, at least once daily 4/3/2023 through 4/10/2023, 4/13/2023, 4/14/2023, 4/16/2023, and 4/17/2023. The code indicated to review R#28's Administration Progress Notes for additional information.
Review of the Administration Progress Notes, dated 3/1/2023 through 4/27/2023 revealed the resident's above referenced medications were not given on the noted dates due to it was either ''On order,'' ''Could not be found,'' or was unavailable in the facility.
4. Review of the clinical record revealed R#31 was admitted to the facility on [DATE] with diagnoses including history of stroke and chronic pain syndrome. The resident was discharged from the facility on 2/1/2023.
Review of the Order Summary Report, dated 12/21/2022 through 2/1/2023 indicated orders for the resident to receive: Fluticasone (a nasal steroid medication) 50 mcg two sprays in each nostril one time daily, Decadron (a steroid anti-inflammatory medication) 4 mg twice daily, Lovenox (a blood thinning medication) 60 mg/0.6 milliliters (ml) inject 0.5 ml twice daily subcutaneously, Fentanyl (a potent pain medication) transdermal patch 75 mcg/hour apply one patch every 72 hours, and oxycodone (a pain medication) 5 mg/ml give 20 ml every four hours as needed.
Review of the MARs dated 12/21/2022 through 2/1/2023 indicated the code ''9'' under: Fluticasone administration for 12/22/2022, 1/13/2023, 1/14/2023, 1/16/2023, and 1/19/2023; Decadron administration for 12/21/2022 and 12/22/2022; Lovenox administration on 12/21/2022 and 12/22/2022; Fentanyl Patch administration for 12/21/2022; and oxycodone administration for 12/28/2022 at 6:13 p.m. The code indicated to review R#26's Administration Progress Notes for additional information.
Review of the Administration Progress Notes, dated 12/21/2022 through 2/1/2023 revealed the resident's above referenced medications were not given on the noted dates due to it was either On order, or unavailable in the facility.
Interview on 4/29/2023 at 10:25 a.m., Licensed Practical Nurse (LPN) OO stated she was familiar with the facility and passed medication frequently. LPN OO stated medication was supposed to be ordered for residents in advance when their supply was low (down to five days' worth of medication). LPN OO stated sometimes medications were not available for residents. She stated if medication was not available for a resident, the pharmacy was to be called and medication could be retrieved from the facility's emergency kit (e-kit). LPN DD further stated not all medication was available in the e-kit so the resident would not receive the medication as ordered. The nurse was to document the medication was not available on the MAR.
Interview on 4/29/2023 at 10:25 a.m., Registered Nurse (RN) PP stated she was an agency nurse and this was her first day passing medication in the facility. She stated she had not been able to administer some of the residents' medications already that day, because they were not available. RN PP was unable to remember specifically which residents' medications were not given but stated, ''It was a few medications this morning and I am not even done with morning medication pass.'' RN PP stated she would re-order the missing medications and would document the lack of availability in each resident's MAR.
Interview 4/27/2023 at 10:30 a.m., LPN QQ indicated she was familiar with passing medications in the facility and stated, We have been out of meds [medications for residents]. I don't know if it is the pharmacy causing the problem or if it is the nurses, we have a lot of agency nurses working here, and they do not order medications. During further interview, she stated she had a list of medications that were unavailable for residents that day from the morning medication pass. She stated she would have to re-order the medications and indicated the medications were unavailable on the MAR.
Interview on 4/29/2023 at 10:45 a.m., LPN RR indicated she was an agency nurse but worked at the facility at least three days per week passing medication. She stated, I have come in to work and found routine medications just not ordered, such as blood pressure meds. Sometimes with narcotics (controlled pain medication) we have to wait one or two days before receiving the ordered medication when they are not available.
Interview on 4/29/2023 at 11:35 a.m., Director of Nursing (DON) stated nurses are expected to reorder medications when a resident's supply was low and before the resident ran out of medication. She stated a lot of medication was available in the Omni-Cell (a computerized emergency kit). She stated only certain nurses had access to the Omni-Cell and stated other nurses were expected to go to a nurse with access to request missing medications. The DON confirmed the 9 charted on the residents' MARs indicated to refer to those notes and the notes documented the medication was not given due to not being available. The DON replied that the lack of administration of medications tells her that the nurses are not going to the Omni Cell to retrieve medications. She stated the facility's biggest issue was newly admitted residents not having access to their medication until the next day after admission. The DON stated if a resident was out of a medication that was not stored in the Omni-Cell, the medication had to be ordered and the resident had to wait for the medication to be delivered to the facility. She stated an issue was the nurses were not reordering medications prior to a resident running out. She stated controlled pain medication require a hard prescription from the physician each time it was reordered, and if this process was not timely enough, the resident would not have their pain medication available until the prescription could be obtained and the medication ordered and delivered.
Interview 4/29/2023 at 3:25 p.m., the Consulting Pharmacist indicated she was in the facility monthly and stated per review of her notes from1/1/2023 forward, she noted a concern with resident medication administration being documented with the number ''9'' and then was unable to find the associated progress notes to indicate why the medication was not administered. The Consulting Pharmacist stated her concern had been discussed with the facility's DON in January and February of 2023.
Interview on 4/29/2023 at 2:20 p.m., the Clinical Nurse Consultant (CNC) serving as interim DON indicated he was familiar with the facility and stated his expectation was that nurses order medications for residents when the resident was down to a seven-day supply. The CNC stated all nurses were expected to be oriented on facility practices, including ordering medications, prior to beginning work independently with residents.

Based on observations, staff interviews, and review of policy titled Storage of Medications, the facility failed to ensure medications were securely stored on one of four medication carts. Specifically, the medication cart on D Wing was left unlocked with the keys hanging from the lock, leaving the contents of the medication cart, including controlled medications, to be easily accessible to anyone in the area. The census was 126.
Findings include:
Review of the policy titled Storage of Medications revised 4/2007, indicated the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Number 2. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner.
Observation on 4/24/2023 at 9:30 a.m. medication cart on D Wing was observed unlocked, unattended, and with the keys hanging from the lock.
On 4/24/2023 at 9:35 a.m., the Director of Nursing (DON) was immediately summoned to the medication cart by the surveyor and stated What the What? Who is on this med cart? I will find out who is on this medication cart right away. This [the unlocked cart] is definitely not okay. The DON was able to indicate the nurse responsible for the medication cart on the D Wing was Registered Nurse (RN) AA. The DON stated RN AA was an agency nurse and it was her first shift working in the facility.
Interview on 4/25/2023 at 10:25 a.m. with RN AA, stated she had to go to the bathroom urgently and ran to bathroom without first locking the cart and safeguarding the keys. She stated, I didn't want to piss myself. RN AA stated she understood the medication cart was to be locked and the keys secured for safety reasons whenever it was not attended by the nurse assigned to the medication cart.
Interview on 4/29/2023 at 2:20 p.m. with the Clinical Nurse Consultant (CNC), serving as interim Director of Nursing (DON) stated his expectation was that the medications carts be kept locked and secured when not attended for safety reasons. CNC acknowledged leaving the medication cart unlocked and the keys accessible created the potential for medications, including controlled medications, to be misappropriated from the cart.